Infection Control Committee Roles and Functions

Infection prevention and control (IPC) is a fundamental component of healthcare quality and patient safety. The infection control committee provides oversight and governance for an organization's infection prevention program. CPHQ candidates should understand the committee's structure, functions, and regulatory requirements.

Committee Structure and Membership

The infection control committee is a multidisciplinary body that typically includes an infection preventionist (IP), a hospital epidemiologist (often a physician with infectious disease expertise), nursing leadership, pharmacy representation, laboratory services, operating room representation, environmental services, administration, and quality/patient safety leadership. The committee should have sufficient authority to implement infection prevention measures and should report to the medical executive committee or the governing body. CMS Conditions of Participation require that hospitals maintain an active infection prevention and control program.

Core Functions

The infection control committee performs several essential functions. Surveillance involves systematic collection, analysis, and interpretation of healthcare-associated infection (HAI) data using standardized definitions (typically CDC/NHSN definitions). Prevention includes developing and implementing evidence-based infection prevention policies and procedures, such as hand hygiene programs, isolation precautions, environmental cleaning protocols, and care bundles. Outbreak investigation and management involves identifying clusters of infections, conducting epidemiological investigations, and implementing containment measures. Education includes training staff on infection prevention practices, hand hygiene, and proper use of personal protective equipment.

Surveillance and Reporting

The committee oversees HAI surveillance, which includes tracking device-associated infections (CLABSI, CAUTI, VAE), surgical site infections, Clostridioides difficile infections, multidrug-resistant organism (MDRO) infections, and other infections as determined by organizational risk assessment. Data is reported using standardized infection ratios (SIRs) that compare observed infections to expected infections based on national benchmarks. Many states require mandatory public reporting of HAI data, and CMS requires participation in the NHSN for quality reporting programs.

Policy and Procedure Oversight

The committee develops, reviews, and approves infection prevention policies and procedures. Key areas include standard and transmission-based isolation precautions, hand hygiene protocols, antimicrobial stewardship (in collaboration with the antimicrobial stewardship committee), environmental cleaning and disinfection standards, construction and renovation infection risk assessment, employee health infection-related policies (such as immunization requirements and exposure management), and reprocessing of medical devices and equipment.

Regulatory Requirements

Multiple regulatory and accrediting bodies set expectations for infection prevention programs. CMS requires an infection prevention program with a designated infection preventionist. The Joint Commission includes infection prevention standards in its accreditation requirements. OSHA regulates bloodborne pathogen exposure prevention and employee safety. State health departments may have additional reporting and program requirements. The infection control committee must ensure compliance with all applicable standards while advancing evidence-based prevention practices. Quality professionals should collaborate closely with infection prevention colleagues, as HAI prevention is a shared priority for both programs.