Epidemiology and Infection Prevention Assessment Tool: Joint Commission International Accreditation Standards for Hospitals COPYRIGHT 5th Edition Complete

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• The goal of an organization's infection prevention and control program is to identify and to reduce the risks of acquiring and transmitting infections among patients, staff, health care professionals, contract offers, volunteers, students, and visitors.
  
  Infection risks and program activities may differ from organization to organization, depending on the organization's clinical activities and services, patient populations served, geographic location, patient volume, and number of employees.
  
  Effective programs have in common identified leaders, well trained staff, methods to identify and to proactively address infection risks, appropriate policies and procedure, staff education, and coordination throughout the organization.

• Please answer Yes to denote compliance with a standard. If compliant, please document the evidence for compliance.

Prevention and Control of Infections (PCI)

Infection Control Officer: Standard PCI. 1 One or more individuals oversee all infection prevention and control activities. This individual(s) is qualified in infection prevention and control practices through education, training, experience, or certification

• Job Description

• Element 1. One or more individuals overall all infection prevention and control activities.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2.This individual(s) is qualified for the size, complexity of activities, and level of risks, as well as the program's scope. The qualification is demonstrated by education; training; experience and/or; certification or licensure.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. This individual(s) fulfills program oversight responsibilities as assigned or described in a job description.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Infection Control Committee: Standard PCI. 2 There is a designated coordination mechanism for all infection prevention and control activities that involves physicians, nurses, and others as based on the size and complexity of the organization.

• Members examples: MD, RN, IT, Sterile Processing Department, epidemiologist, housekeeping, facilities, pharmacy

• Element 1. There is a designated mechanism for the coordination of infection prevention and control program.

  Yes

  No

  N/A

• Evidence of Compliance:

• Recommendations:

• Element 2. The coordination of infection prevention and control activities involves physicians and nurses, and others based on size and complexity of the hospital.

  Yes

  No

  N/A

• Evidence of Compliance:

• Recommendations:

• Element 3. Coordination of infection prevention and control activities involves infection prevention and control professionals.

  Yes

  No

  N/A

• Evidence of Compliance:

• Recommendations:

Infection Prevention Program: Standard PCI. 3 The infection prevention and control program is based on current scientific knowledge, accepted practice guidelines, applicable laws, regulation, and standard for sanitation and cleanliness.

• Element 1. The infection prevention and control program is based on current scientific knowledge, accepted practice guidelines, and local laws and regulations.

  Yes

  No

  N/A

• Evidence of Compliance:

• Recommendations:

• Element 2. The infection prevention and control program is based on standards from national or local agencies for sanitation and cleanliness.

  Yes

  No

  N/A

• Evidence of Compliance:

• Recommendations:

• Element 3. The infection prevention and control program results are reported to public health agencies as required.

  Yes

  No

  N/A

• Evidence of Compliance:

• Recommendations:

• Element 4. The hospital takes appropriate action on reports from relevant public health agencies.

  Yes

  No

  N/A

• Evidence of Compliance:

• Recommendations:

Infection Prevention Resources: Standard PCI.4 Hospital leadership provides resources to support the infection prevention and control program.

• Element 1. The infection prevention and control program is staffed according to the hospital's size, complexity of activities, and level of risks, as well as the program's scope.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. Hospital leadership allocates and approves staffing and resources required for the infection prevention and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Information management systems support the infection prevention and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Infection Control Risk Reduction: Standard PCI. 5 The organization designs and implements a comprehensive program to reduce the risks of health care-associated infections in patients and health care workers.

• Policies. The program includes hand hygiene, systems to identify infections and to investigate outbreaks of infectious disease, and oversight for improving the safe use of antimicrobials.

• Element 1.There is a comprehensive program that crosses all levels of the hospital, to reduce the risk of health care-associated infections in patients.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. There is a comprehensive program that crosses all levels of the hospital, to reduce the risk of health care-associated infections in health care workers.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. The program incorporates a range of strategies that include systematic and proactive surveillance activities to determine usual (endemic) rates of infection.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 4. The program includes systems to investigate outbreaks of infectious diseases.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 5. Risk-reduction goals and measurable objectives are established and reviewed.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Infection Control Risk Reduction Inclusive: Standard PCI. 5.1 All patient, staff and visitor areas of the organization are included in the infection prevention and control program.

• Element 1. All patient care areas of the hospital are included in the infection prevention and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. All staff areas of the hospital are included in the infection preventin and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. All visitor areas of the hospital are included in the infection prevention and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Risk Based Approach: Standard PCI.6 The organization uses a risk-based approach in establishing the focus of the health care-associated infection prevention and reduction program.

