A strong foundation in policies and procedures is essential for success as an Infection Preventionist. When I first entered the field, I was given an orientation binder meticulously compiled by my preceptor. This binder was more than just a reference guide—it was a strategic resource, covering key topics such as high-level disinfection, isolation precautions, environmental services, construction and renovation, outbreak investigations, surveillance, and occupational health. The most valuable component of each section? The corresponding policies governing these areas.

Early in my career, I dedicated significant time to reviewing these policies—not to memorize them verbatim, but to understand their intent and application. My leader often emphasized, “If it’s in the policy, it’s essentially law.” That principle became a guiding force in my approach to infection prevention.

One of the first lessons I learned was the importance of referencing policies and procedures in daily decision-making. Each time I posed a question to my leader, the response was consistent: “Have you checked the policy?” Initially, I was frustrated for not thinking of it myself, but before long, consulting policies became second nature. Now, when addressing inquiries or making decisions, my first step is always to verify the relevant policy.

Policies and procedures are the backbone of an effective infection prevention program. These documents must be regularly reviewed and updated to align with current evidence-based practices. Infection Preventionists must remain well-versed not only in infection prevention-specific policies but also in those where infection prevention plays a consultative role. Furthermore, serving on a facility’s policy committee ensures that infection prevention expertise is integrated into institutional decision-making processes.

Five Critical Policies for Infection Preventionists

Hand Hygiene Policy

Hand hygiene is the single most effective measure to prevent infection, as hands serve as the primary vehicle for pathogen transmission. A robust hand hygiene policy should clearly define:

• Indications for hand hygiene
• Proper techniques for handwashing with soap and water versus the use of alcohol-based hand rubs
• Guidelines for fingernail length and the restriction of artificial nails

Standard and Transmission-Based Precautions Policy

Isolation precautions are fundamental to infection control. This policy should comprehensively outline:

• The different types of isolation (contact, droplet, airborne) and their indications
• Appropriate personal protective equipment (PPE) for each isolation category
• Criteria for discontinuation of isolation precautions
• Requirements for N95 respirator use and fit testing
• Airborne isolation room specifications
• Definitions and protocols for aerosol-generating procedures
• Identification and management strategies for multidrug-resistant organisms (MDROs)

High-Level Disinfection (HLD) Policy

A well-defined HLD policy is essential to ensure the safe and effective reprocessing of medical instruments. Key elements should include:

• Application of the Spaulding classification to determine reprocessing requirements
• Point-of-use cleaning protocols
• Quality control measures
• Proper storage of instruments following reprocessing

Bloodborne Pathogen Exposure Policy

Protecting healthcare personnel from bloodborne pathogens, including HIV, HBV, and HCV, is a critical responsibility. This policy should address:

• Proper use of personal protective equipment (PPE)
• Adherence to safe injection practices
• Protocols for cleaning blood and bodily fluid spills
• Procedures for the handling and disposal of contaminated waste

Construction and Renovation Policy

Infection Preventionists play a pivotal role in mitigating infection risks during construction and renovation projects. This policy should establish:

• Infection Control Risk Assessment (ICRA) requirements
• Guidelines for containment measures, including dust control barriers
• Air quality monitoring and negative pressure room requirements
• Water management strategies to prevent the proliferation of Legionella and other waterborne pathogens

Conclusion

Policies and procedures are not merely bureaucratic documents—they are essential tools that guide evidence-based decision-making in infection prevention. Whether responding to inquiries, implementing new initiatives, or ensuring regulatory compliance, a thorough understanding of institutional policies is critical to professional excellence.

By embracing policies and procedures as indispensable resources, Infection Preventionists can navigate the complexities of their role with confidence, ensuring the highest standards of patient safety and infection control.