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Infection control management plans

Changes to the Public Health Act 2005

As of 1 September 2017, important changes have been made to the Public Health Act 2005 (Queensland) (the Act) that will affect some healthcare service providers. These changes are necessary to help prevent potential infection control breaches. The amendments provide for a broader range of compliance and enforcement actions.

The Queensland Government has strengthened the existing regulatory framework by improving Queensland Health’s ability to respond to unsatisfactory and unsafe infection control practises. Corrective action may now be required of, and penalties for serious breaches applied to, relevant healthcare professionals.

There are no changes to the existing obligation to minimise risks of infection or the Infection Control Management Plan (ICMP) provisions.

Chapter 4 of the Act requires people that perform declared health services, as defined under the Act, to take reasonable precautions and care to minimise the risk of infection to other persons.

The Act places a further onus on the owners/operators of health care facilities to have an Infection Control Management Plan (ICMP) for the facility. The ICMP must identify the infection risks at the facility and detail the measures to be taken to prevent or minimise the risks.

All facilities that perform declared health services as defined under the Act must have an existing ICMP and review and update it before offering new declared health services. New facilities must have an ICMP prior to providing declared health services.

What is an ICMP?

An ICMP is a documented plan to prevent or minimise the risk of infection in relation to declared health services for:

  • persons receiving services at the facility
  • person employed or engaged at the facility
  • other persons at risk of infection at the facility

What is a declared health service?

A declared health service means a service intended to maintain, improve or restore a person’s health; that involves an invasive procedure (the insertion of an instrument, appliance or other object into human tissue, organs, body cavities or body orifices) or activity that exposes the person or another person to blood or another bodily fluid.

Health care facilities

The health-care facilities affected by these changes are those that provide a declared health service. A healthcare facility that provides a declared health service includes mobile premises associated with the facility and other premises or places that persons employed or otherwise engaged at the facility provide the declared health service.It may include, but is not limited to:

  • public hospitals
  • dental clinics
  • blood banks
  • specialist practice clinics
  • podiatry clinics
  • acupuncturists
  • physiotherapists
  • independent midwives
  • pathology laboratories
  • occupational therapists
  • speech therapists
  • optometrists
  • stem cell transplant services
  • radiology services/diagnostic imaging
  • hyperbaric medicine
  • Aboriginal healthcare services
  • diabetes educators
  • dermatology services
  • pharmacies
  • school nurse service
  • correction services
  • Chinese medicine.

Further guidance can be found in section 149 of the Act.

Exempt facilities

There are a number of health care facilities types that do not require an ICMP:

  • General Practice if the practice is accredited against the 'Standards for General Practice' developed by the Royal College of General Practice and accredited by an approved accreditation organisation. (Organisations which assess general practices against the Standards must be approved by the Australian Commission on Safety and Quality in Healthcare. A list of approved accreditation organisations is available on the Commission's website.)
  • a health care facility owned by a local government, if the operator of the health care facility performs an immunisation service and has developed and implemented an occupational exposure policy and a sharps disposal policy.

Additionally the following services are not required to have an ICMP because Chapter 4 of the Act does not apply to them:

  • private health facilities that are regulated by the Private Health Facilities Act 1999 (Queensland)
  • areas within a health care facility used for food services including, for example, the preparation and  handling and storage of food
  • an aged care service conducted by an approved provider under the Aged Care Act 1997 (Cth).

Developing and reviewing ICMP's

An ICMP for a health care facility must state:

  • the infection risks associated with the provision of declared health services
  • the measures to be taken to prevent or minimise the infection risks
  • how the operator is to monitor and review the implementation and effectiveness of the measures
  • details about the provision of training in relation to the ICMP for persons employed or otherwise engaged at the facility
  • how often the ICMP is to be reviewed (the effectiveness and implementation of an ICMP must be reviewed at intervals of not more than one year)
  • the name of any person who is responsible for providing advice about and monitoring the effectiveness of the ICMP.

The ICMP must be written in a way likely to be easily understood by persons employed or otherwise engaged at the facility.

The operator of the facility must:

  • sign and date the ICMP; and
  • sign and date the ICMP each time it is reviewed.

The operator must keep a copy of the ICMP at a place at the facility that is readily accessible to persons employed or otherwise engaged at the facility.

If, after developing an ICMP for a health care facility, the operator of the facility intends to provide a declared health service not identified in the ICMP, the operator must, before providing the service, review and amend the ICMP to address the infection risks associated with the service.

The owner of the facility must provide adequate resources to the operator to ensure the effectiveness and implementation of the ICMP.

Monitoring of compliance

The Communicable Diseases Branch on behalf of the Chief Health Officer (CHO) of Queensland will undertake compliance monitoring audits of health facilities that meet the definition under the Act of providing declared health services. Health facilities being monitored will receive instructions and access details (username and password) for the Compliance Audit Tool.


Infection Control Management Plans for Non-Hosptial Healthcare Facilities (PDF, 886KB)

Infection Control Management Plan Template (DOC 200KB)

ICMP Development Instructions (DOC 104KB)

Further information

Last updated: 11 March 2019