Chapter 2: Infection Control Oversight, Evaluation, and Enforcement
Introduction
Purpose
This chapter establishes requirements for oversight, evaluation, investigation, corrective action, and enforcement of infection control standards within the Adams School of Dentistry (ASOD). Requirements support consistent implementation of the Infection Control Manual, timely correction of identified deficiencies, and continuous improvement of infection prevention practices.
Scope
This chapter applies to ASOD faculty, staff, residents, learners, affiliates, volunteers, temporary personnel, contractors, and other individuals participating in ASOD clinical, educational, laboratory, research, or operational activities. Requirements apply to infection control monitoring, inspections, reported concerns, breach reviews, formal investigations, corrective actions, and enforcement activities.
Definitions
| Category A |
A gross error or high-risk infection control practice that creates a significant risk of exposure or harm |
| Category B |
An infection control breach that creates a low-to-moderate risk of exposure or harm. |
| Corrective Action |
An action taken to address an identified deficiency, reduce risk, restore compliance, or prevent recurrence. |
| Infection Control Breach |
A failure to follow an applicable infection control requirement, procedure, standard, or safe practice. |
| Infection Control Committee |
ASOD committee responsible for oversight, review, and improvement of infection control policies, procedures, and practices. |
| Level I |
Intentional conduct or deliberate failure to follow applicable infection control requirements. |
| Level II |
Unintentional conduct, error, or failure to use required safeguards. |
| Remediation |
Education, retraining, competency assessment, supervision, or other activity intended to restore acceptable performance. |
| Responsible Unit |
Department, division, program, clinic, laboratory, or other ASOD area accountable for addressing an identified concern. |
Infection Control Program Oversight
Infection Control Committee and Director of Clinical Compliance oversee development, implementation, monitoring, and evaluation of the Infection Control Manual. Authority to revise infection control policies and procedures rests with the Infection Control Committee in consultation with the Associate or Assistant Dean responsible for clinical education.
Departments, programs, clinics, laboratories, and other operational areas must implement applicable infection control requirements and cooperate with monitoring, review, investigation, and corrective-action activities. Program requirements must reflect applicable laws, regulations, University requirements, recognized professional standards, and current public health guidance.
Standard Precautions
Standard Precautions apply to every patient encounter and all activities involving potential exposure to blood, saliva, body fluids, contaminated materials, or other infectious hazards.
Known or presumed infection status does not alter the requirement to use appropriate aseptic techniques, personal protective equipment, engineering controls, work practice controls, and other infection prevention measures. Standard Precautions must be incorporated into clinical care, laboratory activities, research, education, environmental cleaning, equipment handling, instrument processing, and other activities addressed by the Infection Control Manual.
Program Evaluation
ASOD evaluates infection control practices through inspections, compliance monitoring, review of reported concerns, assessment of identified breaches, and review of current professional and regulatory guidance. Evaluation activities may include standardized inspections of clinical, preclinical, laboratory, research, and support areas; peer inspections within predoctoral, graduate, specialty, and faculty practice clinics; review of equipment, supplies, environmental conditions, and work practices; assessment of training and supervision; and analysis of recurring concerns or patterns.
Inspection and review results must be documented through the approved process. Identified deficiencies must be corrected within a timeframe appropriate to the level of risk. Infection control concerns may be reported to the responsible supervisor, clinical leadership, department leadership, Infection Control Committee, or Director of Clinical Compliance. Questions or concerns may also be directed to ASOD_ClinicalCompliance@unc.edu.
Review of Infection Control Concerns
ASOD Clinical Compliance, the Infection Control Committee, department leadership, or another authorized unit may review an infection control concern based on its nature, severity, recurrence, or potential effect on patients, personnel, learners, or operations. Reviews must remain objective, appropriately scoped, and limited to information necessary to understand the concern, assess risk, identify contributing factors, determine required action, and prevent recurrence.
Review activities may include:
- Identifying the nature, location, and duration of the concern;
- Determining the procedure or activity being performed;
- Identifying blood, body fluids, specimens, instruments, equipment, or other materials involved;
- Reviewing the work area and applicable infection control practices;
- Identifying devices, equipment, and personal protective equipment in use;
- Reviewing applicable cleaning, disinfection, sterilization, reprocessing, or aseptic requirements;
- Evaluating prior training, supervision, and documented competency;
- Interviewing individuals with relevant knowledge;
- Reviewing prior related concerns or corrective actions;
- Determining whether patients, personnel, learners, or others may have been affected;
- Consulting current literature, subject-matter experts, public health authorities, or institutional offices; and
- Identifying immediate and long-term corrective actions.
