The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0952-6862.htm

HACCP and the

HACCP and the management of management of
healthcare associated infections HCAIs
Are there lessons to be learnt from other
industries? 351
Chris Griffith
University of Wales Institute, Cardiff, South Wales, UK

Abstract
Purpose – Hospital cleaning and healthcare associated infections (HCAIs) continue to attract adverse
media attention and consumer concern. Parallels exist with similar publicity relating to cleaning and
food safety in the food industry almost 13 years earlier. This paper examines some of the management
solutions developed in the food industry, and discusses their application to healthcare delivery.
Design/methodology/approach – The food industry is managing food safety by adopting a dual
approach based on pre-requisite programmes and Hazard Analysis Critical Control Points (HACCP).
How these differ is described and how the approaches and terminology can be adapted for use in
healthcare is discussed.
Findings – The food industry is moving towards external certification of safety using national and
international standards. The HACCP approach, a management tool and a central requirement of these
standards, is evolving and there is interest worldwide from the healthcare community. Its application
to the decontamination of endoscopes, using conventional HACCP, is presented, as well as suggestions
for a simplified format for managing patient-related procedures. Taking this type of approach to the
management of HCAIs could provide greater transparency, reduce infection rates and increase
consumer confidence.
Practical implications – Potential problems in adopting HACCP, including cost and human
resource, are discussed.
Originality/value – The HACCP method/approach has previously been mentioned in the medical
literature but this paper is one of the few to examine, from basic principles, its infection control
application within a broader approach to quality assurance.
Keywords Hospitals, Cleaning, Quality management
Paper type General review

Background
Healthcare delivery, especially the UK National Health Service, has undergone massive
change (Scrivens, 2005). This includes political/managerial changes, as well as
developments in the diagnosis and treatment of illnesses. Although not immediately
obvious, there are some similarities as well as differences between healthcare delivery
and the food industry (a broad term concerning all stages in the food chain, from
production, processing, transport via retailing and food service, up to and including,
activities of the consumer) (Table I).
One point of similarity, although separated by time, includes considerable adverse International Journal of Health Care
media attention. In the late 1980s (Brownsell et al., 1989) newspaper headlines, TV Quality Assurance
Vol. 19 No. 4, 2006
documentaries and even political resignations related to concerns over food safety and pp. 351-367
the cleanliness and management of food operations. Approximately 15 years later q Emerald Group Publishing Limited
0952-6862
super-bugs, healthcare associated infections (HCAIs) and hospital cleanliness are also DOI 10.1108/09526860610671409
 19,4

352

Table I.
IJHCQA

manufacturing and
Comparison of food

healthcare industries
Food manufacturing Healthcare

Size media attention Started late 1980s, continues today Started late 1990s, continues today, possibly
overtaken food in importance as media topic
Quality attributes Many food quality attributes, e.g. taste, smell, Many attributes to quality of patient experience, e.g.
nutrition Food safety and food hygiene prime convenience, caring atmosphere. Patient safety and
importance infection control prime importance
Philosophical approach underpinning safety Precautionary principlea Evidence-based research
Approach to safety management Statutory food hygiene inspections External New statutory hygiene code to be introduced, linked
national/international management procedural to inspections. Infection control policies are expected
standards, e.g. BRC, ISO 22000 which are regularly to conform to national guidelines. Maybe internally
externally audited as part of the standard audited or inspected. Standards tend to be
performance rather than procedural. Subject to
random external checks
Approach to assessing cleanliness Routine microbiology/rapid tests used in Little routine monitoring of the environment. Visual
environmental monitoring, often linked to data assessment primary component of inspections
storage and trend analysis
Note: aThe precautionary principle has been defined as: “when an activity raises threats of human health or the environment, precautionary measures
should be taken even if some cause-and-effect relationships are not fully established scientifically”
Source: Tickner et al. (2000)
regular major news items (Unison, 2005). Central to both, as with many other industries, HACCP and the
is a concern over quality. Quality can be defined in many ways, although the American management of
Society for Quality definition as “the totality of characteristic of a product or service that
bear on its ability to satisfy a stated or implied need” indicates quality is not a single HCAIs
issue but made up of a number of components or attributes (Dillon and Griffith, 1997).
As evidenced by the media attention, within these quality attributes key to
consumers in both healthcare delivery and the food industry is “safety”. Managing 353
food safety and managing patient safety both have a long history; however, their
respective media coverage has resulted in them attracting increased consumer
scrutiny. Patient safety has many dimensions but the one receiving particular media
attention and concerns relates to reducing the level of hospital acquired infections
(National Audit Office, 2004).
In an attempt to bolster flagging confidence in food safety, the Richmond Report
(Richmond, 1991) endorsed the greater application of Hazard Analysis Critical Control
Point (HACCP) as a risk management approach. Details of HACCP, originally
developed for the US space programme, were first published nearly 20 years earlier but
although widely discussed had not been extensively implemented. Since, the early
1990s (Table II), HACCP has emerged worldwide as the basis for managing food
safety.

