Download Infection Prevention and Control Practices Complaint Protocol

Infection Prevention and Control Practices Complaint Protocol
Preamble
The Ontario Public Health Standards (OPHS) are published by the Minister of Health and Long-Term Care under the
authority of the Health Protection and Promotion Act (HPPA)1 to specify the mandatory health programs and services
provided by boards of health. Protocols are program and topic specific documents which provide direction on how boards
of health must operationalize specific requirement(s) identified within the OPHS. They are an important mechanism by
which greater standardization is achieved in the province-wide implementation of public health programs.
Protocols identify the minimum expectations for public health programs and services. Boards of health have the authority to
develop programs and services in excess of minimum requirements where required to address local needs. Boards of health
are accountable for implementing the standards including those protocols that are incorporated into the standards.
Purpose
This protocol has been developed to provide direction to boards of health with respect to reporting, investigating and
responding to infection prevention and control complaints.
Processes for complaints regarding health hazards related to occupational or environmental health are addressed in the
Identification, Investigation, and Management of Health Hazards Protocol, 2008 (or as current) under the Health
Hazards Prevention and Management Standard.
For complaints specific to personal services settings, please refer to the Infection Prevention and Control in Personal
Services Settings Protocol, 2008 (or as current).
Reference to the Standards
The table below identifies the OPHS standard and requirements to which this protocol relates.
Standard
Requirement
Infectious
Diseases
Prevention
and Control
Requirement #9: The board of health shall ensure that the medical officer of health or designate receives
reports of complaints regarding infection prevention and control practices and responds and/or refers to
appropriate regulatory bodies in accordance with applicable provincial legislation and in accordance with
the Infection Prevention and Control Practices Complaint Protocol, 2008 (or as current).
Requirement #10: The board of health shall ensure that the medical officer of health or designate receives
reports of and responds to complaints regarding infection prevention and control practices in settings for
which no regulatory bodies exist, particularly personal services settings. This shall be done in accordance
with the Infection Prevention and Control in Personal Services Settings Protocol, 2008 (or as current)
and the Infection Prevention and Control Practices Complaint Protocol, 2008 (or as current).
Infection Prevention and Control Practices Complaint Protocol
Operational Roles and Responsibilities
1) General
a) The board of health shall have an on-call system for receiving and responding to infection prevention and control
practices complaints on a 24 hours per day, 7 days per week (24/7) basis.
b) The board of health shall develop and maintain written policies and procedures for responding to infection prevention
and control practices complaints. The policies and procedures shall address but are not limited to:
i) Steps for managing a complaint investigation;
ii) Interagency cooperation as required;
iii) Communication with institutions/facilities, temporary dwellings, agencies, regulatory bodies, other settings where
complaints have arisen; and the public as applicable; and
iv) Processes and timelines for referral to regulatory bodies.
2) Responding to complaints regarding infection prevention and control practices in settings or involving health professionals
governed by a regulatory body
a) The board of health shall initiate response to all complaints within 24 hours to determine the risk of communicable
disease transmission, and the appropriate board of health response.
b) If the complaint concerns the conduct of a member of a regulated health profession, for example, a physician, nurse or
chiropractor, the board of health shall consider the complaint and determine, given the information available, whether
a communicable disease is or may be linked to the conduct of the regulated health professional. The board of health
shall, in that event, consider the following:
i) Contacting the regulatory body directly and provide it with any relevant information about the member and
the reported non-adherence to infection prevention and control practice and the link or possible link to a
communicable disease for follow up by the regulatory body;
ii) Providing information to the complainant about how to contact the regulatory body himself or herself; or
iii) Beginning an investigation into the incident involving the member and the complainant from a public health
perspective, in collaboration with the regulatory body.
c) The board of health shall initiate an investigation within 24 hours if a review of communicable disease surveillance
data available to the board indicates that a case of a communicable disease is or may be connected to the setting
named in the complaint.
d) The board of health shall take action based on the findings of its assessment, up to and including issuing orders under
the HPPA.1
e) The board of health shall maintain a record of all complaints received and any investigation and/or referral action
undertaken.
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Infection Prevention and Control Practices Complaint Protocol
3) Responding to complaints regarding infection prevention and control practices in settings or against individuals for which
no health regulatory body exists, including but not limited to: schools, recreational facilities, community centres, and
sports clubs
a) The board of health shall initiate response to all complaints within 24 hours to determine the risk of communicable
disease transmission and initiate an appropriate board of health response.
b) In assessing the complaint, the board of health shall focus on the risk relaed to a potential breach in infection
prevention and control practices in the setting named in the complaint.
i) The assessment of the complaint shall include but not be limited to:
• Visiting the setting named in the complaint;
• Interviewing staff of the setting directly involved in the practice under assessment;
• Determining whether previous complaints or concerns have been reported to the operator and what actions
if any were taken;
• Observing infection prevention and control practices; and
• Reviewing relevant documentation, which includes policies, procedures, records, and logs
(e.g., sterilization practices).
ii) Information obtained during the assessment shall be evaluated on:
• The extent to which routine infection prevention and control practices have been implemented/adhered to;
• The implementation of appropriate precautions where applicable; and
• Adherence to best practices for cleaning, disinfection, and sterilization practices in the setting named
in the complaint.
c) The board of health shall initiate an investigation if its assessment indicates a risk of communicable disease
transmission in the setting named in the complaint. This shall include:
ISBN: 978-1-4249-7590-7 Oct/08 © Queen’s Printer for Ontario
i) Recommending the implementation of appropriate infection prevention and control procedures in
accordance with current best practices;
ii) Providing education to ensure adherence to current best practices;
iii) Scheduling re-inspection to ensure adherence to current infection prevention and control practices;
iv) Engaging in formal look-back case-finding studies where initial investigations raise concerns about an infectious
disease outbreak related to improper infection prevention and control practices;
v) Developing a risk-communication strategy for notification of identified cases;
vi) Ordering corrective action based on the findings of the investigation, up to and including having the medical
officer of health or public health inspector issuing written orders under the HPPA1; and
vii) Advising the party under investigation of his/her responsibility to take corrective action and the consequences
of failing to do so.
d) The board of health shall maintain a record of all complaints received and response activities undertaken.
References
1. Health Protection and Promotion Act, R.S.O. 1990, c. H.7.
Available from http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm.
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