• Policies and procedures.
  Hospital collect and evaluate data on the following relevant infections and sites: a) Respiratory tract, b) Urinary tract, c) Intravascular invasive devices, d) Surgical sites, e) Epidemiologically significant diseases and organisms, and f) Emerging or reemerging infections with the community.
  Device related infections.

• Element 1. The hospital has established the focus of the program through the collection of data reslated to a) through f) in the intent.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. The data collected in a) through f) are analyzed to identify priorities for reducing rates of infection.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Infection control strategies are implemented to reduce the rates of infection fro the identified priorities.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Risk Based Approach: Standard PCI.6.1 The hospital tracks infection risks, infection rates, and trends in health care-associated infection to reduce the risks of those infections.

• Changes made based on surveillance.

• Element 1. Health care-associated infections risks, rates, and trends are tracked

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. Processes are redesigned based on risk, rate, and trend data and information.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. The hospital assesses the infection control risks at least annually and takes action to focus or refocus the infection prevention and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Identification of Risky Processes: Standard PCI.7 The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk.

• Policies and Procedures; Flexible scopes.

• Element 1. The hospital has identified those processes associated with infection risk.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. The hospital has implemented strategies, education, and evidence-based activities to reduce infection risk in those processes.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. The hospital identifies which risks require policies and/or procedures, staff education, practice changes, and other activities to support risk reduction.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Identification of Risky Processes: Standard PCI.7.1 The hospital reduces the risk of infections by ensuring adequate medical technology cleaning and sterilization and the proper management of laundry and line.

• Element 1. Methods for medical technology cleaning, disinfection, and sterilization address the principles of infection prevention and control.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. Methods for medical technology cleaning, disinfection, and sterilization are coordinated and uniformly applied throughout the hospital.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. The principles of infection prevention and control are applied to laundry and linen management, including transportation, cleaning, and storage.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Identification of Risky Processes: Expired Supplies and Single Use Items Standard PCI.7.1.1 The hospital identifies and implements a process for managing expired supplies and the recuse of single-use devices when laws and regulations permit.

• Hospiatlas should have a policy which is consistent with national laws and regulations and professional standards and includes identification of : a) devices and material that may be reused; b) the maximum number of reuses specific for each device and material that is reused; c) the types of wear and cracking, among others, that indicate the device cannot be reused; d) the cleaning process fore each device that starts immediately after use and follows a clear protocol; e) identification of patients on whom reusable medical devices have been used; and f) a proactive evaluation of the safety of reusing single-use items. The hospital collects infection prevention and control data related to reused devices and materials to identify risks and implement actin to reduce risk and improve processes.

• Element 1. The hospital implements a process consistent with national laws and regulations and professional standards that identifies the process for managing expired supplies.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. When single-use devices and materials are reused, the hospital implements a process that addresses item a) through f) in the intent.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Data are used to identify risks, and actions are implemented to reduce risk and improve processes.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Identification of Risky Processes: Waste Standard PCI.7.2 The hospital reduces the risk of infection through proper disposal of waste.

• Element 1. Disposal of infectious waste and body fluids is managed to minimize infection transmission risk.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. The handling of disposal of blood and blood components are managed to minimize infection transmission risk.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Operation of the mortuary and postmortem area is managed to minimize infection transmission risk.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Identification of Risky Processes: Sharps Standard PCI.7.3 The hospital implements practices for safe handling and disposal of sharps and needles.

• Policies and procedures.

• Element 1. The hospital identifies and implements practices to reduce the risk of injury and infection from the handling and management of sharps and needles.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. Sharps and needle are collected in dedicated, closable, puncture-proof, leakproof containers that are not reused.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. The hospital disposes of sharps and needle safely or contracts with sources that ensure the proper disposal of sharps containers in dedicated hazardous waste sites or as determined by national laws and regulations.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Identification of Risky Processes: Food Services Standard PCI.7.4 The hospital reduces the risk of infections associated with the operations of food services.

• Element 1. The hospital stores food and nutrition products using sanitation, temperature, light , moisture, ventilation, and security in a manner that reduces the risk of infection.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. The hospital prepares food and nutrition products using proper sanitation and temperature.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Kitchen sanitation measures are implemented to prevent the risk of cross contamination.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Identification of Risky Processes: Construction Standard PCI.7.5 The hospital reduces the risk of infection in the facility associated with mechanical and engineering controls and during demolition, construction, and renovation.

