Clinical governance standard

CG9 – Infection prevention and control, including reprocessing

Standards for general practices (6th edition)
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      10. CG9 – Infection prevention and control, including reprocessing

CG9 | Infection prevention and control, including reprocessing

Consumer expectation statement: I expect that this practice uses current evidence-based Australian systems to protect me from infections.

CG9.A The practice has a written, practice-specific policy that outlines its infection control processes.

The practice:

  • maintains an up-to-date practice-specific infection control policy that is based on current, evidence-based Australian guidelines and standards (specific requirements are outlined in the criteria guidance)
  • communicates the policy with patients
  • ensures all members of the practice team are aware of and implement the policy.

CG9.B The practice has at least one member of the clinical team with the roles and responsibilities of infection prevention and control coordinator.

The practice:

  • has at least one member of the clinical team who has primary responsibility for infection control and the use of sterile equipment (their responsibilities are outlined in the Infection prevention and control guidelines)
  • documents the responsibilities of the practice’s infection prevention and control coordinator in their job description 
  • ensures all members of the practice team are aware of who is the practice’s infection prevention and control coordinator and their responsibilities.

CG9.C All members of the practice team manage risks of cross-infection in the practice in line with current, evidence-based Australian guidelines and standards.

The practice:

  • manages risk of cross-infection in the practice team, in line with current, evidence-based Australian guidelines and standards (the practice team’s responsibilities are outlined in the criteria guidance)
  • ensures the practice team understands all aspects of standard and transmission-based precautions, in line with current, evidence-based Australian guidelines and standards
  • ensures the practice team has access to personal protective equipment (PPE)
  • safely stores and disposes of sharps and clinical waste.

CG9.D The practice’s patients are informed about appropriate precautionary techniques to prevent the transmission of communicable diseases.

The practice:

  • informs patients about appropriate techniques to prevent the transmission of communicable diseases, including respiratory hygiene
  • provides patients with access to alcohol-based hand sanitiser and tissues
  • provides patients who have respiratory symptoms with access to masks
  • provides patients with access to soap and water after using the toilet.

CG9.E If the practice reprocesses reusable medical devices, it does so in accordance with the RACGP’s Infection prevention and control guidelines or another model that meets the current Australian standard.

The practice:

  • includes in the practice-specific infection control policy details of risk assessment for reprocessing reusable medical devices
  • reprocesses reusable medical devices in accordance with the RACGP’s Infection prevention and control guidelines or another model that meets the current Australian standard.

CG9.F The practice ensures that the record of sterilisation load numbers from the sterile barrier system can be traced to relevant patients.

The practice:

  • has a process to record sterilisation load numbers for each patient when sterile items have been used.


Infection prevention and control reduces the risk of infection being transmitted from patient to patient, or between patients and members of the practice team.


Using current, evidence-based Australian guidelines and standards helps maintain best-practice policies and procedures related to infection prevention and control. The RACGP’s Infection prevention and control guidelines is recommended, as it has been developed by GPs and nurses and uses an Australian evidence-base. Other Australian-based models the practice could consider include (but are not limited to):


Assigning responsibility for infection prevention and control to a member of the practice team is part of good governance and the delivery of safe and high-quality care to patients.


By incorporating a risk-based approach and following the RACGP’s Infection prevention and control guidelines or another model that meets the current Australian standard for reprocessing reusable medical devices, the practice can systematically assess and mitigate potential hazards in order to protect patients from infection risks.


The practice’s up-to-date practice-specific infection control policy needs to contain:

  • the role and position description responsible for infection control and sterilisation processes
  • the appropriate use and application of standard and transmission-based precautions
  • management of sharps injuries
  • management of blood and body-substance spills
  • hand hygiene
  • environmental cleaning of clinical and non-clinical areas of the practice
  • use of aseptic and sterile procedures
  • if relevant, procedures for reprocessing (sterilising) instruments on site or off site, and a requirement to document evidence that this reprocessing is monitored and has been validated
  • management of occupational exposures, including steps to prevent, identify, and manage exposure incidents
  • waste management, including the safe storage and disposal of clinical waste and sharps
  • where patients and the practice team can access PPE
  • how and when members of the practice team are educated about the appropriate application, removal, and disposal of PPE
  • the practice’s process for managing potentially infected patients.


The practice’s infection control policy is an operational document and needs to be reviewed every two years (see criterion F1.E).

Regularly reviewing and updating the infection control policy in line with current, evidence-based Australian guidelines and standards such as the RACGP’s Infection prevention and control guidelines will:

  • promote a culture of safety in the practice
  • protect patients from emerging infectious diseases
  • implement the most effective infection and control strategies
  • address emerging risks such as disease outbreaks or pandemics
  • maintain compliance with federal, state and territory regulations
  • maintain a continuous quality improvement culture.

The practice could:

  • conduct regular audits of the infection control policy, which could include observation of the practice team’s infection control practices, equipment maintenance and environmental cleaning
  • request feedback from patients and members of the practice team about the effectiveness of the policy
  • add ‘infection control moments’ to the standing agenda of practice team meetings.


The responsibilities of the infection prevention and control (IPC) coordinator are outlined in the Risk assessment and planning section of the Infection prevention and control guidelines.

If the practice reprocesses sterile items on site, the IPC coordinator is also responsible for the management of sterile items.


To reduce the risk of infection, all members of the practice team need to be competent in infection prevention and control processes, based on their role. Relevant education could begin during induction and continue throughout their time at the practice.

Policies and procedures that include triage protocols and tools such as checklists will help all members of the practice team to understand their own and others’ roles and responsibilities relating to infection.

Refer to section 1 of the current edition of the RACGP’s Infection prevention and control guidelines for guidance about recording the relevant education of members of the practice team and how to evaluate their competency in this area.

All members of the practice team need to:

  • know who the practice’s infection prevention and control coordinator is
  • have easy access to PPE (for example, masks, gloves, gowns, protective eye wear and hand sanitiser)
  • understand relevant infection risks and modes of transmission of common pathogens
  • know when PPE is required and what type
  • know who is responsible for ensuring that essential procedures are performed and be aware of the cleaning schedule
  • know what to do if there is an accident or incident that risks exposure to infection
  • know how to implement standard and transmission-based precautions, spills management and environmental cleaning (see Managing the risks of cross-infection in the practice below)
  • be trained in the key components of education infection prevention and control, as outlined in the Infection prevention and control guidelines
  • know how to perform hand hygiene
  • educate patients on infection prevention and control activities.


Refer to and follow the applicable sections of the Infection prevention and control guidelines, which recommend the use of standard and transmission-based precautions under the following circumstances:

  • during recognised periods of increased risk of transmission
  • when interacting with potentially infectious patients
  • when cleaning
  • when performing procedures
  • when dealing with spills and handling waste.

The practice could minimise exposure to other patients and members of the practice team by:

  • conducting a risk assessment and identifying strategies to eliminate or minimise the risk of transmission, including the management of non-critical devices (for example, shared patient equipment)
  • implementing effective triage and appointment scheduling
  • implementing distancing techniques, such as:
    • spacing patients in the practice in line with relevant health authority guidance
    • isolating an infected patient in a separate space
    • offering telehealth appointments to patients experiencing respiratory illness (if clinically appropriate)
    • considering home visits for vulnerable patients such as the elderly.


Patient education about appropriate precautionary techniques could involve:

  • educating patients about how ‘respiratory symptoms’ present (for example, a cough, sore throat, runny nose)
  • informing patients (for example, via the practice’s website and social media, or by displaying signs in the waiting room) about how they can reduce the spread of infection while at the practice
  • providing information promoting good respiratory hygiene throughout the practice’s premises
  • running simple social media campaigns educating patients about respiratory hygiene and the situations where telehealth appointments are appropriate in order to prevent the spread of infection
  • using the patient appointment booking system to remind patients about respiratory hygiene techniques (for example, via an alert at the time of booking)
  • including reminders about respiratory hygiene on the practice’s website, email signatures and telephone voicemail
  • directing patients towards state or territory advice and resources.


Isolating infected patients can minimise the risk of infection transmission. Isolated patients need to receive appropriate medical care and observation while isolated and have access to bathroom facilities.

Isolation areas require additional cleaning, especially where there is a risk of multi-resistant organism transmission. The member of the clinical team responsible for coordinating prevention and control of infection needs to collaborate with all relevant members of the practice team to minimise the risk of infection.


The practice needs to develop its own risk assessment process for reprocessing reusable medical devices if these are used at the practice.

The RACGP’s Infection prevention and control guidelines provide advice regarding the reprocessing of reusable medical devices, including a template for general practices to conduct risk-based assessment of reprocessing reusable medical devices.


Refer to and follow Cleaning, laundry and waste management in the Infection prevention and control guidelines, which provide guidance on clinical waste management that could be used when developing an infection prevention and control policy.


Keep up to date with changes in laws and guidelines relating to infection prevention and control and implement them promptly. Establish:

  • systems for monitoring and obtaining information about public health alerts for national and local infection outbreaks
  • protocols for managing outbreaks of infectious disease, in line with local, state and national guidance.


If the practice is performing a procedure at an external home, facility or site:

  • it is still responsible for infection control (including, for example, adherence to the IPC Guidelines, sterility, adherence to aseptic technique)
  • it is not responsible for the site per se, however it is responsible for any service the practice provides at the site
  • it needs to demonstrate that it has oversight of the site’s adherence to the site’s infection prevention and control and cold chain management, insofar as they relate to the practice’s visits to that site.
 
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