Review infection control procedures at least annually and after incidents, audits, or changes in risks, laws, staff, or services.
If you run a clinic, ward, lab, or dental suite, you already follow set steps to keep hands clean, rooms safe, and gear ready. The real question is how often those steps should be checked and tuned.
The short answer is a steady yearly cycle backed by extra reviews when something changes. That rhythm keeps care safe, meets rules, and keeps work smooth.
How Often To Review Infection Control Procedures: Practical Cadence
Use a two part pace. First, complete a full review every year. Second, run event based reviews any time risks, laws, services, or staffing change. Add quick pulse checks after audits or near misses.
That mix fits most settings. High risk services like surgery, dialysis, transplant, or endoscopy add quarterly mini reviews to stay sharp.
Common Review Triggers And Timing
| Trigger | When To Review | What To Update |
|---|---|---|
| Annual program cycle | Every 12 months | Risk assessment, plan, policies, training, audits |
| New service, device, or process | Before launch and within 30–60 days after | Procedures, checklists, competencies |
| Law or guidance change | On release | Policies, signage, PPE lists, cleaning specs |
| Outbreak, cluster, or exposure | Within 48–72 hours | Isolation steps, contact tracing, cleaning scope |
| Audit gap or incident | Within 2 weeks | Root cause fixes, staff refreshers, monitoring |
Step By Step Annual Review
Step 1: Set Scope And Dates
Pick the twelve month window and name the units in scope. List any high risk services. Add the review to meeting agendas so time is held from the start.
Step 2: Pull Last Year’s Evidence
Gather the prior risk assessment, the plan, audits, incident logs, device reprocessing logs, and staff training records. This shows where the load sits.
Step 3: Refresh The Risk Assessment
Use a simple tool with scores. Weigh patient mix, device use, line days, wounds, water risks, ventilation, and building work. Add vendor steps that touch clean or sterile items.
Step 4: Set Three To Five Goals
Pick goals that tackle the biggest risks. Keep each goal specific, dated, and linked to one metric. Avoid giant lists that no one can finish.
Step 5: Update Policies And Procedures
Rewrite steps to match the goals. Keep action words up front, list who does what, and name the proof to keep. Use version numbers and dates.
Step 6: Recheck Training And Competence
Map who needs what. New hires need core training; redeployed staff need unit steps; high risk areas need added skills like endoscope care or sterile tray checks.
Step 7: Tune Audits And Rounds
Pick a small set that fit the goals. Write down the sample size, the method, and who reads the results. Make it easy to trend across months.
Step 8: Walk The Space
Do a short site walk to see work as it runs. Check sinks, hand rub layout, clean storage, dirty holds, flow of people and kit, and label use.
Step 9: Close Gaps Fast
Fix small gaps on the spot and log them. For bigger gaps, write a short action line with an owner and a due date. Share the list so progress is clear.
Step 10: Share The Plan
Give units a one page summary with goals, measures, and review dates. Share wins at staff huddles so the plan feels real, not remote.
Policy And Procedure List To Recheck
- Hand hygiene and glove use
- Personal protective equipment selection and fit
- Respiratory etiquette and source control
- Cleaning and disinfection of rooms and equipment
- Device reprocessing and sterilization steps
- Aseptic insertion and care of lines and catheters
- Isolation categories and patient transport
- Linen, waste, and spill cleanup
- Water safety basics and flushing routines
- Construction, renovation, and dust control
- Post exposure management and reporting
- Outbreak recognition and first actions
Data That Makes Reviews Work
Pick metrics that point to action. Rates alone can hide where to act. Mix a few rate lines with process checks that you can change next week.
A short set works well. Hand hygiene observations, device reprocessing checks, line days, cleaning audit scores, post procedure infection counts, and vaccine uptake for staff can show if the plan works.
Make the data easy to read. One page charts with short captions beat dense dashboards. Show trend lines, last month’s value, and the goal line in plain view.
What Annual Really Means
An annual cycle is not a binder dust off. Treat it as a full reset that checks real risks and aligns work with those risks. Start with a risk assessment, then set goals, then update documents and training to fit the findings.
Regulators back this pace. See the OSHA Bloodborne Pathogens standard 1910.1030 for the yearly Exposure Control Plan update, and use the CDC ICAR assessment tool to run broad checks that feed your plan.
