Icc Meeting Agenda

‫المملكة العربية السعودية‬
Kingdom Saudi Arabia ‫وزارة الصحة‬

Ministry of Health ‫المديرية العامة للشئون الصحية بمنطقة‬
General Directorate of Health Affairs, Najran ‫نجران‬
‫مستشفى الملك خالد‬
King Khalid Hospital ‫قسم مكافحة العدوى‬
Infection Control Department
INVITATION AND AGENDA
TO: INFECTION CONTROL COMMITTEE MEMBERS

(See Distribution List Attached)
FROM: COMMITTEE CHAIRMAN
SUBJECT: INFECTION CONTROL COMMITTEE MEETING

___________________________________________________________________________
I would like to inform you that meeting for the Infection Control Committee will be scheduled on:
Date: 17.09.1432 / 17.08.2011
Day: Wednesday
Location: TQM Conference Room
Time: 11:00 am
All members are requested to punctually attend.
AGENDA:
Agenda Item Presented By: Time Allotment
1. Matters arising from the previous minutes Infection Prevention & 10 minutes
Control Director
1. New Agenda : Infection Prevention & 10 minutes
2.1 Discussion of Healthcare Associated Control Director
Infections Surveillance Data , Shaban
1432
2.2.Discussion of Hand Hygiene Infection Prevention & 10 minutes
Compliance Report, Shaban 1432 Control Director
2.2 Preparation for JCI Mock Survey. Infection Prevention & 10 minutes
Control Director
2.3 Physical Fitness Report for non KKH Infection Prevention & 10 minutes
Staff. Control Director
2.4 Availability of Infection Control site on Infection Prevention & 10 minutes
KKH website Control Director
DR. M. P. DIVAKARAN
MEDICAL DIRECTOR
CHAIRMAN – INFECTION PREVENTION & CONTROL COMMITTEE

17.11.1432 / 16.10.2011

___________________________________________________________________________
Date: 18.11.1432 / 16.10.2011
Day: Sunday
Location: TQM Conference Room (Near to New ICU)
Time: 11:00 am
AGENDA:
Control Director
2. Discussion of Healthcare Associated Infection Prevention & 10 minutes
Infections Surveillance Data , Shawwal Control Director
1432
3. Discussion of Hand Hygiene Infection Prevention & 10 minutes

Compliance Report, September 2011 Control Director
4. Discussion of JCI Mock Survey Feedback Infection Prevention & 10 minutes
Control Director
5. Use of Colistin inhalation for Dr. Mohd Arshad 10 minutes
Management of Multidrug Resistant Chest Physician
(MDR) Colonization
6. Antimicrobial Stewardship Program and Infection Prevention & 10 minutes
Campaign Control Director
DR. M. P DIVAKARAN
MEDICAL DIRECTOR
CO-CHAIRMAN - COMMITTEE CHAIRMAN
AD-LD-002 (1) Form 10


14.10.1432 / 12.09.2011

___________________________________________________________________________
Date: 16.10.1432 / 14.09.2011
Day: Monday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data , Ramadan Control Director
1432

Compliance Report, August 2011 Control Director
4. Discussion of Trainees Orientation Infection Prevention & 10 minutes
Control Director
5. Shortage Supply of Hamper Bag Infection Prevention & 10 minutes
Control Director
6. Miscellaneous Infection Prevention & 10 minutes
Control Director
DR. M. P DIVAKARAN
MEDICAL DIRECTOR
AD-LD-002 (1) Form 10


12.03.1433 / 04.02.2012

___________________________________________________________________________
Date: 13.03.1433 / 05.02.2012
Day: Sunday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data , Safar Control Director
1433
Compliance Report, January 2012 Control Director
4. Discussion of Sharp Injuries Measure or Infection Prevention & 10 minutes
Indicator for Performance Improvement. Control Director
5. Arrangement for opening of CSSD Infection Prevention & 10 minutes
Control Director
6. Implementation of MRSA Decolonization Infection Prevention & 10 minutes
for all cases admitted to High Risk Areas. Control Director
DR. M. P DIVAKARAN
MEDICAL DIRECTOR
AD-LD-002 (1) Form 10


14.04.1433 / 07.03.2012

___________________________________________________________________________
Date: 18.04.1433 / 11.03.2012
Day: Sunday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data , R. Awal Control Director
1433
Compliance Report, February, 2012 Control Director
4. Feedback Report of AGI Mock Survey Infection Prevention & 20 minutes
Control Director
5. Preparation for Celebration with Infection Prevention & 10 minutes
International Hand Hygiene Day, 5th May, Control Director
2012
DR. M. P DIVAKARAN
MEDICAL DIRECTOR

10.05.1433 / 02.04.2012

___________________________________________________________________________
Date: 11.05.1433 / 03.04.2012
Day: Tuesday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data , R. Thani Control Director
1433
Compliance Report, March, 2012 Control Director
4. Announcement of Symposium in Prevention Infection Prevention & 10 minutes
& Control of Intensive Care Associated Control Director
Infections, "Fundamental for Safe
Critical Care"
5. Discussion of Long Term Cases in ICU Infection Prevention & 10 minutes
Control Director
Control Director
DR. M. P DIVAKARAN
MEDICAL DIRECTOR

09.06.1433 / 30.04.2012

___________________________________________________________________________
Date: 10.06.1433 / 01.05.2012
Day: Tuesday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data, J. Awal Control Director
1433
Compliance Report, April, 2012 Control Director
4. Preparation of Global Hand Hygiene Day Infection Prevention & 10 minutes
Celebration on 5th May, 2012 Control Director
5. Finishing the Reconstruction of 8 Negative Infection Prevention & 10 minutes
Pressure Rooms (ICU, M1, M2, ER) Control Director
6. CSSD Staff Training & Education Infection Prevention & 10 minutes
Control Director
DR. M. P DIVAKARAN
MEDICAL DIRECTOR