Investigation Committees
A temporary review committee may be established when a concern requires formal investigation, multidisciplinary assessment, or recommendations beyond the authority of the initial reviewer.
Committee membership must reflect the individuals, programs, and operational areas affected by the concern. Membership may include faculty, staff, learners, clinical leadership, subject matter experts, or institutional representatives. Director of Clinical Compliance may chair or coordinate the committee. Learner related investigations should include appropriate faculty and learner representation when permitted by academic, privacy, and investigative requirements. Personnel-related investigations should include appropriate administrative, leadership, or employee representation.
Committee participation does not replace the authority of academic, Human Resources, legal, privacy, safety, or other institutional processes.
Risk Classification
Confirmed infection control breaches must be evaluated according to the nature of the practice, potential for exposure or harm, intent, recurrence, prior history, and surrounding circumstances. Classification must be based on available evidence and professional judgment. Assignment of a category or level does not independently determine the final corrective or disciplinary action.
| Classification |
Application |
| Category A |
Gross error or high-risk practice that creates a significant risk of exposure or harm to patients, personnel, learners, or others. |
| Category B |
Breach of infection control practice that creates a low-to-moderate risk of exposure or harm. |
| Level I |
Intentional conduct or deliberate failure to follow applicable infection control requirements. |
| Level II |
Unintentional conduct, error, or failure to use required safeguards. |
Assessment, Corrective Action, and Enforcement
Failure to comply with infection control requirements may result in remedial, academic, administrative, employment, clinical, or disciplinary action. Actions must be proportionate to the identified risk, intent, recurrence, individual role, prior history, and effect on patients, personnel, learners, or operations.
| Review Area |
Requirements |
| Patient and Public Health Assessment |
Additional assessment may be required when a breach could have exposed patients or others to bloodborne pathogens, communicable diseases, contaminated instruments, inadequately processed equipment, or another significant hazard. Review may consider the duration of the breach, individuals potentially affected, available clinical and public health information, nature and likelihood of exposure, and guidance from subject-matter experts or public health authorities. Appropriate clinical, legal, privacy, public health, and institutional authorities must coordinate decisions involving testing, medical follow-up, disclosure, notification, or public health reporting. |
| Corrective Action |
Responsible leadership must address confirmed infection control concerns and system deficiencies. Corrective action may include immediate correction, education, counseling, remedial training, competency reassessment, increased supervision, equipment repair or replacement, workflow modification, environmental changes, policy or procedure revision, temporary restriction of duties, or referral to an academic, employment, professional, or disciplinary process. |
|
Level II:
Initial or Isolated Non-Compliance
|
Counseling, education, remediation, competency reassessment, increased supervision, or documentation through the applicable academic or employment process may be required. |
|
Level II:
Repeated or Significant Non-Compliance
|
Formal warning, restricted duties, temporary clinical suspension, referral to department or program leadership, or additional review through the applicable academic or employment process may be required. |
|
Level II:
Serious or Continuing Non-Compliance
|
Indefinite restriction or suspension may be imposed pending review. Additional action may include dismissal from an academic program or termination of employment when authorized by applicable University policy. |
|
Level I:
Intentional Non-Compliance
|
Immediate restriction or suspension of clinical or operational duties may be imposed. Referral may be made to the applicable academic, administrative, Human Resources, professional, or disciplinary process. |
|
Level I:
Substantial Risk of Harm
|
Additional action may include dismissal from an academic program or termination of employment, subject to applicable University requirements and due-process protections. |
| Role Based Coordination |
Faculty and staff matters must be coordinated with department leadership and Human Resources when appropriate. Learner matters must be addressed through the applicable academic, professionalism, or performance review process. |
Documentation and Communication
Investigation findings, corrective actions, and enforcement outcomes must be documented through approved systems. Information may be shared with individuals or offices responsible for patient safety, academic oversight, employment action, legal review, compliance, or operational improvement.
Access must be limited to individuals with an authorized need. Individuals who report concerns may receive confirmation that review occurred but may not receive confidential academic, personnel, health, or disciplinary information.
Quality Improvement
ASOD Clinical Compliance and the Infection Control Committee must use inspection findings, identified breaches, reported concerns, and investigation outcomes to identify trends and opportunities for improvement. Quality improvement activities may include revisions to training, equipment, environmental controls, supervision, policies, procedures, monitoring methods, and communication practices. Analysis must focus on reducing risk and preventing recurrence while protecting confidential patient, learner, and personnel information. Recommendations requiring broader clinical or organizational action must be forwarded to the Quality of Patient Care Committee or another authorized oversight body for review and action within its authority.
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