Audit Tool For University Hospital

• Conducted on

  Date

• Novelet McKenzie-Murray

• UHWI
  Address

• Number of Physician

  Media

• Number of Nurses

  Yes

  No

  N/A

• Number of PCA

  Yes

  No

  N/A

• Number of House Keepers

  Yes

  No

  N/A

• Number of Porters

  Yes

  No

  N/A

• Number of Clerks

  Yes

  No

  N/A

• Students

  Yes

  No

  N/A

• Other Workers

  Yes

  No

  N/A

• General Hospital policies in place & available

  Yes

  No

  N/A

• Nursing policy manual

  Yes

  No

  N/A

• Unit/area specific manual

  Yes

  No

  N/A

• Unit/area specific policy manual

  Yes

  No

  N/A

• Nursing policy manual

  Yes

  No

  N/A

• Staff Orientation manual

  Yes

  No

  N/A

• Infection Control manual

  Yes

  No

  N/A

• Equipment/Service Manual

  Yes

  No

  N/A

• Procedural Guidelines

  Yes

  No

  N/A

• Clinical practice guidelines

  Yes

  No

  N/A

• Occupational Health and Safety Guidelines

  Yes

  No

  N/A

• Infection Prevention & control guidelines

  Yes

  No

  N/A

• Do managers, supervisors and employees have a clear understanding of their roles and responsibilities

  Yes

  No

  N/A

• Is there evidence of compliance with statutory requirement

  Yes

  No

  N/A

Communication

• Is there communication procedure/protocol

  Yes

  No

  N/A

• Are employees knowledgeable about health and safety management

  Yes

  No

  N/A

• Are managers aware of Heath of the heath and safety role and responsibilites

  Yes

  No

  N/A

• Are relevant health and safety policies and procedures communicated to employees

  Yes

  No

  N/A

• Are policies and procedures manual easily accessible at the workplace

  Yes

  No

  N/A

• Is there a policy and procedure in place for reporting incidents and near mises

  Yes

  No

  N/A

• Are incidents/accidents written as per policy

  Yes

  No

  N/A

TRAINING AND SUPERVISION

• Is safety and health training made available for all employees

  Yes

  No

  N/A

• Are all employees aware pf their duies to attend safety and health training

  Yes

  No

  N/A

• Is non attendance at training programmes recorded/managed

  Yes

  No

  N/A

• Do employees understand the limitations and use of PPE

  Yes

  No

  N/A

• Is training programmes in place

  Yes

  No

  N/A

• Is there a system for flagging refresher training

  Yes

  No

  N/A

• Is refresher training provided

  Yes

  No

  N/A

• Is there a formal orientation programme for new employees

  Yes

  No

  N/A

• Is health and safety adequately addressed in the orientation programme

  Yes

  No

  N/A

• Are employees given instruction, training and supervision in a form, manner and as appropriate, language that is likely to be understood by the employee

  Yes

  No

  N/A

• Is instruction, training and supervision provided to employees in recruitment, transfer, change task, on new equipment, new tehnology etc.

  Yes

  No

  N/A

• Blood, bodily fluid exposure management posted

  Yes

  No

  N/A

• Hazardous chemical: labels and MSDSs

  Yes

  No

  N/A

• Restricted area

  Yes

  No

  N/A

• Fire exits

  Yes

  No

  N/A

• Evacuation routes

  Yes

  No

  N/A

• Isolation signs

  Yes

  No

  N/A

• Wet Floor

  Yes

  No

  N/A

• Eye wash stations (e.g. lab, chemical storage areas)