06.06.1433 / 27.05.2012

___________________________________________________________________________
Date: 08.07.1433 / 29.05.2012
Day: Tuesday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data, J. Thani Control Director
1433 / May, 2012
Compliance Report, May, 2012 Control Director
4. 6 Monthly Tracking Report for Risk Infection Prevention & 10 minutes
Assessment & Risk Assessment Action Plan Control Director
1433 / 2012
5. Arrangement for the Second Annual KKH Infection Prevention & 10 minutes
Hand Hygiene Campaign Control Director
6. Approval of MOH on Reconstruction of Infection Prevention & 10 minutes
Another 16 Negative Isolation Pressure Control Director
Rooms
7. Introduction of New Antimicrobial Catheter Infection Prevention & 10 minutes
Lock Solution (TauroLock) Control Director
DR. M. P DIVAKARAN
MEDICAL DIRECTOR

19.08.1433 / 09.07.2012

___________________________________________________________________________
Date: 20.08.1433 / 10.07.2012
Day: Tuesday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data, Rajab Control Director
1433 / June, 2012
Compliance Report, June, 2012 Control Director
4. Feedback of JCI Final Survey Infection Prevention & 10 minutes
Control Director
Control Director
DR. HASSAN AL GHAMDI

MEDICAL DIRECTOR
21.12.1433 / 06.11.2012

___________________________________________________________________________
Date: 22.12.1433 / 07.11.2012
Day: Wednesday
Location: QPS Conference Room (Near to New ICU)
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data, Dhul Qadah Control Director
1433 / October, 2012
Compliance Report, October, 2012 Control Director
4. Unavailability of Mupirocin (Bactroban) Infection Prevention & 10 minutes
Indicated for MRSA Decolonization. Control Director
5. Increase number of Needle Stick Injury Infection Prevention & 10 minutes

Rate among Healthcare Workers Control Director
6. Feedback of Hand Hygiene Campaign Infection Prevention & 10 minutes

directed and targeted to ICU Visitors Control Director
DR. IBRAHEM SAHEM HAMEEM

MEDICAL DIRECTOR
CO-CHAIRMAN – INFECTION CONTROL COMMITTEE
24.01.1434 / 08.12.2012

___________________________________________________________________________
Date: 25.01.1434 / 09.12.2012
Day: Sunday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data, Dhul Hajj Control Director
1433 / Nov. 2012 & & Yearly HAI’s Trend, 1433
Compliance Report, November, 2012 Control Director
4. Discussion of Endemic Rate of Healthcare Infection Prevention & 10 minutes
Associated Infections over the year 1433 Control Director
5. Approval of KKH Education Plan 1434 Infection Prevention & 10 minutes

Control Director
6. Approval of Risk Assessment & Risk Infection Prevention & 10 minutes

Assessment Action Plan 1434 Control Director

Control Director
DR. IBRAHEM SALEH HAMEEM

MEDICAL DIRECTOR
18.02.1434 / 31.12.2012

___________________________________________________________________________
Date: 19.02.1434 / 01.01.2012
Day: Tuesday
Time: 2:00 pm
AGENDA:
Control Director
Infections Surveillance Data, Muharram Control Director
1434/Dec. 2012
3. Discussion of Hand Hygiene Compliance Infection Prevention & 10 minutes
Report, 2012 Control Director
4. Emerging of Pan Drug Resistant in ICU Infection Prevention & 10 minutes
Control Director
5. Discuss the Results of Finger Print Before Infection Prevention & 10 minutes
& After Scrubbing in OR Control Director
6. Discussion of Rusty Old Surgical Infection Prevention & 10 minutes

Instruments Control Director

MEDICAL DIRECTOR
16.03.1434 / 28.01.2013

___________________________________________________________________________
Date: 17.03.1434 / 29.01.2013
Day: Tuesday
Time: 2:00 pm
AGENDA:
1. Matters arising from the previous minutes Dr. Ibraheem Saleh Hammem 10 minutes
Medical Director
2. Discussion of Healthcare Associated Dr. Nahla Moustafa 10 minutes
Infections Surveillance Data, Safar Infection Prevention &
1434 / January, 2013 Control Director
3. Discussion of Hand Hygiene Compliance , Dr. Nahla Moustafa 10 minutes
January, 2013 Infection Prevention &
Control Director
4. Establishment of Electronic Medical Record Dr. Nahla Moustafa 10 minutes
Health File Infection Prevention &
Control Director
5. Electronic Monitoring System for Hand Dr. Nahla Moustafa 10 minutes
Hygiene Infection Prevention &
Control Director
6. Discussion of Antibiogram for the month of Dr. Venugopal Jayapal 10 minutes
Safar, 1434 Microbiologist

MEDICAL DIRECTOR
10.04.1434 / 20.02.2013
TO: PROJECT MEMBERS
SUBJECT: ERADICATION OF MULTIDRUG RESITANT ORGANISMS (MDRO) MEETING

___________________________________________________________________________
I would like to inform you that meeting for the Eradication of MDRO Project Committee will be
scheduled on:
Date: 10.04.1434 / 20.02.2013
Day: Wednesday
Time: 2:00 pm
AGENDA:
1. Clarify Current Knowledge of the Process Dr. Nahla Moustafa 15 minutes

Infection Prevention &
Control Director
2. Understand Process Variation & Capability Dr. Nahla Moustafa 15 minutes
Infection Prevention &
Control Director
3. Strategy on how to Eradicate Multidrug Dr. Nahla Moustafa 15 minutes
Resistant Organisms Infection Prevention &
Control Director
DR. NAHLA MOUSTAFA