Date

1960s Pillsbury/US Natick Lab/NASA

1971 US national conference on food protection (1st mention of HACCP)
1973 Federal Drug Administration regulation low acid canned foods. Recommended use of
HACCP
1985 National Academy of Science report on HACCP
1988 Creation of National Advisory Committee on Microbiological Criteria of Food International
Committee on Microbiological Safety of Food document
1989 National Advisory Committee of Microbiological Specification for Food document endorsing
HACCP approach
1990 Richmond Report. Advocated use of HACCP
1991 Codex HACCP draft
1992 NACMSF document on HACCP
1993 EU Commission 93/43/ECC Recommended use of 5 HACCP principles Codex’93 Guidelines
1994 General Agreement on Tariff and Trade SPS/TBT
1995 5 HACCP Principles Mandatory in EU
1997 Pennington Report (recommended licensing of butchers, coupled with full HACCP
requirement) HACCP Mandatory US Seafoods Codex’97 Guidelines on HACCP (basis of
today’s approach)
1998 HACCP Mandatory in US Large Red Meat/Poultry NACMSF ’98 Guidelines
1999 HACCP Mandatory in US Medium Red Meat/Poultry WHO – Strategies for SLDBs
(document for small less developed businesses)
2000 HACCP Mandatory in US Small Red Meat/Poultry HACCP/Licensing English Butchers
Codex SLDB – HACCP document
2002 Ongoing application of HACCP principles to catering, e.g. Safe Catering in Northern Ireland
2004 EC 852/2004 Requirement for all food businesses to adopt HACCP principles in EU Table II.
2006 Legal requirements to apply HACCP in food businesses (other than primary production) History of HACCP –
across EU HACCP origins and
2006 þ Increase worldwide use of HACCP in food safety legislation development
IJHCQA References to the potential application of HACCP to aspects of healthcare start to
19,4 appear in the early 1990s (Hunter, 1991). However, like the food industry, there seems
to be a latent period and in spite of periodic additional articles it remains largely
unused. The aim of this paper is to argue, as HACCP evolves, there is a need to
re-examine food industry based approaches to risk management and their adaptation
and application to infection control.
354
Food industry-based approaches to quality and safety
The food industry is a chain stretching from production to service/consumption. A key
theme of a number of links in the chain has been, in addition to legislation, the
development and implementation of a number of external standards. These include, for
example, the British Retail Consortium (BRC) Global Standard Food (Issue 4) (BRC,
2005) and SQF2000 (SQF Institute, 2004) for food processing. Europgap and SQF1000
are similar standards for primary production. Central to these standards is safety and
for food processing, management is based on HACCP, a specific approach to risk
management. This works in conjunction with appropriate pre-requisite programmes
(PRPs) (general approach to risk management). Both are central to the BRC and SQF
standards. More recently, an international ISO standard (ISO: 22000), incorporating
these has been developed. The driving force behind the development of such schemes
is the need to provide evidence of, and demonstrate a company’s ability to, manage
food safety in relation to a global standard. Therefore, a key element of all these
schemes, in addition to business being subjected to their normal statutory
environmental health inspections, is the requirement for these standards to be
externally audited (minimum of one-and-half a days or longer depending on size and
complexity) by trained specialist auditors. Failure to achieve the standard could result
in the non-acceptance of the company’s products by supermarket chains and the loss of
major customers and sales.
The food service or catering industry does not make so much use of external
standards, although these are starting to emerge. Whilst the HACCP five elements
have been a theoretical requirement for all food businesses since 1995, new legislation
introduced in January 2006 requires, as a consequence of EC Regulation No. 852/2004,
all food business operators to have in place, implement and maintain a permanent
procedure based on HACCP principles (Codex Alimentarius Commission, 1997). These
will be subject to inspection by environmental health officers.
The HACCP approach was originally developed for manufacturing and an
international set of guiding principles and steps were agreed (Table III and Figure 1).
However, food service or catering operations are different from manufacturing
(Griffith, 2000) and HACCP has not, to date, been adopted by large numbers of smaller
catering businesses. The argument being that food production in catering is much less
standardised and controllable, with many more complex interactions, than a food
manufacturing process, with claims that classic HACCP is not applicable. The latest
legislative requirement for all food business has, therefore, exerted a powerful
evolutionary force on HACCP. If it is to be adopted, especially by small businesses, it
has to evolve and, therefore, it is perhaps timely to review its healthcare application.
The rationale being if HACCP is the internationally accepted method for food safety
management, is it applicable to managing HCAIs? The need for the latter, not only
because of media attention, alleviation of patient suffering, economic consequences of
 HACCP and the
Term Definition
management of
Hazard Biological, chemical or physical agent with the potential to cause an adverse HCAIs
health effect
Risk A function of the probability of an adverse health effect and the severity of that
effect, consequential to a hazard(s) in food
Concern Seriousness of a hazard: Severity and risk, e.g. high, medium, low or none 355
Risk management A structured approach/employment of actions to control/minimise or eliminate
risk
HACCP A system which identifies evaluates and controls hazards which are significant
for food safety (NHS Scotland, 2001)
Food Safety Management Systems based upon identified, named and validated Table III.
control measures, implemented at critical control points (Dillon and Griffith, 2001) Definitions

