Performance Indicators for Hospitals Participating in the VICNISS Type 2 Surveillance Program July 2008 - June 2009

• These Performance Indicators 2008-09 (PDF File 30kb, opens in new window) as detailed below, are also available to download as a PDF document.
• The Performance Indicators 2007-08 (PDF File 36kb, opens in new window), are also available to download as a PDF document.
• Due dates for the submission of data to the VICNISS Coordinating Centre for 2008 – 2009 are also available along with other VICNISS Key Dates.
• Notice of Inability to Undertake VICNISS Surveillance Activities - As advised in the VICNISS eBulletin April 2008, if a hospital is unable to undertake the surveillance activities as listed in the Performance Indicator document for any period of time, formal notification to the VCC is required by completing the form Notice of Inability to Undertake VICNISS Surveillance Activities (PDF File 23 kb, opens in new window). This notification needs to be signed by the Infection Control Coordinator and the Infection Control Executive Sponsor. This information will then be forwarded to the Department.

Hospitals that do not follow VICNISS Type 2 Surveillance Hospital Participation Indicators as listed below, are requested to document this decision with an outline of the reasons for not following these activities, and submit to the VICNISS Coordinating Centre. The documentation will then be forwarded to DHS with Hospital Participation Indicators.

This document lists the revised VICNISS Hospital Participation Indicators and the VICNISS Data Quality Indicators for all hospitals participating in Type 2 surveillance activities.

These Performance Indicators have been endorsed by the VICNISS Advisory Committee and the Department of Human Services.

1. VICNISS Type 2 Surveillance Hospital Participation Indicators

Required Surveillance Activities

1.1 Small Hospitals

• 1.1.1 Multi Resistant Organism surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.1.2 Bloodstream infection surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.1.3 Occupational Exposure surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.1.4 Notification of Deep and Organ space surgical site infections to the VICNISS Coordinating Centre quarterly.

1.2 Medium Hospitals

• 1.2.1 Multi Resistant Organism surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.2.2 Bloodstream infection surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.2.3 Occupational Exposure surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.2.4 Notification of Deep and Organ space surgical site infections to the VICNISS Coordinating Centre quarterly.

1.3 Large Hospitals

Outcome Indicator Modules

• 1.3.1 Bloodstream infection surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.3.2 Occupational Exposure surveillance data - collect and submit to the VICNISS Coordinating Centre quarterly.
• 1.3.3 Notification of Deep and Organ space surgical site infections to the VICNISS Coordinating Centre quarterly.

Process Indicator Modules

• 1.3.4 Annual Surgical Antibiotic Prophylaxis module.
• 1.3.5 Other process indicators optional.

2. VICNISS Type 2 Surveillance Data Quality Indicators

Data Quality Indicators

• 2.1 Quarterly surveillance data submitted within 1 week of the required date (as notified by VICNISS Coordinating Centre).
• 2.2 Complete organism data including antibiotic resistance patterns be submitted for all Multi Resistant Organism and bloodstream infections.

Inquiries regarding the Performance Indicators to Mr Clinton Dunkley Senior Program Advisor, Infection Control & Cleaning, Quality and Safety Programs Unit, Department of Human Services. Ph: 9096 7324. Email: Clinton.Dunkley @ dhs.vic.gov.au