  Yes

  No

  N/A

• Instruction for use of Personal Protective Equipment

  Yes

  No

  N/A

• Noise protection required

  Yes

  No

  N/A

• Bio-hazard areas

  Yes

  No

  N/A

• Radiation area

  Yes

  No

  N/A

• Hand Hygiene posters

  Yes

  No

  N/A

WASTE DISPOSAL

• Written bio-hazardous waste protocol present

  Yes

  No

  N/A

• Written regular waste disposal protocol present

  Yes

  No

  N/A

• Appropriately label containers/bag for waste

  Yes

  No

  N/A

• Waste facility in good condition

  Yes

  No

  N/A

• Waste segregation adhere to

  Yes

  No

  N/A

PSYCHO-SOCIAL HAZARD

• Contact for security posted

  Yes

  No

  N/A

• Emergency number for internal and external contacts are available

  Yes

  No

  N/A

• Visitors/Contractors rules in place

  Yes

  No

  N/A

• THERE IS A SYSTEM IN PLACE TO IMPLEMENT, MONITOR AND EVALUATE INFECTION PREVENTION AND CONTROL

  Select Yes No N/A

  • Yes
  • No
  • N/A

• There is an active IPC Committee at the hospital {meeting and action items evident}

  Yes

  No

  N/A

• The committee meets at least every 2 months

  Yes

  No

  N/A

• The Health Facility's Infection Control Policies and Procedures Manual is readily available in the Nursery

  Yes

  No

  N/A

• Staff of the Nursery of the Nursery are aware of the key concepts contained in the manual

  Yes

  No

  N/A

• The ward sister/charge nurse/team leader is aware of their role and responsibility in relation to infection prevention and control (IPC)

  Yes

  No

  N/A

• Within the Nursery, there is a lead person responsible for IPC

  Yes

  No

  N/A

• There is evidence of a multi-professional approach to IPC {meetings & Minutes}

  Yes

  No

  N/A

• There is evidence that at least one (1) Audit on IPC practices has been conducted in the nursery within the last 12 months

  Yes

  No

  N/A

• There is evidence of improvements in keeping with corrective action schedule from the last audit

  Yes

  No

  N/A

• IPC nurse conduct daily visits to the neonatal nursery

  Yes

  No

  N/A

• Incidents related to IPC are reported immediately to IPC committee and Hospital Directorate immediately

  Yes

  No

  N/A

• There is evidence that outbreak of an infection or increased incidence of an infection is reported to the surveillance Unit of the Ministry of Health within 24 hours

  Yes

  No

  N/A

• There is evidence that incidents related to infection prevention and control are actioned appropriately

  Yes

  No

  N/A

HAND HYGIENE

• There is adequate Eqiupment and Supplies for hand hygiene

  Yes

  No

  N/A

• Soft absorbent paper towels are available at all hand washing sinks

  Yes

  No

  N/A

• Soap available in dispensers

  Yes

  No

  N/A

• Adequate Hot water available

  Yes

  No

  N/A

• Adequate cold water availble

  Yes

  No

  N/A

• Sinks clean and well maintained

  Yes

  No

  N/A

• Wash hand sinks present in dirty utility room

  Yes

  No

  N/A

• Sinks present in clean room

  Yes

  No

  N/A

• Clean and dirty sink identified

  Yes

  No

  N/A

• Hand sanitizer dispenser clean & good working order

  Yes

  No

  N/A

• Soap dispenser in clean & good working order

  Yes

  No

  N/A

Linen

• Proper Management of Soil or contaminated linen

  Yes

  No

  N/A

Drug

• Proper storage

  Yes

  No

  N/A

• Expired

  Yes

  No

  N/A

• Date and time of used medication

  Yes

  No

  N/A

• Safe Injection Practices

  Yes

  No

  N/A

Suitable Personal Protective Equipment; Adequate Supplies of:

