Audit Tool For University Hospital

• Conducted on

  Date

• Auditors

• Ward/ Department

• Overall findings

  Select

• Number of Physician

• Number of Nurses

• Number of PCA

• Number of House Keepers

• Number of Porters

• Number of Clerks

• Students

• Other Workers

• 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

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

  Yes

  No

  N/A

• Staff knowledgeable about management of spills

  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

• Staff of the unit 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 unit, there is a lead person responsible for IPC

  Yes

  No

  N/A

HAND HYGIENE

• There is adequate Eqiupment for hand hygiene

  Yes

  No

  N/A

• 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 available

  Yes

  No

  N/A

• Sinks clean and well maintained

  Yes

  No

  N/A

• Wash hand sinks present in dirty utility/ sluice room

  Yes

  No

  N/A

• Sinks present in clean room

  Yes

  No

  N/A

• Clean and dirty sink identified

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Staff knowledgeable about hand hygiene procedure

  Yes

  No

  N/A

• Staff aware of the 5 moments of hand hygiene

  Yes

  No

  N/A

Environmental Cleaning and disinfection

• Cleaning schedule available and accessible

  Yes

  No

  N/A

• Check list available and completed

  Yes

  No

  N/A

• Cleaning and sanitizing done at least twice per day

  Yes

  No

  N/A

• Patient immediate environment clean and sanitize after each use

  Yes

  No

  N/A

• Staff aware of the cleaning and sanitizing procedure

  Yes

  No

  N/A

• Disinfectant use is the correct concentration

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• High touch areas are cleaned at least every two hours

  Yes

  No

  N/A

Procedure for handling infectious cases

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

  Yes

  No

  N/A

• Are dedicated equipment used on these patients

  Yes

  No

  N/A

• Are equipment cleaned and disinfected after each use

  Yes

  No

  N/A

• Are Protocols for contact, droplet and airborne precautions adhered to

  Yes

  No

  N/A

Linen

• Proper management of clean linen

  Yes

  No

  N/A

• Proper management of soil and contaminated linen

  Yes

  No

  N/A

Medication

• Proper storage

  Yes

  No

  N/A

• Not Expired

  Yes

  No

  N/A

• Date and time of multi vial medication indicated

  Yes

  No

  N/A

• Safe Injection Practices

  Yes

  No

  N/A

• Storage temperature for medication appropriate

  Yes

  No

  N/A

• Storage temperature refrigerator logged

  Yes

  No

  N/A

• No food present in medication refrigerator

  Yes

  No

  N/A

• Medication refrigerator clean & in good working order

  Yes

  No

  N/A

Suitable Personal Protective Equipment; Adequate Supplies of:

• N95 respirator available and in adequate amount

  Yes

  No

  N/A

• Protective eye wear available and in adequate amount

  Yes

  No

  N/A

• Impermeable gowns available and in adequate amount

  Yes

  No

  N/A

• Workers trained in donning and doffing of PPE

  Yes

  No

  N/A

• Disposable gowns available and in adequate supply

  Yes

  No

  N/A

• Respirator available for handling chemicals

  Yes

  No

  N/A

• Surgical Masks available and in adequate amount

  Yes

  No

  N/A

PATIENT CARE AREA

• Furniture in good condition (can be easily cleaned)

  Yes

  No

  N/A

• Refrigerator temperature recorded & Maintained

  Yes

  No

  N/A

• Refrigerator clean and in good working condition

  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

• No damaged or 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

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

  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

• Dialysis machines cleaned and sanitized and maintained according to manufacturer

  Yes

  No

  N/A

• Cleaning procedure adhered to as per protocol & schedule available

  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

• Are reusable devices/equipment handled according to guidelines

  Yes

  No

  N/A

SHARPS HANDLING

• Sharps disposal at point-of-use

  Yes

  No

  N/A

• Sharps container not more than 3/4 full

  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

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

  Yes

  No

  N/A

• Waste segregation adhere to

  Yes

  No

  N/A

WATER AND PLUMBING

• Schedule cleaning for water storage tank

  Yes

  No

  N/A

• Residual chlorine present in tap water

  Yes

  No

  N/A

• Chlorine residual reading

• Plumbing Fixture clean and in good working condition

  Yes

  No

  N/A

• Air Conditioning unit clean and in good working condition

  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

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 appear safe and in good condition

  Yes

  No

  N/A

• Rails intact and in place

  Yes

  No

  N/A

• Ramps for disable present

  Yes

  No

  N/A

• Adequate storage space available

  Yes

  No

  N/A

• FIFO praciced

  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 intact

  Yes

  No

  N/A

• Outlets sufficient to avoid overloading

  Yes

  No

  N/A

VENTILATION AIR EXCHANGE

• Minimum 12 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

• MO satisfactory

  Yes

  No

  N/A

• VOC 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

Air Conditioning Unit (non HVAC)

• AC clean and in good working in condition

  Yes

  No

  N/A

• Temperature within acceptable standards

  Yes

  No

  N/A

• Cleaning schedule available for the unit

  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 condition

  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

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

  Yes

  No

  N/A

• Containers with proper lids

  Yes

  No

  N/A

Sewage Manaagement

• Signage place on lavatory door

  Yes

  No

  N/A

• Toilet clean and in good working codition

  Yes

  No

  N/A

Chemicals

• Proper and adequate storage space

  Yes

  No

  N/A

• Proper label

  Yes

  No

  N/A

• MSDS available

  Yes

  No

  N/A

• Manager

  Sign