LLUMC Medical Staff Bylaws

  I.   COMPOSITION:

The Infection Control Committee shall consist of a minimum of six (6) members of the Medical Staff including the Medical Staff member who is the Medical Director of Clinical Epidemiology and Infection Prevention, a representative from Medical Center Administration, the Patient Safety Officer, a representative from Nursing Administration, and the Infection Preventionists from the Medical Center Department of Clinical Epidemiology and Infection Prevention. Other members may be added by decision of the Committee Chair.

 II.   DUTIES:

The Committee shall:

1. Approve the Medical Center Infection Control Plan developed by the Medical Center Department of Clinical Epidemiology and Infection Prevention. This plan shall include:
   1. A set of definitions used to distinguish nosocomial infections from other infections;
   2. A system for identifying, analyzing, and reporting the frequency (and where appropriate, the rate) of selected nosocomial infections;
   3. A system for monitoring the Medical Center environment for selected risks associated with nosocomial infections;
   4. A program for education of Medical Center employees on issues related to control of nosocomial infections.
2. Monitor the implementation of the approved infection control plan.
3. Recommend and/or approve actions to reduce the frequency and/or risk of nosocomial infection in the Medical Center.
4. Review and approve all Medical Center and Medical Staff policies related to infection control. This shall include, but not be limited to:
   1. The Medical Center and/or Medical Staff policy relating to the authority of the Committee or its designee to institute appropriate infection control measures;
   2. Isolation policies and procedures;
   3. Disinfection/sterilization policies and procedures;
   4. Policies regarding the use of equipment in sterile environments;
   5. Visitor policies as they impact on infection control;
   6. Employee Health policies as they relate to infection control and communicable diseases.
5. Approve the selection of antibiotics used in antimicrobial sensitivity testing by the Clinical Laboratory.
6. Report, by way of minutes, the actions taken on items (a) through (c) above to:
   1. The Medical Staff Executive Committee;
   2. The Administrator;
   3. The Medical Center Senior Vice President for Nursing;
   4. The person responsible for Medical Center quality improvement activities.

III.   MEETINGS:

The Committee shall meet at least quarterly.