STAFFCOMPLIMENT

Number of Physician
Number of Nurses
Number of PCA
Number of House Keepers
Number of Porters
Number of Clerks
Students
Other Workers

LEADERSHIP/GOVERNANCE

Unit/area specific policy manual

Nursing policy manual

Staff Orientation manual

Infection Control manual

Equipment/Service Manual

Procedural Guidelines

Clinical practice guidelines

Occupational Health and Safety Guidelines

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

Staff knowledgeable about management of spills

SIGNAGE PRESENT & INSTRUCTIONS CLEAR

Blood, bodily fluid exposure management posted

Hazardous chemical: labels and MSDSs

Restricted area

Fire exits

Evacuation routes

Isolation signs

Wet Floor

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

Instruction for use of Personal Protective Equipment

Noise protection required

Bio-hazard areas

Radiation area

Hand Hygiene posters

WASTE DISPOSAL

Written bio-hazardous waste protocol present

Written regular waste disposal protocol present

Appropriately label containers/bag for waste

Waste bins not more than 3/4 full and in good working condition

Waste segregation adhere to

PSYCHO-SOCIAL HAZARD

Contact for security posted

Emergency number for internal and external contacts are available

Visitors/Contractors rules in place

INFECTION PREVENTION & CONTROL

Staff of the unit are aware of the key concepts contained in the manual

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

Within the unit, there is a lead person responsible for IPC

HAND HYGIENE

There is adequate Eqiupment for hand hygiene

Paper towels are available at all hand washing sinks

Soap available in dispensers

Adequate Hot water available

Adequate cold water available

Sinks clean and well maintained

Wash hand sinks present in dirty utility/ sluice room

Sinks present in clean room

Clean and dirty sink identified

Soap Hand sanitizer and towel dispensers clean & in good working order

Staff knowledgeable about hand hygiene procedure

Staff aware of the 5 moments of hand hygiene

Environmental Cleaning and disinfection

Cleaning schedule available and accessible

Check list available and completed

Cleaning and sanitizing done at least twice per day

Patient immediate environment clean and sanitize after each use

Staff aware of the cleaning and sanitizing procedure

Disinfectant use is the correct concentration

Reusable cleaning cloth washed, disinfected and allowed to dry after use

High touch areas are cleaned at least every two hours

Procedure for handling infectious cases

Are infectious (MDRs) cases reported as class 1 notifiable disease

Are dedicated equipment used on these patients

Are equipment cleaned and disinfected after each use

Are Protocols for contact, droplet and airborne precautions adhered to

Linen

Proper management of clean linen

Proper management of soil and contaminated linen

Medication

Proper storage

Not Expired

Date and time of multi vial medication indicated

Safe Injection Practices

Storage temperature for medication appropriate

Storage temperature refrigerator logged

No food present in medication refrigerator

Medication refrigerator clean & in good working order

Suitable Personal Protective Equipment; Adequate Supplies of:

N95 respirator available and in adequate amount

Protective eye wear available and in adequate amount

Impermeable gowns available and in adequate amount

Workers trained in donning and doffing of PPE

Disposable gowns available and in adequate supply

Respirator available for handling chemicals

Surgical Masks available and in adequate amount

PATIENT CARE AREA

Furniture in good condition (can be easily cleaned)