Figure 1.
Codex logic sequence
IJHCQA HCAIs and bed shortages but also because of increasing concerns over multi-drug
resistant organisms, limited availability of new antibiotics and effective treatment of
19,4 patients.

The clinical application of PRPs and a classical HACCP approach

Patients may have a compromised immune system and subjected to procedures
356 designed to bypass the body’s defences. Thus, some level of HCAI is unavoidable,
however, the aim of infection control should be to keep this to a minimum and it has
been estimated that approximately 33 per cent are preventable during particular
medical procedures (NHS Scotland, 2001). Achieving a reduction in infection rates is an
interaction of a number of functions (Figure 2). HACCP could provide a risk
management approach. However, it should be emphasised that individual human
behaviour, in the context of the prevailing organisational infection control culture, is an
important determinant of success. Outside the scope of this paper, compliance with
infection control policies, is known to be variable and often poor (Pittet, 2004), with a
prevailing culture, which in-spite of positive statements made by some Chief
executives is composed of mixed messages.
HACCP does not work in isolation but operates in conjunction with PRPs. As a
specific risk management system HACCP is designed to reduce identified hazards and
risks associated with a particular product or process, whilst PRPs are general risk
reduction practices and procedures (Tables IV and V, and Figure 3).
HACCP þ PRPs ¼ Safer Food
HACCP þ PRPs ¼ Healthier Patients?

Figure 2.
Factors influencing
patient quality and safety
The question is, can existing HACCP, or an adapted form, ensure healthier patients? HACCP and the
Before concentrating on HACCP, it is worthwhile examining PRPs in slightly more management of
detail. Definitions from the food industry have been modified for healthcare in
Tables IV and V and Figure 3 and examples of PRP related hospital procedures
HCAIs
include:

357
Term Definition

PRPs Describes all those activities other than specific HACCP plans, which affect food
(patient) safety. Universal steps or procedures that control the operational activities
within a food establishment allowing production of safe food (clinical environment to
minimise patient infection). Managed and documented Table IV.
Clinical HACCP Conduct hazard analysis The process of collecting and evaluating information on Definition of HACCP,
hazards and conditions leading to their presence to decide which are significant for PRPs, etc. – food and
patient safety and therefore should be addressed in the HACCP plan clinical

PRPs HACCP

Indirectly with food safety (patient’s health) Directly with food safety (patient health)
General Product: process specific (procedure specific) Table V.
Lower risk food poisoning (HAI) High risk food poisoning (HAI) PRPs versus HACCP

Figure 3.
PRPs, HACCP and
healthcare
IJHCQA .
design (layout), siting, construction of premises;
19,4 .
Siting, construction of equipment;
.
pest control;
. cleaning/sanitation;
.
raw materials (including water/consumables);
358 .
traceability and recall;
.
personal hygiene; and
.
training.