Event Driven Reviews That Cannot Wait
Outbreaks and single high risk events demand fast checks. Pull a small team, confirm the organism, trace contacts, and test the break points in hand hygiene, cleaning, device care, and isolation. Then adjust the procedure where the chain failed.
New services or devices change task steps. Build a brief risk check before go live, run a tabletop test, and capture sign off. Plan a second review a month or two later to catch real world snags.
Staffing shifts can raise risk. When a unit opens, closes, or moves, or when many new starters arrive, refresh local steps and fit the training plan to the mix of skills on the roster.
Build A Review Calendar That People Can Use
A simple calendar beats a thick manual. Map one focus per month so the load spreads out and nothing gets missed. Keep each task small, timed, and linked to evidence you can show.
Tie the calendar to routine meetings. Drop five minute review slots into huddles and a deeper slot into a monthly safety meeting. Use the same template every time so people know what to bring.
Sample 12 Month Infection Control Review Calendar
| Month Or Window | Focus Area | Proof To Keep |
|---|---|---|
| Jan–Feb | Risk assessment, goals, plan | Risk tool, goal sheet, approvals |
| Mar | Hand hygiene and PPE fit | Observation logs, fit test list |
| Apr | Room and surface cleaning | Checklists, ATP logs if used |
| May | Device reprocessing | Scope logs, chemical checks |
| Jun | Sharps and BBP steps | Sharps audit, ECP sign off |
| Jul | Isolation and transport | Signage set, transport worksheet |
| Aug | Water safety basics | Temp logs, flushing records |
| Sep | Linen and waste flow | Vendor proof, route map |
| Oct | Construction and dust | Barriers, negative air checks |
| Nov | Outbreak drill | Tabletop notes, lessons learned |
| Dec | Program evaluation | Scorecard, next year draft |
Roles, Records, And Proof
Give clear owners. The infection prevention lead runs the cycle, unit leads own local steps, and a senior sponsor clears roadblocks. Name backups so the pace holds during leave or turnover.
Keep tidy proof. Minutes, sign offs, and dated copies show that the review really happened. Store checklists, photos of fixes, and short training rosters. Tag each file with a date and a link to the risk that drove the change.
Close the loop. When you fix a gap, add a measure and a date to check if the fix worked. Add the check to the calendar so it is not forgotten.
Scaling The Cadence For Different Settings
Small clinics can run with lean steps. Use a short risk tool, two or three priority goals, and a one page plan. Keep reviews tight: a short monthly huddle item and one deeper annual sweep.
Large hospitals need more layers. Blend a system wide plan with unit level calendars. Use dashboards so leaders can see which units are on track and which need help.
Long term care, dialysis, and ambulatory surgery centers can use the same backbone with topic tweaks. Tie the plan to device reprocessing, transport, and vendor work where those risks run highest.
Common Pitfalls That Delay Real Progress
- Treating the annual cycle as a paperwork chore. Fix by tying each update to the risk assessment and to a measurable goal.
- Waiting for the next meeting after an exposure. Fix by using a light rapid review within two days and logging the actions the same week.
- Updating a policy but skipping training or audits. Fix by pairing each change with a short brief, a huddle note, or a quick video, plus one check later to see if the change stuck.
- Letting devices or new services launch without a pre check. Fix by adding a go live checklist to the change process and naming who signs it.
- Running long lists that people cannot finish. Fix by picking fewer goals and using a steady monthly beat.
Audit Tools And Smart Shortcuts
Use standard checklists to speed the work. The CDC ICAR tool gives a wide view and helps spot gaps across settings. Local boards in many countries host board assurance tools you can adapt.
Simple data helps the review land. Track five or six metrics that link to your goals, like soap and sanitizer use, hand hygiene observations, cleaning hits and misses, device soak times, and post procedure infection counts.
Make change easy to see. Post one page visuals near sinks, clean rooms, sluices, and reprocessing areas. Short, clear cues beat thick binders in a busy unit.
Clear Takeaway
Run a yearly review for the whole infection control program and add fast checks when risks, laws, services, staff, or audits push you. Keep a simple calendar, keep proof, and keep fixes linked to real risks. That steady rhythm keeps people safe and keeps care moving.