Missouri Revised Statutes Title XII. Public Health and Welfare § 197.154. Regulation review and update required, standards

(1) Maintaining databases to be used for infection tracking;

(2) Developing hospital protocols related to aseptic technique and infection control practices including but not limited to hand washing, isolation, and other infection control policies;

(3) Developing appropriate corrective action plans and follow-ups for any deficiencies identified in hospital infection control practices;

(4) Conducting root cause analysis and follow-up of sentinel events, as defined by the Joint Commission on Accreditation of Health Organizations, attributable to nosocomial infections; and

(5) Ensuring that hospital and ambulatory surgical center policies and medical staff bylaws are in place to promote and enforce compliance with infection control policies.