Cleaning wards/hospital rooms, etc. a subject of much media attention, would in most
cases, be regarded as a PRP rather than as part of HACCP. The precise role of cleanliness
in HCAIs is the subject of debate. One view is that “the inanimate environment is of little
importance in endemic hospital infections but may occasionally have a role in
outbreaks” (Ayliffe et al., 2000), although this view has been questioned (Griffith et al.,
2000; Dancer, 2002). Classified as a PRP, rather than part of HACCP, does not mean the
subject is ignored or unmanaged. The food manufacturing industry certainly places
great importance on cleaning as a means of pathogen control and uses routine
microbiological and ATP testing (a measure of residual organic soil) in cleaning
validation and verification (Griffith, 2005). Considered beneficial for monitoring the
cleaning effectiveness in the food industry, in general these techniques are little used in
healthcare, except possibly microbiological surface testing in outbreak investigations.
Reliance in hospitals is based on simple visual inspection of surfaces, which is known to
be flawed (Griffith et al., 2000; Cooper et al., 2006). In both food and healthcare, the subject
of pathogen reservoirs, survival and prolonged environmental persistence is receiving
increased attention (Griffith, 2005; Griffith, 2006; Sexton et al., 2006; Dancer, 1999; Sattar,
2004; Lemmen et al., 2004). Recent studies (Griffith et al., 2000; Malik, et al., 2002)
highlighted hospital cleaning method inadequacies and how simple changes, along the
lines of food industry good practice, can give significantly better results.
Systems such as HACCP have been mentioned occasionally in the medical literature
(Table VI), although reference to it in winning ways (Department of Health, 2003) has
probably provided the greatest impetus for reviewing its applicability. Included in
action area 1, it would probably have been more accurately located in action area 2
with cleaning equivalent to action area 3/4. Clinical applications of HACCP to date
(Table VI) have tended to concentrate on the prevention of gastrointestinal problems or
be concerned with medical devices. This is perhaps not so surprising given the food
origins of HACCP and the “safe product” orientation of both food processing and the
manufacturing of medical devices.
The Codex approach to food HACCP is based upon the following seven principles,
which are subdivided into 12 steps/logic sequence (Figure 1) (Codex Alimentarius
Commission, 1997):
(1) conduct hazard analysis;
(2) determine CPPs;
(3) establish critical limits;
(4) establish monitoring procedures;
 HACCP and the
Year Area Application
management of
1995 Airborne contamination Clean rooms HCAIs
1999 Gastrointestinal infection Expressed breast milk
1999 Gastrointestinal infection Infant formula
2000 General infection control Work flow: minimising cross infection
2000 Gastrointestinal infection Enterobacterial feeds 359
2001 Specific infection control problem Post operative endophthalmitis
2001 Gastrointestinal infection Hospital food
2002 Infection Control Guidelines for Main application to reprocessing of instruments
Acupuncture in Victoria, Australia
2002 Risk management in infection control Various, e.g. management of intravenous lines
2003 Clinical engineering Repair of specific devices
2003 Respiratory infection SARS
2003 Pharmaceutical production Management of specific products, e.g. antibiotics
2004 Specific infection control problems Cystic-fibrosis patient Table VI.
2005 Prevention of MRSA Cleaning Examples from the
2005 Medical devices and infection control Endoscopes literature of clinical
in general applications of HACCP

(5) establish corrective actions;

(6) establish verification procedures; and
(7) establish documentation.

