Toolkit 10: auditable standards
Published 21 January 2025
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This toolkit provides suggested auditable standards related to outbreak management. Any audit against the standards should be included as part of the outbreak report.
| Standard | Data Source | Suggested compliance | ||
|---|---|---|---|---|
| Outbreak recognition | Initial risk assessment to clarify the nature of the outbreak commenced within 24 hours where outbreak detected in-hours [note 1] | UKHSA incident management system | 100% | |
| Outbreak declaration | Decision made and recorded regarding outbreak declaration and convening of incident management team | UKHSA incident management system | 100% | |
| Incident management team (IMT) | IMT held within three working days of decision to convene [note 1] | Minutes [note 2] and report | 95% | |
| Roles and responsibilities of IMT members, including identification of lead organisation, agreed and recorded | Minutes [note 2] and report | 95% | ||
| IMT minutes sent out within seven days of IMT meeting being held | Minutes [note 2] | 95% | ||
| Outbreak investigation and control | Descriptive epidemiology undertaken and reviewed by the IMT where IMT convened. This should include: number of cases in line with case definition, description of key characteristics, typically including sex, ethnicity (where available), geographic spread, linked inclusion health settings, pertinent risk factors, and an outbreak hypothesis. | Minutes [note 2] and report | 95% | |
| Analytical study considered and rationale for decision recorded | Minutes [note 2] and report | 95% | ||
| Risk assessment reviewed on receipt of new outbreak investigation findings | Minutes [note 2] and report | 95% | ||
| Outbreak control measure decisions are documented with clear timescales for implementation and responsibility | Minutes [note 2] and report | 100% | ||
| Case definition agreed and recorded | Minutes [note 2] and report | 95% | ||
| Communications | Communications strategy agreed at first IMT meeting and reviewed regularly, where IMT convened, including community engagement needs | Minutes | 100% | |
| End of outbreak | Where decision made to complete an outbreak report, the report should be completed within 12 weeks of the formal closure of the outbreak | Report | 95% | |
| Where a report is produced, report recommendations and lessons identified are reviewed within 12 months of formal closure of the outbreak | Dependent on local arrangements for reviewing recommendations and lessons identified. | 100% |
Note 1: Immediate risk assessment will determine the appropriate urgency according to the severity and potential risks of the illness concerned. Specific infection protocols should be followed. Note: risk assessment and investigation of less urgent outbreaks within a 24-hour period, and the convening of an IMT, where indicated, within three days, may not be always be practical or required when an outbreak is identified out of hours.
Note 2: If a report has not been written (for example for routine incidents) minutes should be used to assess compliance.