INFECTION PREVENTION & CONTROL DIRECTOR
CHAIRMAN OF COMMITTEE
Cc: DR. ABDU AL ZOBYDI

Hospital Director
DR. IBRAHEEM SALEH HAMEEM

Medical Director
10.04.1434 / 20.02.2013
DISTRIBUTION LIST OF INVATATION
COMMITTEE: Eradication of MDRO Project Committee
Date: 10.04.1434 / 20.02.2013

Day: Wednesday
Time: 2:00 pm
Chairman: Dr. Nahla Moustafa (Infection Prevention & Control Director)
SN Name Position Signature
1. Dr. Nahla Moustafa PCI Director
2. Dr. Hassan Mohd ICU Consultant
3. Dr. M. P. Divakaran QPS Director
4. Ms. Fatma Yahya Majrashi Director of Nursing
5. Ms. Anacita Catherine ICU Charge Nurse
6. Ms. Remya Joseph IC Facilitator
7. Ms. Rosita Aromin IC Practitioner

15.04.1434 / 25.02.2013

___________________________________________________________________________
Date: 16.04.1434 / 26.02.2013
Day: Tuesday
Time: 2:00 pm
AGENDA:
Medical Director
Infections Surveillance Data, Rabi 1 PCI Director
1434 / February, 2013
February, 2013 PCI Director
4. Incomplete Filling of Notification Form Dr. Nahla Moustafa 10 minutes
PCI Director
5. Findings of Infection Control Dr. Nahla Moustafa 10 minutes
Environmental Rounds PCI Director
6. Eligibility of Sick Leave Report Issued by Dr. Ismael Mabrouk 10 minutes
Private Health Sector EHC Director

MEDICAL DIRECTOR
20.05.1434 / 01.04.2013

___________________________________________________________________________
Date: 21.05.1434 / 02.04.2013
Day: Tuesday
Time: 2:00 pm
AGENDA:
Medical Director
Infections Surveillance Data, Rabi 2 PCI Director
1434 / February, 2013
4. Continues Shortage of Medical Supply Dr. Nahla Moustafa 10 minutes
PCI Director
5. Misuse of Disinfectants in Organization Dr. Nahla Moustafa 10 minutes
PCI Director
6. Surveillance & Notification of Corona Dr. Nahla Moustafa 10 minutes
Virus PCI Director

MEDICAL DIRECTOR
19.06.1434 / 29.04.2013

___________________________________________________________________________
Date: 20.06.1434 / 30.04.2013
Day: Tuesday
Time: 2:00 pm
AGENDA:
Medical Director
2. Discussion of Healthcare Associated Dr. Ismail Mabrouk 10 minutes
Infections Surveillance Data, Jumada 1 Acting PCI Director
1434 / March, 2013
3. Discussion of Hand Hygiene Compliance , Dr. Ismail Mabrouk 10 minutes
March, 2013 Acting PCI Director
4. Recent Circular Related to Viral Dr. Ismail Mabrouk 10 minutes
Hemorrhagic Fever (VHF) Acting PCI Director
5. Infrequent Recurrent Failure of CSSD Dr. Ismail Mabrouk 10 minutes
Sterilization Process Acting PCI Director

MEDICAL DIRECTOR
17.08.1434 / 27.05.2013

___________________________________________________________________________
Date: 18.08.1434 / 28.05.2013
Day: Tuesday
Time: 2:00 pm
AGENDA:
Medical Director
Infections Surveillance Data, Jumada 2 PCI Director
1434 / April, 2013
April, 2013 PCI Director
4. Observed Findings of Hand Hygiene Dr. Nahla Moustafa 10 minutes
Campaign & Corrective Action PCI Director
5. Updated Memo of Novel Corona Virus Dr. Nahla Moustafa 10 minutes

PCI Director
6. Updated Antibiotic Policy According to Dr. Nahla Moustafa 10 minutes
Antibiogram PCI Director

MEDICAL DIRECTOR

14.08.1434 / 23.06.2013

___________________________________________________________________________
Date: 15.08.1434 / 24.06.2013
Day: Monday
Time: 2:00 pm
AGENDA:
Medical Director
Infections Surveillance Data, Rajab, PCI Director
1434 / May, 2013
May, 2013 PCI Director
4. Mixing of Clean & Infected Cases during Dr. Nahla Moustafa 10 minutes
Admission in Surgical Ward PCI Director
5. Shortage of Bedsheet all over the Dr. Nahla Moustafa 10 minutes

Organization PCI Director
6. Improper Storage of IV Fluids & Dr. Nahla Moustafa 10 minutes

Medications in Preparation Room. PCI Director
7. Coordination of number of Infection Dr. Nahla Moustafa 10 minutes

Control Trainees per month PCI Director

MEDICAL DIRECTOR

26.10.1434 / 02.09.2013

___________________________________________________________________________
Date: 27.10.1434 / 03.09.2013
Day: Tuesday
Location: QPS Conference Room (Near to M4)
Time: 11:00 am
AGENDA:
Medical Director
Infections Surveillance Data, Ramadan, PCI Director
1434 / July, 2013
July, 2013 PCI Director
4. Presentation of CSSD Extension Dr. Nahla Moustafa 10 minutes
PCI Director
5. Discussion of Electronic system for Dr. Nahla Moustafa 10 minutes

Reporting of Communicable Disease PCI Director

MEDICAL DIRECTOR

20.11.1434 / 26.09.2013

___________________________________________________________________________
Date: 23.11.1434 / 29.09.2013
Day: Sunday
Time: 2:00 pm
AGENDA:
Medical Director
2. Discussion of Healthcare Associated Dr. Ismael Mabrouk 10 minutes

Infections Surveillance Data, Shawwal, Acting PCI Director
1434 / August, 2013
3. Discussion of Hand Hygiene Compliance , Dr. Ismael Mabrouk 10 minutes
August, 2013 Acting PCI Director
4. Guidelines for Disinfection process of Dr. Ismael Mabrouk 10 minutes
Water Treatment Plant in AKU Acting PCI Director