These principles and steps can be directly applicable to some clinical applications, for
example, the decontamination of endoscopes. Providing a full worked example of a
HACCP plan is beyond our scope, but some examples of how Codex principles could be
adapted for the construction of an endoscopy decontamination HACCP plan are
provided. HACCP starts with assembling a team, which could include:
. nurses;
.
specialist practitioners;
.
administrators/domestic managers;
.
doctors;
.
infection control/microbiologists; and
. external consultants (?)

Assembling a team is Codex Principle 1 (P1); Logic Sequence 1 (LS1), Figure 4 a

process flow diagram P1/LS4, Table VII some known microbial hazards – Stage 1 of
Hazard Analysis P1/LS6, Table VIII application of the Codex Decision Tree
(identification of critical control points P2.LS7). Monitoring, defined as “The act of
conducting a planned sequence of observations or measurements of control parameters
to assess whether a CCP is under control” (P4/LS9) requires real time data for
appropriate corrective action to be taken and how this could help in managing the
process has previously been reported (Obee et al., 2005) All stages in the HACCP
process are important and the above are examples of how just some require little
clinical adaptation.
IJHCQA
19,4

360

Figure 4.
Endoscopy
decontamination flow
diagram
 HACCP and the
Cleaning Disinfection Rinsing Automated Contaminated processing
Bacteria procedure process process processor or water bottle management of
P aeruginosa X X X X X
HCAIs
Klebsiella sp. X X
Enterobacter sp. X X
Serratia X X 361
marcesns
Salmonella sp. X X X
Incl. typhi
Helocobacter X X X
pylori
Bacillus sp. X X
Proteus sp. X X
Mycobacterium X X
tuberculosis
Atypical X X X X
mycobacteria
Fungi
Trichosporon sp. X X X
Rhodotorula sp. X X X
Parasite Table VII.
Strongyloides X X Microogranisms
Virus transmitted by (or shown
Hepatitis B X X to contaminate)
Hepatitis C X X X endoscopes

Decision Tree
Questions
Process step Hazard Control measures 1 1a 2 3 4 CCP Y/N

Autodisinfection Survival of vegetative Chemical disinfection Y – Y – – Y Table VIII.

pathogens Determine CCPs: output
from use of codex
Note: Application of the decision tree for the chemical processing stage of an endoscope. The results decision tree when
of the individual questions are recorded as indicated to provide transparency of decision making and decontaminating
can be audible. Question 1a refers to the question “Is control at this step necessary for safety?” endoscopes

Clinicians may argue that hazards associated with endoscopies are well recognised and
numerous sets of decontamination guidelines exist (British Society of Gastroenterology,
2003). However, these are “sets of guidelines” and do not describe how the whole process
should be managed, which can cause problems (Hine, 2005). A comparison of an
endoscopy HACCP plan with the current management processes in two existing
endoscopy units is presented in Table IX. This illustrates a critical message about
HACCP that needs to be communicated to clinicians “HACCP does not tell you new
control measures, but how to manage their implementation”. The knowledge base
concerning appropriate/relevant control measures still lies with clinical staff/medical
microbiologists but the change relates to the application of new management skills.
IJHCQA
HACCP LS Unit A Unit B
19,4
LS1 No Partial
LS2 No Partial
LS3 No No
LS4 No No
362 LS5 No No
LS6 No Partial
LS7 Partial Partial
Table IX. LS8 Partial Partial
Comparison between LS9 No No
HACCP and management LS10 No No
systems in two LS11 No Partial
endoscopy units LS12 No Partial

Future clinical development of HACCP

Another criticism of the possible clinical application of HACCP has been “this could
work with medical devices or sterilised goods but not with other areas of infection
control, especially where procedures with patients are involved”. Such comments have
validity in that taking a “classical HACCP approach” is unlikely to be successful in
such circumstances and there are a number of hurdles (Table X) when reducing HCAIs
associated with patient procedures. However, some of the hurdles also apply to
catering HACCPs, which are being overcome. Use of sterilised items/medical devices,
like food production, is usually from “stock” and production or processing uses
automated equipment. Catering operations and infection control processes involving
patients are more procedural rather than product based, with a more varied
environment and monitoring difficulties. The catering industry has, over the past 3-4
years, taken HACCP principles but simplified processes, and as it evolves (Figure 5) it
becomes more relevant to their needs. Such developments include “Safer Food, Better
Business” (FSA, 2005), Safe Catering (Irish Model) and Cook Safe (Scottish Model). In
these examples, the linear product HACCP’s classical approach been adapted for a
catering processes. Similarly, a clinical HACCP approach for surgical equipment,
medical devices, etc. could evolve and be adapted for a process/patient approach, e.g.
for surgical site infections, urinary tract infections and intravenous catheters. Work on
these adaptations has already started (Griffith, 2006) and there are signs that other
initiatives (Department of Health, 2005) are borrowing ideas from HACCP.

