Title Page
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Conducted on
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Auditors
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Ward/ Department
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Overall findings
STAFFCOMPLIMENT
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Number of Physician
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Number of Nurses
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Number of PCA
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Number of House Keepers
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Number of Porters
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Number of Clerks
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Students
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Other Workers
LEADERSHIP/GOVERNANCE
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Unit/area specific policy manual
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Nursing policy manual
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Staff Orientation manual
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Infection Control manual
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Equipment/Service Manual
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Procedural Guidelines
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Clinical practice guidelines
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Occupational Health and Safety Guidelines
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Do managers, supervisors and employees have a clear understanding of their roles and responsibilities
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Staff knowledgeable about management of spills
SIGNAGE PRESENT & INSTRUCTIONS CLEAR
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Blood, bodily fluid exposure management posted
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Hazardous chemical: labels and MSDSs
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Restricted area
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Fire exits
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Evacuation routes
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Isolation signs
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Wet Floor
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Eye wash stations (e.g. lab, chemical storage areas)
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Instruction for use of Personal Protective Equipment
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Noise protection required
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Bio-hazard areas
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Radiation area
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Hand Hygiene posters
WASTE DISPOSAL
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Written bio-hazardous waste protocol present
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Written regular waste disposal protocol present
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Appropriately label containers/bag for waste
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Waste bins not more than 3/4 full and in good working condition
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Waste segregation adhere to
PSYCHO-SOCIAL HAZARD
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Contact for security posted
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Emergency number for internal and external contacts are available
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Visitors/Contractors rules in place
INFECTION PREVENTION & CONTROL
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Staff of the unit are aware of the key concepts contained in the manual
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The ward sister/charge nurse/team leader is aware of their role and responsibility in relation to infection prevention and control (IPC)
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Within the unit, there is a lead person responsible for IPC
HAND HYGIENE
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There is adequate Eqiupment for hand hygiene
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Paper towels are available at all hand washing sinks
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Soap available in dispensers
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Adequate Hot water available
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Adequate cold water available
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Sinks clean and well maintained
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Wash hand sinks present in dirty utility/ sluice room
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Sinks present in clean room
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Clean and dirty sink identified
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Soap Hand sanitizer and towel dispensers clean & in good working order
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Staff knowledgeable about hand hygiene procedure
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Staff aware of the 5 moments of hand hygiene
Environmental Cleaning and disinfection
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Cleaning schedule available and accessible
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Check list available and completed
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Cleaning and sanitizing done at least twice per day
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Patient immediate environment clean and sanitize after each use
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Staff aware of the cleaning and sanitizing procedure
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Disinfectant use is the correct concentration
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Reusable cleaning cloth washed, disinfected and allowed to dry after use
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High touch areas are cleaned at least every two hours
Procedure for handling infectious cases
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Are infectious (MDRs) cases reported as class 1 notifiable disease
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Are dedicated equipment used on these patients
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Are equipment cleaned and disinfected after each use
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Are Protocols for contact, droplet and airborne precautions adhered to
Linen
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Proper management of clean linen
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Proper management of soil and contaminated linen
Medication
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Proper storage
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Not Expired
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Date and time of multi vial medication indicated
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Safe Injection Practices
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Storage temperature for medication appropriate
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Storage temperature refrigerator logged
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No food present in medication refrigerator
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Medication refrigerator clean & in good working order
Suitable Personal Protective Equipment; Adequate Supplies of:
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N95 respirator available and in adequate amount
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Protective eye wear available and in adequate amount
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Impermeable gowns available and in adequate amount
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Workers trained in donning and doffing of PPE
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Disposable gowns available and in adequate supply
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Respirator available for handling chemicals
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Surgical Masks available and in adequate amount
PATIENT CARE AREA
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Furniture in good condition (can be easily cleaned)
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Refrigerator temperature recorded & Maintained
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Refrigerator clean and in good working condition
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Personal Items neatly placed
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Nurses station clean and tidy
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Isolation room appropriately ventilated
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Is there patient call system in the unit/functional
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Are patient aware of the system
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Does staff respond to alarms/buzzers
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No damaged or broken beds, stretchers, Wheel Chair/tables/lockers/mattresses
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Handrails/grab bars in bathroom
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non skid tiles/bath boards in shower
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Is there standard spacing between patients > or = to 3ft
Equipment Procedure
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Autoclave clean & in good working condition
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Frequent Microbiological testing
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Microwave clean & in good working order
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Glucometer, oximeters, monitoring equipment clean