MEDICAL DIRECTOR

29.12.1434 / 03.10.2013

___________________________________________________________________________
Date: 01.01.1435 / 04.10.2013
Day: Monday
Time: 2:00 pm
AGENDA:
1. Matters arising from the previous minutes Dr. Ragheb A. El Salam 10 minutes
Acting Medical Director
2. Discussion of Healthcare Associated Dr. Ismael Mabrouk 10 minutes

Infections Surveillance Data, Dhul - Qadah, Acting PCI Director
1434 / September, 2013
3. Discussion of Hand Hygiene Compliance , Dr. Ismael Mabrouk 10 minutes
September, 2013 Acting PCI Director
4. Suspected Viral Hemorrhagic Fever Dr. Ismael Mabrouk 10 minutes
Outbreak Documentation Acting PCI Director
5. Increased Trend of Surgical Site Infection Dr. Raouf Abdel Baky 10 minutes
Chief of Surgery
DR. ADEL RAGHEB ABD EL SALAM

ACTING MEDICAL DIRECTOR

29.01.1435 / 02.12.2013

___________________________________________________________________________
Date: 30.01.1435 / 03.12.2013
Day: Tuesday
Time: 11:00 am
AGENDA:
1. Matters arising from the previous minutes Dr. Hassan Al Ghamdi 05 minutes
Asst. General Supervisor
for Medical Affairs
Infections Surveillance Data, D- Hajj, 1434/Oct. PCI Director
2013 & Hand Hygiene Compliance, October, 2013
3. Presentation of Endemic Rate of Healthcare Dr. Nahla Moustafa 05 minutes
Associated Infections (HAI’S), 1434 PCI Director
4. Trend of Compliance with Implementation of Dr. Nahla Moustafa 10 minutes
Infection Prevention Bundle, 1434 PCI Director
5. Approval of PCI Education Plan, 1435 Dr. Nahla Moustafa 10 minutes
PCI Director
6. Approval of Risk Assessment & Risk Dr. Nahla Moustafa 10 minutes
Assessment Action Plan, 1435 PCI Director
7. Approval of Infection Control Budget, 1435 Dr. Nahla Moustafa 05 minutes
PCI Director
8. Trend of Needle Sharp Injuries, 1434 Dr. Ismail Mabrouk 10 minutes
EHC Director
9. Tracing of Suspected Viral Hemorrhagic Fever Dr. Nahla Moustafa 10 minutes
Cases PCI Director
10. Colistin Prescription Without Culture & Dr. Nahla Moustafa 10 minutes
Sensitivity PCI Director

MEDICAL DIRECTOR
26.02.1435 / 29.12.2013

___________________________________________________________________________
Date: 28.02.1435 / 31.12.2013
Day: Tuesday
Time: 11:00 am
AGENDA:
Medical Director

Infections Surveillance Data, Moharram, PCI Director
1435 / Nov. 2013
November, 2013 PCI Director
4. Presentation of CBAHI Reaccreditation Dr. Nahla Moustafa 10 minutes
Standard Allocation Plan PCI Director
5. VHF Outbreak Executive Summary Dr. Nahla Moustafa 10 minutes

PCI Director
6. Infection Control Operational Plan for the Dr. Nahla Moustafa 10 minutes
Year 2014 PCI Director
7. Presentation of Research Related to Dr. Nahla Moustafa 10 minutes

Infection Control PCI Director

MEDICAL DIRECTOR

25.03.1435 / 26.01.2014

___________________________________________________________________________
Date: 27.03.1435 / 28.01.2014
Day: Tuesday
Time: 2:00 pm
AGENDA:
Medical Director

Infections Surveillance Data, Safar, PCI Director
1435 / December, 2013
December, 2013 PCI Director
4. Feedback of CBAHI Reaccreditation Team Dr. Nahla Moustafa 10 minutes
Meeting PCI Director
5. Extension Project for CSSD Dr. Nahla Moustafa 10 minutes

PCI Director

ASSISTANT GENERAL SUPERVISOR FOR MEDICAL AFFAIRS
17.04.1435 / 17.02.2014

___________________________________________________________________________
Date: 18.04.1435 / 18.02.2014
Day: Tuesday
Time:11:00 am
AGENDA:
Asst. General Supervisor for
Medical Affairs
Infections Surveillance Data, R. Awal, PCI Director
1435 / January, 2014
3. Discussion of Hand Hygiene Compliance, Dr. Nahla Moustafa 10 minutes
January, 2014 PCI Director
4. CBAHI Accreditation Meeting Feedback Dr. Nahla Moustafa 10 minutes
PCI Director
5. Discuss the Result of Environmental Dr. Nahla Moustafa 10 minutes

Cultures in Burn Unit PCI Director
6. Introduction of New Surface Disinfectant & Dr. Nahla Moustafa 10 minutes

Surgical Hands Scrub PCI Director


24.05.1435 / 25.03.2014

___________________________________________________________________________
Date: 25.05.1435 / 26.03.2014
Day: Wednesday
Time:2:00 pm
AGENDA:
Medical Affairs
Infections Surveillance Data, R. Thani, PCI Director
1435 / February, 2014
3. Discussion of Hand Hygiene Compliance, Dr. Nahla Moustafa 10 minutes
4. Summary Execution Report of Food Dr. Nahla Moustafa 10 minutes
Poisoning Outbreak PCI Director
5. Traffic Control in ER Dr. Nahla Moustafa 10 minutes