Catering/IC Manufacturing/sterilised

Demand: work to order Demand: work to stock

Poor time control: short notice Better time control: Longer notice
Little scientific back up Good scientific back up
Procedure based involving patients/consumers Product based
Table X. Monitoring problematic Monitoring easier
HACCP and different Small scale equipment Larger scale equipment
types of operations Less automatic Greater automation
 HACCP and the
management of
HCAIs

363

Figure 5.
Evolution of HACCP

Benefits, barriers and costs of clinical HACCP

A key feature of introducing a HACCP-based approach is that greater consistency is
achieved either in the product or the process (Dillon and Griffith, 2001). Varying degrees of
additional documentation may be required but have the advantage in that they provide
transparency in what is being undertaken, are auditable and can be used to demonstrate
due diligence. One of the key HACCP stages is verification (P6LS11) and auditing is a
major component/requirement. Another key feature is that HACCP is proactive and
designed to “prevent” infections happening, and this philosophy is gaining in importance.
Hospital administrators [managers] are slowly starting to see the business case for
preventing infections and not just controlling them (Anon, 2005).
The potential outputs from adapting HACCP to infection control include a reduced risk of
infection, improved bed turnover, less wastage and improved confidence. However, a
number of benefits and barriers to the successful introduction of HACCP exist. These
include:
(1) Benefits.
.
consistency: documentation and records;
.
transparency: audibility;
.
comprehensive and specific; and
.
pro-active/preventative.
(2) Barriers.
. attitudes;
.
behavioural change;
.
costs; and
.
potential to save money and improve health.
IJHCQA Resource costs (training, time, etc.) may be barriers, although in the food industry they
19,4 have often initially been overestimated and real costs often include changes associated
with PRPs (good general hygiene), rather than HACCP (Mortlock et al., 2000; Griffith
et al., 2003). However, rather than just assessing the costs of introducing HACCP, there
needs to be balance against the potential savings by reducing infection (Figure 6),
although even a perfect HACCP will never eliminate them. Resource costs can be
364 divided into initial costs and ongoing or recurring costs; however, ultimately human
barriers may prove to be the greater problem. In the food industry, there is now a legal
requirement for a HACCP-based approach and this is a powerful driving force (“stick”).
However, the most influential factor in introducing HACCP into food manufacturing
was the pull (“carrot”), with retailers wanting their suppliers to use HACCP to manage
food safety and rewarding them with increased business. With recent changes in the
NHS market structure it is possible to envisage a situation where GPs might exert
similar requirements. They would want independent reassurance about the adequacy
of the infection control procedures before sending patients. Possible human barriers
may be clinical staff resentment, “doing things differently” and closed minds to new
approaches, lack of expertise, etc. Of interest is that exactly the same human and
perceived costs barriers were experienced in food manufacturing and, to some extent,
are still being experienced in the catering industry in introducing HACCP.

Summary and conclusions

Suggestions concerning the applicability of HACCP, a risk-based management
approach for use in infection control, have come from a number of sources/countries.
There are parallels between its introduction in the food chain, as well as differences.
Clinical HACCP has the potential to evolve in its own right. However, overcoming
barriers to its introduction in a clinical setting should not be underestimated and these
will include resource and human issues, with the latter potentially the greater.
Ultimately whether or when HACCP will be adapted for infection control depends on
perceived need and benefits, which in part will also depend upon hospital managers’
and clinicians’ receptiveness and their willingness to investigate management
approaches from other industries.