- Yes
- No
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Patient lift available, maintained & clean
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Bedpan flusher/sterilizers clean and in good working condition
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Oxygen Cylinder storage appropriate
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Dialysis machines cleaned and sanitized and maintained according to manufacturer
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Cleaning procedure adhered to as per protocol & schedule available
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Guarding safety device in place
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Start/stop switches clearly marked and easy to reach
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Safe operating procedure available
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Lockout procedure available
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Training given in safe use of tools and machinery
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Manufacturer's manuals available for all tools and machinery
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Are reusable devices/equipment handled according to guidelines
SANITARY ENGINEERING
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Schedule cleaning for water storage tank
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Residual chlorine present in tap water
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Plumbing Fixture clean and in good working condition
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Air Conditioning unit clean and in good working condition
ERGONOMICS
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Suitable ergonomics chairs available
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Foot rest provided for desk
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Countertops & Work station at appropriate height & adjustable
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Ergonomic lifting device available
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Store heavy items at waste height
SHARPS HANDLING
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Sharps disposal at point-of-use
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Sharps container not more than 3/4 full
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Sharps container appropriate
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Safety Engineered needles available
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Sharps containers elevated
ENVIRONMENTAL HEALTH - Physical Environment
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Floor slip-proof
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Floor, walls, doors, and ceiling clean & intact
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Floor & doorway clear and free of obstructions
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Good drainage for spills
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Changes in floor level clearly marked
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No mold or fungus
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No cords on floors & other tripping hazards
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Shelves present and adequate to support material
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Steps appear safe and in good condition
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Rails intact and in place
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Ramps for disable present
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Adequate storage space available
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FIFO praciced
LIGHTING/ELECTRICAL
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Lighting adequate, maintained
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Task specific lighting present where appropriate
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Natural lighting adequate
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Emergency lighting provided and Maintained
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Electrical outlets intact
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Outlets sufficient to avoid overloading
VENTILATION AIR EXCHANGE
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Minimum 12 total air changes per <br> hour
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Minimum 3 air changes of outdoor <br>air per hour
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Negative pressure in Isolation areas, autopsy suite
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Positive pressure in operating room
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Mechanical ventilation for hazardous emissions such as sterilizing chemicals
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Temperature Satisfactory
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Relative Humidity Satisfactory
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CO2 satisfactory
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MO satisfactory
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VOC Satisfactory
Exhaust Fume Hood
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Physical integrity satisfactory
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Signs of blockage
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Unusual Noise
Filters
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Type of Filters satisfactory
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Filter efficiency satisfactory
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Filter clean
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Signs of by passing
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Change out schedule
Duct Work
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Physical integrity satisfactory
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Dryness & Cleanliness satisfactory
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Signs of blockage from static pressure
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Air balancing records
Reheat Coils/Mixing Boxes
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Dryness & Cleanliness Satisfactory
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VAV(Variable air volume) calibration set for at least minimum
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Required outside air delivery at all times
HVAC Equipment( e.g. Heating/cooling units, stacks and condensers)
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Physical integrity
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Dryness & Cleanliness satisfactory
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No slime, mold, dirt bird dropping, soot accumulation
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Integrity & cleanliness of chamber floor, wall and ceiling
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Cleanliness & operation of various components satisfactory
Thermostats
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Type & Location appropriate
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Set appropriately
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Access controlled
Air Conditioning Unit (non HVAC)
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AC clean and in good working in condition
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Temperature within acceptable standards
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Cleaning schedule available for the unit
EMERGENCY EXITS & FIRE PROTECTION
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Emergency exits visible
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Emergency exit free from obstruction
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Emergency evacuation plan posted
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Fire extinguishers present
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Fire extinguishes regularly inspected
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Fire Protection equipment (e.g hoses) accessible & maintained
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Clear access to electrical panels/no combustible material stored
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Sockets in good condition
Staff Areas: Clean and Orderly Appearance, enough room to work
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Staff lockers/change area accessible and available
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Staff lounge present & clean with no medical supplies or device
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Staff toilet clean
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Refrigerator in good working orde
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Furniture/office equipment secure from tripping: appropriate work being done
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Treatment room
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Equipment storage
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Chemical storage
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Staff Areas
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Work areas(e.g.lab benches, maintenance rooms
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Containers with proper lids
Sewage Manaagement
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Signage place on lavatory door
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Toilet clean and in good working codition
Chemicals
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Proper and adequate storage space
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Proper label
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MSDS available
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Signature
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Manager