PCI Director
6. Non – Compliance with Reporting of Dr. Nahla Moustafa 10 minutes

Communicable Disease Policy PCI Director


22.06.1435 / 22.04.2014

___________________________________________________________________________
Date: 23.06.1435 / 23.04.2014
Day: Wednesday
Time: 2:00 pm
AGENDA:
Medical Affairs
2. Discussion of Healthcare Associated Evangelina Ubalde 10 minutes
Infections Surveillance Data, J. Awal, Infection Control Practitioner
1435 / March, 2014
3. Discussion of Hand Hygiene Compliance, Rosita Aromin 10 minutes
March, 2014 Infection Control Practitioner
4. Preparation for Celebration of International Dr. Nahla Moustafa 10 minutes
Hand Hygiene Day, 2014 PCI Director
5. Feedback of Monitoring Performance of Dr. Nahla Moustafa 10 minutes

Reconstruction Project within the PCI Director
Organization
6. Assessment of Infection Control Supply Dr. Nahla Moustafa 10 minutes
Required for the Next Half Year PCI Director
7. Approval of Cleaning Schedule Prepared by Dr. Nahla Moustafa 10 minutes

Housekeeping Department PCI Director

29.07.1435 / 28.05.2014


___________________________________________________________________________
Date: 30.07.1435 / 29.05.2014
Day: Thursday
Time: 11:00 am
AGENDA:
Medical Affairs
Infections Surveillance Data, J. Thani, Infection Control Practitioner
1435 / April, 2014
April, 2014 Infection Control Practitioner
4. Updated Guidelines for MERS-CoV Dr. Nahla Moustafa 10 minutes
PCI Director
5. Preparation of Separate Isolation Wards for Dr. Nahla Moustafa 10 minutes

MERS-CoV PCI Director
6. Rearrange of ER Triage Dr. Nahla Moustafa 10 minutes

PCI Director
7. Corrective Action for Partially Met Dr. Nahla Moustafa 10 minutes

Standards in CBAHI Reaccreditation PCI Director

25.08.1435 / 23.06.2014


___________________________________________________________________________
Date: 26.08.1435 / 24.06.2014
Day: Tuesday
Time:2:00 pm
AGENDA:
Medical Affairs
Infections Surveillance Data, Rajab, Infection Control Practitioner
1435 / May, 2014
May, 2014 Infection Control Practitioner
4. Activation of Hand Hygiene Electronic Dr. Nahla Moustafa 10 minutes
Monitoring System PCI Director
5. Infection Control Environmental Rounds Dr. Nahla Moustafa 10 minutes

Feedback PCI Director

21.10.1435 / 17.08.2014


___________________________________________________________________________
Date: 22.10.1435 / 18.08.2014
Day: Monday
Time:2:00 pm
AGENDA:
Medical Affairs
Infections Surveillance Data, Ramadan, Infection Control Practitioner
1435 /July, 2014
July, 2014 Infection Control Practitioner
4. Opening of Respiratory Fit Test Clinic Dr. Nahla Moustafa 10 minutes
PCI Director
5. Availability of 6 Fit Test Kit Dr. Nahla Moustafa 10 minutes

PCI Director
6. Feedback of Electronic Monitoring Hand Dr. Nahla Moustafa 10 minutes

Hygiene System PCI Director
7. New Environmental Infection Control Dr. Nahla Moustafa 10 minutes

Supply PCI Director

19.11.1435 / 14.09.2014


___________________________________________________________________________
Date: 20.11.1435 / 15.09.2014
Day: Monday
Time:2:00 pm
AGENDA:
Medical Affairs
Infections Surveillance Data, Shawwal, Infection Control Practitioner
1435 / August, 2014
August, 2014 Infection Control Practitioner
4. Final Report of MOH Inspection Team Dr. Nahla Moustafa 10 minutes
PCI Director
5. Feedback of Training of South Region on Dr. Nahla Moustafa 10 minutes

Fit Testing PCI Director
6. KKH Educational Program on Respiratory Dr. Nahla Moustafa 10 minutes

Protection & Respiratory Fit Test PCI Director
7. Approval of Work Permit for Reconstruction Dr. Nahla Moustafa 10 minutes

of Negative Pressure Isolation Room PCI Director

18.12.1435 / 12.10.2014


___________________________________________________________________________
Date: 19.12.1435 / 13.10.2014
Day: Monday
Time:2:00 pm
AGENDA:
Medical Affairs
Infections Surveillance Data, Dhul-Qadah, Infection Control Practitioner
September, 2014 Infection Control Practitioner
4. Misused of Colistin Dr. Nahla Moustafa 10 minutes
PCI Director
5. Delayed MERS-CoV Notification Dr. Nahla Moustafa 10 minutes
PCI Director
6. Improper following of MERS-CoV Case Dr. Nahla Moustafa 10 minutes
Definition PCI Director
7. Need for more Negative Pressure Dr. Nahla Moustafa 05 minutes
Isolation Room in ER PCI Director
8. Availability of Negative Pressure Dr. Nahla Moustafa 05 minutes
Isolation Room in Female Wards PCI Director

23.01.1436 / 16.11.2014


___________________________________________________________________________
Date: 24.01.1436 / 17.11.2014
Day: Monday
Time:2:00 pm
AGENDA:
Agenda Item Presented By: Time
Allotment
Medical Affairs
Infections Surveillance Data, Dhul Hajj Infection Control Practitioner
1435 / Oct. 2014 & & Yearly HAI’s Trend, 1435
October, 2014 Infection Control Practitioner
4. Presentation of Endemic Rate of Healthcare Dr. Anjum Hashmi 10 minutes
Associated Infections (HAI’S), 1435 Infection Control Specialist
5. Trend of Compliance with Implementation of Dr. Anjum Hashmi 5 minutes
Infection Prevention Bundle, 1435 Infection Control Specialist
6. Approval of PCI Education Plan, 1436 Dr. Nahla Moustafa 5 minutes
PCI Director
7. Approval of Infection Control Budget, 1436 Dr. Nahla Moustafa 5 minutes
PCI Director
8. Trend of Needle Sharp Injuries, 1435 Dr. Safiya Abdelhaleem 5 minutes
EHC Director
9. Fit Test Coverage Rate for KKH Staff / 1435 Dr. Nahla Moustafa 5 minutes
PCI Director
10. Receiving of Chemotherapy Preparation Dr. Nahla Moustafa 10 minutes
Room PCI Director
11. Problems arise with SRACO Company Dr. Nahla Moustafa 10 minutes
PCI Director