Figure 6.
Cost balance of HACCP
introduction
References HACCP and the
Anon (2005), APIC News Editorial 24:15. management of
Ayliffe, G.A.J., Francis, A.P., Geddes, A.M. and Mitchell, K. (2000), Control of Hospital Infections:
A Practical Handbook, 4th ed., Arnold Publishing, London.
HCAIs
BRC (2005), BRC Global Standard – Food (4), British Retail Consortium, January, available at:
www.brc.org.uk/standards/about_food.htm
British Society of Gastroenterology Endoscopy Committee (2003), “BSG guidelines for 365
decontamination of equipment for gastrointestinal endoscopy”, available at: www.bsg.org.
uk/clinical_prac/guidelines/disinfection.htm (accessed 26 July 2004).
Brownsell, V., Griffith, C.J. and Jan, E. (1989), Applied Science for Food Studies (Longman
Hotelwork & Catering Series), Longman, Harlow, ISBN 0582413672.
Codex Alimentarius Commission (1997), Hazard Analysis and Critical Control Points (HACCP)
System Principles and Guidelines for its Application, Annex II CAC/RCP-1 1969; Rev 3 M
99/13A, Appendix II.
Cooper, R.A., Griffith, C.J., Malik, R.E., Obee, P. and Looker, N. (2006), “Monitoring the
effectiveness of cleaning in four British hospitals”, Journal of Hospital Infection(in press).
Dancer, S.J. (1999), “Mopping up hospital infection”, Journal of Hospital Infection, Vol. 43,
pp. 85-100.
Dancer, S.J. (2002), “Hospital acquired infection: is cleaning the answer?”, CPD Infection, Vol. 3
No. 2, pp. 40-6.
Department of Health (2003), Winning Ways: Working together to Reduce Healthcare Associated
Infections in England, Chief Medical Office, London.
Department of Health (2005), “Saving lives: a delivery programme to reduce healthcare
associated infections (HCAIs) including MRSA: skills for implementation”, June, available
at: www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HealthcareAcquired
Infection/HealthcareAcquiredGeneralInformation/SavingLivesDeliveryProgramme/fs/en
Dillon, M. and Griffith, C.J. (1997), How to Audit: Verifying Food Control Systems, MD Associates,
Humberside, ISBN 1900134055.
Dillon, M. and Griffith, C.J. (2001), How to HACCP: An Illustrated Guide, 3rd ed., MD Associates,
Humberside.
FSA (2005), Safer Food, Better Business, Food Standards Agency, available at: www.
foodstandards.gov.uk/foodindustry/hygiene/sfbb/
Griffith, C.J. (2000), “Food safety in catering establishments”, in Farber, J.M. and Todd, E.C.D.
(Eds), Safe Handling of Foods, Marcel Dekker.
Griffith, C.J. (2005), “Monitoring the effectiveness of cleaning: detection and sampling”, in
Lelieveld, H.L.M, Mostert, M.A., Holah, J. and White, B. (Eds), Improving Hygiene in the
Food Industry, Woodhead Publishing Ltd, Cambridge.
Griffith, C.J. (2006), available at: www.riph.org/
Griffith, C.J., Hayburn, G. and Clayton, D. (2003), “An evaluation of the Butchers’ licensing
initiative in England”, A report for the Food Standards Agency, London.
Griffith, C.J., Cooper, R.A., Gilmore, J., Davies, C. and Lewis, M. (2000), “An evaluation of hospital
cleaning regimes and standards”, Journal of Hospital Infection, Vol. 45 No. 1, pp. 19-28.
Hine, D. (2005), The Report of an Independent Review of Endoscope Decontamination in Northern
Ireland, DHSS ref 2 96/2004.
Hunter, P. (1991), “Application of HACCP to the handling of expressed breast milk in a neonatal
unit”, Journal of Hospital Infection, Vol. 17, pp. 139-46.
IJHCQA Lemmen, S.W., Häfner, H., Zolldann, D., Stanzel, S. and Lütticken, R. (2004), “Distribution of
multi-resistant gram-negative versus gram-positive bacteria in the hospital inanimate
19,4 environment”, Journal of Hospital Infection, Vol. 56 No. 3, pp. 191-7.
Malik, R.E., Cooper, R.A. and Griffith, C.J. (2002), “The use of audit tools to evaluate the efficacy
of cleaning systems in hospitals”, American Journal of Infection Control, Vol. 31 No. 3,
pp. 181-7.
366 Mortlock, M.P., Peters, A.C. and Griffith, C.J. (2000), “A national survey of food hygiene training
and qualification levels in the UK food industry”, International Journal of Environmental
Health Research, Vol. 10 No. 2, pp. 111-23.
National Audit Office (2004), “Improving patient care by reducing the risk of hospital acquired
infections”, Report by the Comptroller and Auditor General, HMSO London, HC 876
Session 2003-2004: 14 July.
NHS Scotland (2001), “Managing the risk of healthcare associated infection in NHS Scotland”,
Report of a Joint Scottish Executive Health Department and NHS Scotland Working
Group, April, available at: www.show.scot.nhs.uk/sehd/mels/HDL200153Carey.pdf
Obee, P., Griffith, C., Cooper, R.A., Cooke, R.P., Bennion, N.E. and Lewis, M. (2005), “The
application of real-time monitoring to the disinfection of flexible gastrointestinal (GI)
endoscopes”, American Journal of Infection Control, Vol. 33 No. 4, pp. 202-6.
Pittet, D. (2004), “The lawbury lecture: behaviour in infection control”, Journal of Hospital
Infection, Vol. 58, pp. 1-13.
Richmond, M. (1991), “The microbiological safety of food. Part II”, Report of the Committee on
the Microbiological Safety of Foods, HMSO, London, Chairman.
Sattar, S.A. (2004), “Microbicides and the environmental control of nosocomial viral infections”,
Journal of Hospital Infection, Vol. 56 No. (Supp 2), pp. 64-9.
Scrivens, E. (2005), Quality, Risk and Control in Healthcare, Open University Press, Maidenhead.
Sexton, T., Clarke, P., O’Neill, E., Dillane, T. and Humphreys, H. (2006), “Environmental
reservoirs of methicillin-resistant Staphylococcus aureus in isolation rooms: correlation
with patient isolates and implications for hospital hygiene”, Journal of Hospital Infection,
Vol. 62 No. 2, pp. 133-260.
SQF (2004), Safe Quality Food Institute, available at: www.sqfi.com/
Tickner, J., Raffensperger, C. and Myers, N. (2000), The Precautionary Principle in Action
Handbook, 1st ed., written for the Science and environmental Health Network, available at:
www.biotech-info.net/handbook.pdf
Unison (2005), “Hospital contract cleaning and infection control”, available at: www.unison.org.
uk/acrobat/14564.pdf