• N95 respirator in adequate amount

  Yes

  No

  N/A

• Protective eyewear

  Yes

  No

  N/A

• Impermeable gowns

  Yes

  No

  N/A

• Workers trained in PPE

  Yes

  No

  N/A

• PPE available and worn when necessary

  Yes

  No

  N/A

• Disposable gowns

  Yes

  No

  N/A

• Shoe coverings

  Yes

  No

  N/A

• Surgical Masks

  Yes

  No

  N/A

PATIENT CARE AREA

• Furniture in good condition

  Yes

  No

  N/A

• Refrigerator temperature recorded & Maintained

  Yes

  No

  N/A

• Personal Items neatly placed

  Yes

  No

  N/A

• Nurses station clean and tidy

  Yes

  No

  N/A

• Isolation room appropriately ventilated

  Yes

  No

  N/A

• Is there patient call system in the unit/functional

  Yes

  No

  N/A

• Are patient aware of the system

  Yes

  No

  N/A

• Does staff respond to alarms/buzzers

  Yes

  No

  N/A

• Broken beds, stretchers, Wheel Chair/tables/lockers/mattresses

  Yes

  No

  N/A

• Handrails/grab bars in bathroom

  Yes

  No

  N/A

• non skid tiles/bath boards in shower

  Yes

  No

  N/A

• Are patient aware of the system

  Yes

  No

  N/A

Equipment Procedure

• Autoclave clean & in good working condition

  Yes

  No

  N/A

• Frequent Microbiological testing

  Yes

  No

  N/A

• Microwave clean & in good working order

  Yes

  No

  N/A

• Glucometer, oximeters, monitoring equipment clean

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Patient lift available, maintained & clean

  Yes

  No

  N/A

• Bedpan flusher/sterilizers clean and in good working condition

  Yes

  No

  N/A

• Oxygen Cylinder storage appropriate

  Yes

  No

  N/A

• Cleaning procedure appropriate

  Yes

  No

  N/A

• Guarding safety device in place

  Yes

  No

  N/A

• Start/stop switches clearly marked and easy to reach

  Yes

  No

  N/A

• Safe operating procedure available

  Yes

  No

  N/A

• Lockout procedure available

  Yes

  No

  N/A

• Training given in safe use of tools and machinery

  Yes

  No

  N/A

• Manufacturer's manuals available for all tools and machinery

  Yes

  No

  N/A

SANITARY ENGINEERING

• Schedule cleaning for water storage tank

  Yes

  No

  N/A

• Residual chlorine present in tap water

  Yes

  No

  N/A

• Plumbing Fixture

  Yes

  No

  N/A

• Air Conditioning unit

  Yes

  No

  N/A

ERGONOMICS

• Suitable ergonomics chairs available

  Yes

  No

  N/A

• Foot rest provided for desk

  Yes

  No

  N/A

• Countertops & Work station at appropriate height & adjustable

  Yes

  No

  N/A

• Ergonomic lifting device available

  Yes

  No

  N/A

• Store heavy items at waste height

  Yes

  No

  N/A

Sharps Handling

• Sharps disposal at point-of-use

  Yes

  No

  N/A

• Sharps container not overfilled(2/3)