22.02.1436 / 14.12.2014


___________________________________________________________________________
Date: 23.02.1436 / 15.12.2014
Day: Monday
Time:2:00 pm
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data, Muharram Infection Control Practitioner
1436 / Nov. 2014
November, 2014 Infection Control Practitioner
4. Approval of Updated Infection Prevention Dr. Nahla Moustafa 10 minutes
& Control Manual Fourth Edition PCI Director
5. Update the Hand Hygiene Electronic Dr. Nahla Moustafa 10 minutes
Monitoring System PCI Director
6. Request for Ebola PPE Supplies & Dr. Anjum Hashmi 10 minutes
Preparation for Internal Ebola Drill Infection Control Specialist
7. Introduction of Safety Syringes Dr. Nahla Moustafa 5 minutes
PCI Director
8. Hospital Employees Facilitating the Dr. Nahla Moustafa 10 minutes
Relatives for Visitation in ICU PCI Director
9. Request for Negative Pressure Isolation Dr. Nahla Moustafa 5 minutes
Room in ER PCI Director
10. Availability of Negative Pressure Isolation Dr. Nahla Moustafa 5 minutes
Room in Female Wards PCI Director

22.03.1436 / 13.01.2015


___________________________________________________________________________
Date: 23.03.1436 / 14.01.2015
Day: Wednesday
Time:2:00 pm
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data, Safar Infection Control Practitioner
1436 / Dec. 2014
December & Yearly Hand Hygiene Infection Control Practitioner
Trend / 2014
4. Establishment of KKH Antimicrobial Dr. Nahla Moustafa 10 minutes
Stewardship Program PCI Director
5. Fit Testing for New Staff & Missed Staff Dr. Anjum Hashmi 10 minutes
Infection Control Specialist
6. Patient & Family Infection Prevention & Dr. Nahla Moustafa 10 minutes
Control Educational Plan / 2015 PCI Director

17.05.1436 / 08.03.2015


___________________________________________________________________________
Date:18.05.1436 / 09.03.2015
Day: Monday
Time:2:00 pm
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data and Hand Infection Control Practitioner
Hygiene Compliance Rabi 2, 1436 / Feb. 2015
3. Feedback from MOH Team last Wednesday Rosita Aromin 10 minutes
15.05.1436 Infection Control Practitioner
4. Update for Respiratory Fit Test Coverage Dr. Nahla Moustafa 10 minutes
Rate. PCI Director
5. Infection Control Symposium Accredited Dr. Nahla Moustafa 5 minutes
from Saudi Council PCI Director
6. Issue Electronic Infection Control Manual Dr. Nahla Moustafa 5 minutes
PCI Director
7. Organize Environmental Cleaning - Rapid Dr. Nahla Moustafa 10 minutes
Response Team (RRT) PCI Director

25.06.1436 / 14.04.2015


___________________________________________________________________________
Date: 26.06.1436 / 15.04.2015
Day: Wednesday
Time:2:00 pm
AGENDA:
Allotment
Medical Affairs
2. Discussion of Healthcare Associated Rose Aromin 10 minutes
Infections Surveillance Data and Hand Infection Control
Hygiene Compliance Jumada 2, 1436 / Mar. 2015 Practitioner
3. Re-training of Assigned Staff on Nasopharyngeal Dr. Anjum Hashmi 10 minutes
Swabbing Technique Infection Control Specialist
4. Introduce Containment Stretcher (Negative Dr. Nahla Moustafa 10 minutes
Pressure Isolation Cell) for MERS-CoV & EVD PCI Director
Transportation
5. MOH Stop Supplying the N95 (3M – cap shape) Dr. Nahla Moustafa 10 minutes
PCI Director
6. Summary Execution Report of Food Poisoning Dr. Nahla Moustafa 10 minutes
Outbreak PCI Director

25.06.1436 / 14.04.2015


___________________________________________________________________________
Date: 26.06.1436 / 15.04.2015
Day: Wednesday
Time:2:00 pm
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data, Jumada 1, Infection Control Practitioner
1436 / Jan. 2014
January, 2015 Infection Control Practitioner
4. Feedback of MOH Visitors in ER & ICU Dr. Nahla Moustafa 10 minutes

and Command & Control Center PCI Director
5. Release of Microbiological Results without Dr. Nahla Moustafa 10 minutes
Specific Organisms PCI Director

14.07.1436 / 03.05.2015


___________________________________________________________________________
Date: 15.07.1436 / 04.05.2015
Day: Monday
Time:2:00 pm
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data, Jumada 2, Infection Control Practitioner
1436 / April, 2015
3. Discussion of Hand Hygiene Compliance, Abdulrahman Essa 10 minutes
April, 2015 Infection Control Practitioner
4. Overcrowding at Visual Triage and Data Dr. Nahla Moustafa 10 minutes
Entry being done by Triage Nurse PCI Director
5. Laundry Problems in Supplying Clean Dr. Nahla Moustafa 10 minutes
Linens and Collection of Dirty Linens PCI Director
6. Improper Environmental Cleaning in Late Dr. Nahla Moustafa 10 minutes
and Night Shifts PCI Director