Further reading
Denton, M., Wilcox, M.H., Parnell, P., Green, D., Keer, V., Hawkey, P.M., Evans, I. and Murphy, P.
(2004), “Role of environmental cleaning in controlling an outbreak of acinetobacter
baumanii on a neurosurgical intensive care unit”, Journal of Hospital Infection, Vol. 56,
pp. 106-10.
Griffith, C.J., Obee, P., Cooper, R.A. and Lewis, M. (2006), “The effectiveness of existing and
modified cleaning regimes in a welsh hospital”, Journal of Hospital Infection(in press).
Health Service Executive (2005) Report on a National Acute Hospitals Hygiene Audit,
undertaken on behalf of the national hospitals office, available at: www.hse.ie/en/News/
title,2621,en.html
Mortlock, M.P., Peters, A.C. and Griffith, C.J. (1998), “Applying HACCP to small retailers and HACCP and the
caterers: a cost benefit approach”, paper presented at Economics of HACCP: New Studies
on Costs and Benefits Conference, Washington. July. management of
Redmond, E.C. and Griffith, C.J. (2005), “Evaluation of consumer food safety education initiatives HCAIs
in the UK and determination of effective strategies for food safety risk communication”,
A report for the Food Standards Agency, London.
Royal Society of Gastroenteriology (2003), “Guidelines for the decontamination of endoscopes for 367
gastrointestinal endoscopy”, Report of the Working Party of the Endoscopy Committee,
October.

Corresponding author
Chris Griffith can be contacted at: cgriffith@uwic.ac.uk

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints