Mrs Phoebe Wang1, Mrs Debie Crisologo1, Mrs Susan Ryan1
1Monash Health, 246 Clayton Rd, Clayton VIC 3168, Australia
Biography:
Phoebe Wang is a Senior Infection Prevention Clinical Nurse Consultant at Monash Health with five years in the role and over ten years’ clinical experience locally and overseas. She is passionate about improving patient outcomes and reducing healthcare-associated infections through leadership, education, and continuous quality improvement initiatives, evidence-based clinical practice.
Debie Crisologo, a registered nurse with 17 years’ experience in Australia and the Philippines, has spent the past five years in Infection Prevention at Monash Health. Passionate about patient safety, she drives evidence-based strategies, promotes best practices, and supports knowledge sharing to reduce healthcare-associated infections and improve quality of care.
Susan Ryan is an experienced nurse with over 37 years practice, including leadership roles in Critical Care and Infection Prevention. She is currently the Infection Prevention Site Lead at the Victorian Heart Hospital. Susan has a strong interest in infection prevention research and is committed to driving quality improvement initiatives.
Abstract:
Background
Sustainable governance of Infection Prevention (IP) procedures is essential to ensure consistent, evidence-based practice across large health services. At Monash Health, oversight had been predominantly reliant on a single senior Clinical Nurse Consultant (CNC), creating risks to continuity and scalability. A Procedure Working Group (PWG) was established to distribute responsibility, strengthen governance processes, and build workforce capability.
Methods
The PWG includes a senior infectious diseases consultant, senior IP CNCs, and novice CNCs from multiple sites with varied IP experience and clinical backgrounds. A senior IP CNC coordinates the group, allocates review tasks, and provides mentorship. A standardised review approach was adopted, with allocated procedures presented at monthly meetings for multidisciplinary discussion, feedback, and consensus-based decision-making.
Results
The PWG is operational and has strengthened cross-site collaboration, increased novice CNCs’ exposure to governance processes, and supported the development of procedural review capabilities. Reliance on a single portfolio holder has reduced; however, the senior CNC workload has not yet decreased.
As the PWG remains in the early stages of implementation, additional time is required for coordination, mentoring, and iterative feedback as novice reviewers develop competence, resulting in short-term efficiency challenges.
Conclusion
The PWG demonstrates a practical approach to translating governance knowledge into action by strengthening procedural oversight and workforce capability. Addressing identified barriers will improve efficiency, sustainability, and timeliness. This model offers a transferable framework for healthcare organisations seeking to decentralise governance and strengthen workforce capability in IP.