Standard 3 - Audit Report

Criterion 1 - Governance and systems for infection prevention, control and surveillance

3.1.1 A risk management approach is taken in policies, procedures and/or protocols and implemented for:
• standard infection control precautions
• transmission based precautions
• aseptic technique
• safe handling and disposal of sharps
• prevention and management of occupational exposure to blood and body substances
• environmental cleaning and disinfection
• antimicrobial prescribing
• outbreaks or unusual clusters of communicable infection
• processing of reusable medical devices
• single-use devices
• surveillance and reporting of data where relevant
• reporting of communicable and notifiable diseases
• provision of risk assessment guidelines to workforce
• exposure-prone procedures

3.1.2 The use of policies, procedures and/or protocols is regularly monitored

3.1.3 The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of governance in the organization

3.1.4 Action is taken to improve the effectiveness of infection prevention and control policies, procedures and/ or protocols (Developmental)

3.2.1 Surveillance systems for healthcare associated infections are in place

3.2.2 Healthcare associated infection surveillance data is regularly monitored by the delegated workforce and/or committees

3.3.1 Mechanisms to regularly assess the healthcare associated infection risks are in place

3.3.2 Action is taken to reduce the risks of healthcare associated infection

3.4.1 Quality improvement activities are implemented to reduce and prevent healthcare associated infections (Developmental)

3.4.2 Compliance with changes in practice are monitored (Developmental)

3.4.3 The effectiveness of changes to practice are evaluated (Developmental)

Criterion 2 - Infection prevention and control strategies

3.5.1 Workforce compliance with current national hand hygiene guidelines is regularly audited

3.5.2 Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organization

3.5.3 Action is taken to address non-compliance, or the inability to comply, with the requirements of the current national hand hygiene guidelines

3.6.1 A workforce immunization program that complies with current national guidelines is in use

3.7.1 Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are implemented to address:
• communicable disease status
• occupational management and prophylaxis
• work restrictions
• personal protective equipment
• assessment of risk to healthcare workers for occupational allergies
• evaluation of new products and procedures

3.8.1 Compliance with the system for the use and management of invasive devices is monitored

3.9.1 Education and competency-based training in invasive devices protocols and use is provided for the workforce who perform procedures with invasive devices (Developmental)

3.10.1 The clinical workforce is trained in aseptic technique (Developmental)

3.10.2 Compliance with aseptic technique is regularly audited (Developmental)

3.10.3 Action is taken to increase compliance with the aseptic technique protocols (Developmental)

Criterion 3 - Managing patients with infections or colonizations

3.11.1 Standard precautions and transmission-based precautions consistent with the current national guidelines are in use

3.11.2 Compliance with standard precautions is monitored

3.11.3 Action is taken to improve compliance with standard precautions

3.11.4 Compliance with transmission-based precautions is monitored

3.11.5 Action is taken to improve compliance with transmission‑based precautions

3.12.1 A risk analysis is undertaken to consider the need for transmission-based precautions including:
• accommodation based on the mode of transmission (Developmental)
• environmental controls through air flow
• transportation within and outside the facility
• cleaning procedures
• equipment requirements

3.13.1 Mechanisms are in use for checking for pre-existing healthcare associated infections or communicable disease on presentation for care

3.13.2 A process for communicating a patient’s infectious status is in place whenever responsibility for care is transferred between service providers or facilities

Criterion 4 - Antimicrobial stewardship

3.14.1 An antimicrobial stewardship program is in place

3.14.2 The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage

3.14.3 Monitoring of antimicrobial usage and resistance is undertaken (not applicable for dental practices)

3.14.4 Action is taken to improve the effectiveness of antimicrobial stewardship

Criterion 5 - Cleaning, disinfection and sterilization

3.15.1 Policies, procedures or protocols for environmental cleaning that address the principles of infection prevention and control are implemented, including:
• maintenance of building facilities
• cleaning resources and services
• risk assessment (undertaken as part of 3.1.1) for cleaning and disinfection based on transmission based precautions and the infectious agent involved
• waste management within the clinical environment
• laundry and linen transportation, cleaning and storage

3.15.2 Policies, procedures and/or protocols for environmental cleaning are regularly reviewed

3.15.3 An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly

3.16.1 Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilization of reusable instruments and devices is regularly monitored

3.17.1 A traceability system that identifies patients who have a procedure using sterile reusable medical instruments and devices is in place

3.18.1 Action is taken to maximize coverage of the relevant workforce trained in a competency based program to decontaminate reusable medical devices (Developmental)

Criterion 6 - Communicating with patients and carers

3.19.1 Information on the organization’s corporate and clinical infection risks and initiatives implemented to minimize patient infection risks is provided to patients and/or carers

3.19.2 Patient infection prevention and control information is evaluated to determine if it meets the needs of the target audience (Developmental)

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.