17.10.1436 / 02.08.2015


___________________________________________________________________________
Date: 18.10.1436 / 03.08.2015
Day: Monday
Time:2:00 pm
AGENDA:
Allotment
1. Matters arising from the previous Dr. Hassan Al Ghamdi 10 minutes
minutes Asst. General Supervisor for
Medical Affairs
Infections Surveillance Data, Ramadan, Infection Control Practitioner
1436 / July, 2015
3. Discussion of Hand Hygiene Compliance, Rose Aromin 10 minutes
July, 2015 Infection Control Practitioner
4. Non Compliance of Medical Waste Abdurahman Essa 10 minutes
Management Policy & Procedure Acting Infection Control Director
5. Shortage of Electric Power Supply in Abdurahman Essa 10 minutes

Negative Pressure Isolation Room in M4, Acting Infection Control Director
AKU & CCU

15.11.1436 / 30.08.2015


___________________________________________________________________________
Date: 16.11.1436 / 31.08.2015
Day: Monday
Time: 2:00 pm
AGENDA:
Allotment
1. Matters arising from the previous Dr. Talal Mohammed Al Shehri 10 minutes
Medical Affairs
2. Discussion of Healthcare Associated Abdurahman Essa 10 minutes
Infections Surveillance Data, Shawwal, Infection Control Practitioner
1436 / August, 2015
August, 2015 Infection Control Practitioner
4. Updated MERS-CoV Guidelines, June Dr. Nahla Moustafa 10 minutes
2015 PCI Director
5. Shortage of Medical Supplies Dr. Nahla Moustafa 10 minutes
PCI Director
6. Incomplete Filling of Notification Form Dr. Nahla Moustafa 10 minutes
PCI Director
DR. TALAL MOHAMMED AL SHEHRI

21.12.1436 / 04.09.2015


___________________________________________________________________________
Date: 22.12.1436 / 05.09.2015
Day: Monday
Time: 2:00 pm
AGENDA:
Allotment
Medical Affairs
2. Discussion of Healthcare Associated Abdurahman Essa 10 minutes
Infections Surveillance Data, D-Qadah, Infection Control Practitioner
4. No Coordination Between Project Manager & Dr. Nahla Moustafa 10 minutes
Infection Control During Reconstruction PCI Director
within the Organization
5. Introduction of New MERS-CoV PPE Kit Dr. Nahla Moustafa 10 minutes
PCI Director
6. Dr. Nahla Moustafa 5 minutes
PCI Director
7. Discuss the Result of Environmental Abdurahman Essa 10 minutes
Cultures in Cath. Lab. Infection Control Practitioner

26.01.1437 / 08.11.2015

___________________________________________________________________________
Date: 27.01.1437 / 09.11.2015
Day: Monday
Time: 2:00 pm
AGENDA:
Allotment
Medical Affairs
2. Presentation of Healthcare Associated Abdurahman Essa 10 minutes
Infections Surveillance Data, D-Hajj, Infection Control Practitioner
1436 & INICC Trend of HAI’s / 1436
4. Approval of PCI Educational Plan / 1437 Dr. Nahla Moustafa 05 minutes
PCI Director
5. Approval of Risk Assessment & Risk Dr. Nahla Moustafa 05 minutes
Assessment Action Plan / 1437 PCI Director
6. Request for more number of Negative Dr. Nahla Moustafa 05 minutes
Pressure Isolation Rooms for patient under PCI Director
Airborne precautions
7. Infection Control Annual Operational Dr. Nahla Moustafa 10 minutes
Plan / 1437 PCI Director
8. EPINET Trend of Sharp Injuries / 1436 Abdurahman Essa 05 minutes
Infection Control Practitioner
9. Approval of Infection Control Budget / 1437 Dr. Nahla Moustafa 05 minutes
PCI Director
10. Discussion of Antibiogram / 1436 Dr. Nahla Moustafa 05 minutes
PCI Director

24.02.1437 / 06.12.2015


___________________________________________________________________________
Date: 25.02.1437 / 07.12.2015
Day: Monday
Time: 2:00 pm
AGENDA:
Allotment
Medical Affairs
2. Presentation of Healthcare Associated Dr. Sherif Khorshid 10 minutes
Infections Surveillance Data, Muharam, Infection Control Specialist
1437 / Nov. 1436
3. Discussion of Hand Hygiene Rose Aromin 10 minutes
Compliance, October, 2015 Infection Control Practitioner
4. Updated Guidelines for Management of Dr. Nahla Moustafa 10 minutes
H1N1 PCI Director
5. Non Compliance of HVAC (Heater/ Dr. Nahla Moustafa 10 minutes
Ventilation/Air Condition/Circuit) PCI Director
Cleaning Schedule
6. Miscellaneous Dr. Sherif Khorshid 10 minutes

23.04.1437 / 02.02.2016


___________________________________________________________________________
Date: 24.04.1437 / 03.02.2016
Day: Wednesday
Time: 02:00pm
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data, Rabi 1, Infection Control Practitioner
1437 / Dec. 1436
3. Discussion of Hand Hygiene Rose Aromin 10 minutes
Compliance, December, 2015 Infection Control Practitioner
4. Zika Virus Update Dr. Sherif Khorshid 10 minutes
5. Power in Implementing Visitation Policy Dr. Nahla Moustafa 10 minutes
in Isolation Rooms PCI Director
6. Wound Culture for all Trauma Cases Dr. Nahla Moustafa 05 minutes
(Bomb Blast, RTA, Gunshot….) upon PCI Director
Admission

23.05.1437 / 03.03.2016

___________________________________________________________________________
Date: 27.05.1437 / 07.03.2016
Day: Monday
Time: 02:00pm
AGENDA:
Allotment
1. Matters arising from the previous minutes Dr. Talal Mohammed Al Shehri 10 minutes
Medical Affairs
Infections Surveillance Data, Rabi 2, 1437 / Infection Control Practitioner
January, 2016
January, 2016 & Yearly Hand Hygiene Infection Control Practitioner
Trend, 2015/1436
4. Presentation of Surveillance Care Bundle, Dr. Nahla Moustafa 05 minutes
Hospital Wide/January, 2016 & Trend of PCI Director
Bundle / 2015
5. Implementation of MDR Infection Dr. Nahla Moustafa 05 minutes
Prevention Bundle PCI Director
6. Preparation of MERS-CoV Drill Dr. Nahla Moustafa 05 minutes

PCI Director
7. Mixing of Culture & Sensitivity Results Dr. Nahla Moustafa 10 minutes
Released in Achieving System PCI Director
9. Incomplete Gathering of Patient Dr. Nahla Moustafa 05 minutes
Information from Admission Office PCI Director

25.06.1437 / 03.04.2016

___________________________________________________________________________
Date: 26.06.1437 / 04.04.2016
Day: Monday
Time: 02:00pm
AGENDA:
Allotment
1. Matters arising from the previous minutes Dr. Nahla Moustafa 05 minutes
Medical Affairs
Infections Surveillance Data, February, 2016 Infection Control Practitioner

February, 2016 Infection Control Practitioner
4. Preparation of CBAHI Reaccreditation Abdurahman Essa 10 minutes

5. Discussion of Quarterly Antibiogram Report Dr. Syed Mujeeb 10 minutes
(Month 1 to 3, 2016) Microbiologist
6. Delayed Releasing of Culture & Sensitivity Abdurahman Essa 10 minutes

Results Infection Control Practitioner
DR. NAHLA MOUSTAFA

25.06.1437 / 03.04.2016


___________________________________________________________________________
Date: 26.06.1437 / 04.04.2016
Day: Monday
Time: 02:00pm
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data, February, 2016 Infection Control Practitioner
February, 2016 Infection Control Practitioner
4. Preparation of CBAHI Reaccreditation Abdurahman Essa 10 minutes

5. Discussion of Quarterly Antibiogram Report Dr. Syed Mujeeb 10 minutes
(Month 1 to 3, 2016) Microbiologist
6. Delayed Releasing of Culture & Sensitivity Abdurahman Essa 10 minutes

Results Infection Control Practitioner
DR. NAHLA MOUSTAFA

02.08.1437 / 09.05.2016


___________________________________________________________________________
Date: 03.08.1437 /10.05.2016
Day: Tuesday
Time: 11:00am
AGENDA:
Allotment
Medical Affairs
Infections Surveillance Data, March, 2016 Infection Control Practitioner
3. Discussion of Hand Hygiene Compliance, Abdurahman Essa 10 minutes
March, 2016 Infection Control Practitioner
4. Outbreak of Food Poisoning Abdurahman Essa 05 minutes
5. CBAHI Survey Visit Feedback Dr. Nahla Moustafa 10 minutes
Medical Affairs
6. Hand Hygiene Celebration Dr. Nahla Moustafa 10 minutes
May 05, 2016 Asst. General Supervisor for
Medical Affairs
7. JCI Preparation Dr. Nahla Moustafa 10 minutes
Medical Affairs
DR. NAHLA MOUSTAFA

28.08.1437 / 04.06.2016


___________________________________________________________________________
Date: 29.08.1437 /05.06.2016
Day: Sunday
Time: 11:00am
AGENDA:
Allotment
1. Matters arising from the previous minutes. Dr. Nahla Moustafa 05 minutes
Medical Affairs
Infections Surveillance Data, April, 2016. Infection Control Practitioner
3. Discussion of Hand Hygiene Compliance, Abdurahman Essa 10 minutes
April, 2016 . Infection Control Practitioner
4. Delay Result for MERS COV Screening. Abdurahman Essa 05 minutes
5. MDRO Surveillance. Dr. Sherif Khorshid 05 minutes
6. Oncology Unit Transfer to Old Dental. Dr. Sherif Khorshid 05 minutes
Center
DR. NAHLA MOUSTAFA


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‫المملكة العربية السعودية‬

Kingdom Saudi Arabia ‫وزارة الصحة‬

INVITATION AND AGENDA

TO: INFECTION CONTROL COMMITTEE MEMBERS

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 17.09.1432 / 17.08.2011

Location: TQM Conference Room

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 18.11.1432 / 16.10.2011

Location: TQM Conference Room (Near to New ICU)

3. Discussion of Hand Hygiene Infection Prevention & 10 minutes

AD-LD-002 (1) Form 10

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 16.10.1432 / 14.09.2011

Location: TQM Conference Room (Near to New ICU)

3. Discussion of Hand Hygiene Infection Prevention & 10 minutes

AD-LD-002 (1) Form 10

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 13.03.1433 / 05.02.2012

Location: TQM Conference Room (Near to New ICU)

AD-LD-002 (1) Form 10

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 18.04.1433 / 11.03.2012

Location: TQM Conference Room (Near to New ICU)

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 11.05.1433 / 03.04.2012

Location: TQM Conference Room (Near to New ICU)

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 10.06.1433 / 01.05.2012

Location: TQM Conference Room (Near to New ICU)

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 08.07.1433 / 29.05.2012

Location: TQM Conference Room (Near to New ICU)

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 20.08.1433 / 10.07.2012

Location: TQM Conference Room (Near to New ICU)

DR. HASSAN AL GHAMDI

INVITATION AND AGENDA

FROM: COMMITTEE CHAIRMAN

SUBJECT: INFECTION CONTROL COMMITTEE MEETING

Date: 22.12.1433 / 07.11.2012

Location: QPS Conference Room (Near to New ICU)

5. Increase number of Needle Stick Injury Infection Prevention & 10 minutes

6. Feedback of Hand Hygiene Campaign Infection Prevention & 10 minutes

DR. IBRAHEM SAHEM HAMEEM

INVITATION AND AGENDA