  Yes

  No

  N/A

• Sharps container appropriate

  Yes

  No

  N/A

• Safety Engineered needles available

  Yes

  No

  N/A

• Sharps containers elevated

  Yes

  No

  N/A

ENVIRONMENTAL HEALTH - Physical Environment

• Floor slip-proof

  Yes

  No

  N/A

• Floor, walls doors, and ceiling clean & intact

  Yes

  No

  N/A

• Floor & doorway clear and free of obstructions

  Yes

  No

  N/A

• Good drainage for spills

  Yes

  No

  N/A

• Changes in floor level clearly marked

  Yes

  No

  N/A

• No mold or fungus

  Yes

  No

  N/A

• No cords on floors & other tripping hazards

  Yes

  No

  N/A

• Shelves present and adequate to support material

  Yes

  No

  N/A

• Steps and rails adequate

  Yes

  No

  N/A

• Ramps for disable present

  Yes

  No

  N/A

LIGHTING/ELECTRICAL

• Lighting adequate, maintained

  Yes

  No

  N/A

• Task specific lighting present where appropriate

  Yes

  No

  N/A

• Natural lighting adequate

  Yes

  No

  N/A

• Emergency lighting provided and Maintained

  Yes

  No

  N/A

• Electrical outlets well located

  Yes

  No

  N/A

• Outlets sufficient to avoid overloading

  Yes

  No

  N/A

VENTILATION AIR EXCHANGE

• Minimum 15 total air changes per <br> hour

  Yes

  No

  N/A

• Minimum 3 air changes of outdoor <br>air per hour

  Yes

  No

  N/A

• Negative pressure in Isolation areas, autopsy suite

  Yes

  No

  N/A

• Positive pressure in operating room

  Yes

  No

  N/A

• Mechanical ventilation for hazardous emissions such as sterilizing chemicals

  Yes

  No

  N/A

• Temperature Satisfactory

  Yes

  No

  N/A

• Relative Humidity Satisfactory

  Yes

  No

  N/A

• CO2 satisfactory

  Yes

  No

  N/A

Exhaust Fume Hood

• Physical integrity satisfactory

  Yes

  No

  N/A

• Signs of blockage

  Yes

  No

  N/A

• Unusual Noise

  Yes

  No

  N/A

Filters

• Type of Filters satisfactory

  Yes

  No

  N/A

• Filter efficiency satisfactory

  Yes

  No

  N/A

• Filter clean

  Yes

  No

  N/A

• Signs of by passing

  Yes

  No

  N/A

• Change out schedule

  Yes

  No

  N/A

Duct Work

• Physical integrity satisfactory

  Yes

  No

  N/A

• Dryness & Cleanliness satisfactory

  Yes

  No

  N/A

• Signs of blockage from static pressure

  Yes

  No

  N/A

• Air balancing records

  Yes

  No

  N/A

Reheat Coils/Mixing Boxes

• Dryness & Cleanliness Satisfactory

  Yes

  No

  N/A

• VAV(Variable air volume) calibration set for at least minimum

  Yes

  No

  N/A

• Required outside air delivery at all times

  Yes

  No

  N/A

HVAC Equipment( e.g. Heating/cooling units, stacks and condensers)

• Physical integrity

  Yes

  No

  N/A

• Dryness & Cleanliness satisfactory

  Yes

  No

  N/A

• No slime, mold, dirt bird dropping, soot accumulation

  Yes

  No

  N/A

• Integrity & cleanliness of chamber floor, wall and ceiling

  Yes

  No

  N/A

• Cleanliness & operation of various components satisfactory

  Yes

  No

  N/A

Thermostats

• Type & Location appropriate

  Yes

  No

  N/A

• Set appropriately

  Yes

  No

  N/A

• Access controlled

  Yes

  No

  N/A

EMERGENCY EXITS & FIRE PROTECTION

• Emergency exits visible

  Yes

  No

  N/A

• Emergency exit free from obstruction

  Yes

  No

  N/A

• Emergency evacuation plan posted

  Yes

  No

  N/A

• Fire extinguishers present

  Yes

  No

  N/A

• Fire extinguishes regularly inspected

  Yes

  No

  N/A

• Fire Protection equipment (e.g hoses) accessible & maintained

  Yes

  No

  N/A

• Clear access to electrical panels/no combustible material stored

  Yes

  No

  N/A

• Sockets in good condition

  Yes

  No

  N/A

Staff Areas: Clean and Orderly Appearance, enough room to work

• Staff lockers/change area accessible and available

  Yes

  No

  N/A

• Staff lounge present & clean with no medical supplies or device

  Yes

  No

  N/A

• Staff toilet clean

  Yes

  No

  N/A

• Refrigerator in good working orde

  Yes

  No

  N/A

• Furniture/office equipment secure from tripping: appropriate work being done

  Yes

  No

  N/A

• Treatment room

  Yes

  No

  N/A

• Equipment storage

  Yes

  No

  N/A

• Chemical storage

  Yes

  No

  N/A

• Staff Areas

  Yes

  No

  N/A

• Work areas(e.g.lab benches, maintenance rooms

  Yes

  No

  N/A

• Containers with proper lids

  Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A