Infection prevention and control is the one part of the standard that touches every patient, every day — and it's the part that scales most directly to clinics, not just surgical facilities. In a non-hospital surgical facility, the College of Physicians & Surgeons of Alberta (CPSA) sets it out in IPC.1.0 of the IPC/MDR standard: a documented, evidence-based program that runs from the hand-hygiene sink to surgical-site-infection surveillance. It's a cornerstone of the Quality Management System, and a close cousin of the CPSA IPC inspection that community clinics already face.
What CPSA expects
- A documented, evidence-based IPC program — written policies grounded in current guidelines, a designated IPC lead with delegated authority and appropriate training (plus access to an infection-control consultant), and documented staff training at orientation, at least annually, and whenever something changes.
- Surgical-site-infection surveillance. Active surveillance of infectious complications, your SSI rate compared against an external benchmark, and investigation plus corrective action where the benchmark isn't met.
- An IPC-appropriate physical plant. Design that minimizes bioburden, cleanable work surfaces, separation of clean and dirty areas, and a pest control program.
- A PPE program. Backed by a risk assessment — appropriate gloves (with non-powdered/alternative options for latex sensitivity), and eye, face, and respiratory protection with fit-testing — and training on selection, donning, and doffing.
- Hand hygiene infrastructure and the 4 Moments. Dedicated hand-hygiene stations in the right locations, alcohol-based product at 60–90% alcohol, recommended technique, an artificial-nails/polish policy, and regular hand-hygiene audits with feedback and corrective action.
- Safe gels and topicals. Single-dose sterile gels for higher-risk procedures, and storage/handling that prevents contamination — gel containers are never washed, refilled, or warmed.
- Patient-care exposure control. Screening for communicable disease, transmission- based additional precautions, an outbreak policy, source control, and cleaning the examination table (and changing the barrier sheet) between patients.
- Sterile field and surgical aseptic technique — documented, best-practice-based policies, with all relevant staff trained.
- A full housekeeping and environmental-cleaning program. Defined cleaning and disinfection with DIN-registered disinfectants, cleanliness controls during construction, trained housekeeping staff, proper cleaning-supply storage, and IPC laundering of linens.
Why facilities struggle with it
- Hand hygiene isn't audited. The infrastructure is there; the audit-and-feedback loop the standard wants — measuring the 4 Moments and acting on it — usually isn't.
- SSI surveillance is passive. Infections are noticed, but not tracked against a benchmark with corrective action.
- Cleaning uses the wrong products. Household wipes appear in clinical areas instead of DIN-registered disinfectants used to their contact times.
- The IPC lead is unnamed or untrained. Responsibility is assumed across the team rather than delegated to a trained, named person.
What "getting it right" looks like
- A named, trained IPC lead and a written, evidence-based program with documented training.
- Hand-hygiene audits with feedback driving improvement, and the 4 Moments actually measured.
- SSI surveillance against a benchmark, feeding corrective action.
- An environmental-cleaning program with the right disinfectants, used correctly.
How Zosimos helps
IPC is a program-and-evidence discipline, and that's where we help: building the IPC program and policies, standing up hand-hygiene and SSI surveillance with the audit-and-feedback loop, and keeping the training and cleaning records straight. The Compliance Tracker and Accreditation Audit Tool we're building on the Zosimos Enterprise hub — launching soon — are designed to run the audits, track SSI rates against benchmarks, and keep the IPC evidence retrievable.
For non-surgical clinics: this is the most directly transferable section in the whole standard. The IPC program, hand hygiene, PPE, patient-care exposure control, and environmental cleaning apply almost unchanged — see our IPC inspection checklist for the clinic-focused version.
See our IPC & CPSA compliance support or get in touch if your hand-hygiene or SSI surveillance isn't measured today. This completes the procedure wave of the series — for the whole picture, start with what a Quality Management System really means.