Refrigerator temperature recorded & Maintained

Refrigerator clean and in good working condition

Personal Items neatly placed

Nurses station clean and tidy

Isolation room appropriately ventilated

Is there patient call system in the unit/functional

Are patient aware of the system

Does staff respond to alarms/buzzers

No damaged or broken beds, stretchers, Wheel Chair/tables/lockers/mattresses

Handrails/grab bars in bathroom

non skid tiles/bath boards in shower

Is there standard spacing between patients > or = to 3ft

Equipment Procedure

Autoclave clean & in good working condition

Frequent Microbiological testing

Microwave clean & in good working order

Glucometer, oximeters, monitoring equipment clean

Patient lift available, maintained & clean

Bedpan flusher/sterilizers clean and in good working condition

Oxygen Cylinder storage appropriate

Dialysis machines cleaned and sanitized and maintained according to manufacturer

Cleaning procedure adhered to as per protocol & schedule available

Guarding safety device in place

Start/stop switches clearly marked and easy to reach

Safe operating procedure available

Lockout procedure available

Training given in safe use of tools and machinery

Manufacturer's manuals available for all tools and machinery

Are reusable devices/equipment handled according to guidelines

SANITARY ENGINEERING

Schedule cleaning for water storage tank

Residual chlorine present in tap water

Plumbing Fixture clean and in good working condition

Air Conditioning unit clean and in good working condition

ERGONOMICS

Suitable ergonomics chairs available

Foot rest provided for desk

Countertops & Work station at appropriate height & adjustable

Ergonomic lifting device available

Store heavy items at waste height

SHARPS HANDLING

Sharps disposal at point-of-use

Sharps container not more than 3/4 full

Sharps container appropriate

Safety Engineered needles available

Sharps containers elevated

ENVIRONMENTAL HEALTH - Physical Environment

Floor slip-proof

Floor, walls, doors, and ceiling clean & intact

Floor & doorway clear and free of obstructions

Good drainage for spills

Changes in floor level clearly marked

No mold or fungus

No cords on floors & other tripping hazards

Shelves present and adequate to support material

Steps appear safe and in good condition

Rails intact and in place

Ramps for disable present

Adequate storage space available

FIFO praciced

LIGHTING/ELECTRICAL

Lighting adequate, maintained

Task specific lighting present where appropriate

Natural lighting adequate

Emergency lighting provided and Maintained

Electrical outlets intact

Outlets sufficient to avoid overloading

VENTILATION AIR EXCHANGE

Minimum 12 total air changes per
hour

Minimum 3 air changes of outdoor
air per hour

Negative pressure in Isolation areas, autopsy suite

Positive pressure in operating room

Mechanical ventilation for hazardous emissions such as sterilizing chemicals

Temperature Satisfactory

Relative Humidity Satisfactory

CO2 satisfactory

MO satisfactory

VOC Satisfactory

Exhaust Fume Hood

Physical integrity satisfactory

Signs of blockage

Unusual Noise

Filters

Type of Filters satisfactory

Filter efficiency satisfactory

Filter clean

Signs of by passing

Change out schedule

Duct Work

Physical integrity satisfactory

Dryness & Cleanliness satisfactory

Signs of blockage from static pressure

Air balancing records

Reheat Coils/Mixing Boxes

Dryness & Cleanliness Satisfactory

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

Required outside air delivery at all times

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

Physical integrity

Dryness & Cleanliness satisfactory

No slime, mold, dirt bird dropping, soot accumulation

Integrity & cleanliness of chamber floor, wall and ceiling

Cleanliness & operation of various components satisfactory

Thermostats

Type & Location appropriate

Set appropriately

Access controlled

Air Conditioning Unit (non HVAC)

AC clean and in good working in condition

Temperature within acceptable standards

Cleaning schedule available for the unit

EMERGENCY EXITS & FIRE PROTECTION

Emergency exits visible

Emergency exit free from obstruction

Emergency evacuation plan posted

Fire extinguishers present

Fire extinguishes regularly inspected

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

Clear access to electrical panels/no combustible material stored

Sockets in good condition

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

Staff lockers/change area accessible and available

Staff lounge present & clean with no medical supplies or device

Staff toilet clean

Refrigerator in good working orde

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

Treatment room

Equipment storage

Chemical storage

Staff Areas

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

Containers with proper lids

Sewage Manaagement

Signage place on lavatory door

Toilet clean and in good working codition

Chemicals

Proper and adequate storage space

Proper label

MSDS available

Signature

Manager
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.