• Engineering controls include: positive pressure ventilation, biological hoods in laboratories, and thermostats on refrigeration units

• Element 1. Engineering controls are implemented to minimize infection risk in the hospital.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. The hospital has a program developed that use risk criteria to assess the impact of renovation or new construction and implements the program when demolition renovation, or construction on air quality and infection prevention and control activities are assessed and managed.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. The risks and impact of the demolition, renovation, or construction on air quality and infection prevention and control activities are assessed and managed.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Isolation Standard PCI.8 The hospital provides barrier precautions and isolation procedures that protect patients, visitors, and staff from communicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone.

• Policies and Procedures.
  If a negative pressure room is not available, then HEPA filtration system at the rate of 12 air exchanges per hour.

• Element 1. Patients with know or suspected contagious diseases are isolated in accordance with recommended quiedlenes.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. Patients with communicable diseases are separated from patients and staff who are at greater risk due to immunosuppression or other reasons.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Negative-pressure rooms are monitored routinely and available for infectious patients who require isolation for airborne infections; when negative-pressure rooms are not immediately available, rooms with HEPA filtration systems with a minimum of 12 air changes per hour may be used.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 4. Cleaning of infectious rooms during the patient's hospitalization and after discharge follow infection control guidelines.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Isolation during Influx Standard PCI.8.1 The hospital develops and implements a process to mange a sudden influx of patients with airborne infections and when negative-pressure rooms are not available.

• Policies and Procedures.
  If a negative pressure room is not available, then HEPA filtration system at the rate of 12 air exchanges per hour.

• Element 1. The hospital develops and implements a process to address managing patients with airborne infections for short periods of time when negative-pressure rooms are not available.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. The hospital develops and implements a process for managing an influx of patients with contagious diseases.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Staff are educated in the management of infectious patients when there is a sudden influx or when negative-pressure rooms are not available.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Personal Protective Equipment Standard PCI.9 Gloves, masks, eye protection, other protective equipment, soap, and disinfectants are available and used correctly when required.

• Policies and procedures.

• Element 1. The hospital identifies situations in which personal protective equipment is required and ensures that it is available at any site of care at which it could be needed.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. Personal protective equipment is correctly used in those identified sitations.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Surface disinfecting procedures are implemented for areas and situations in the hospital identified as at risk for infection transmission.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 4. Soap, disinfectants, and towels or other means of drying are located in areas where hand-washing and hand-disinfecting procedures are required.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Integration with Quality Improvement and Patient Safety Program Standard PCI.10 The infection prevention and control processes is integrated wit the organization's overall program for quality improvement and patient safety.

• Element 1. Infection prevention and control activities are integrated into the hospital's quality improvement and patient safety program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. Monitoring data are collected and analyzed for the infection prevention and control activities and include Epidemiologically important infections.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. Monitoring data are used to evaluate and support improvements to the infection prevention and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 4. Monitoring data are documented and reports of data analysis and recommendations are provided to leadership on a quarterly basis.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Education Standard PCI.11 The hospital provides education on infection prevention and control practices to staff, physicians, patients, families, and other caregivers when indicated by their involvement in the care.

• Element 1. The hospital provides education about infection prevention and control to all staff and other professionals.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 2. The hospital provides education about infection prevention and control to patients and families.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 3. All staff are educated on the policies, procedures, and practices of the infection prevention and control program.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 4. Periodic staff education is provided in response to significant trends in infection data.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

• Element 5. Findings and trends from the measurement activities are communicated throughout the hospital and included as part of periodic education.

  Yes

  No

  N/A

• Evidence of compliance:

• Recommendations:

Assessment of Patients (AOP)

Laboratory Services

• A laboratory safety program is in place, followed, and documented. AOP.5.1

  Yes

  No

  N/A

• Laboratory results are available in a timely was as defined by the organization. AOP.5.3

  Yes

  No

  N/A

• There is a process for reporting critical results of diagnostic tests. AOP.5.3.1

  Yes

  No

  N/A

• Procedure for collecting, identifying, handling, safely transporting, and disposing of specimens are followed. AOP.5.6

  Yes

  No

  N/A

Quality Improvement anf Patient Safety (QPS)

Standards

• Those responsible for governing and managing the organization participate in planning and measuring a quality improvement and patient safety program. GPS.1

  Yes

  No

  N/A

• The organization's leaders collaborate to carry out the quality improvement and patient safety program. QPS.1.1

  Yes

  No

  N/A

• The leaders prioritize which processes should be measured and which implement and patient safety activities should be carried out. QPS.1.2

  Yes

  No

  N/A

• The leaders provide technological and other support to the quality improvement and patient safety program. QPS.1.3

  Yes

  No

  N/A

• Quality improvement and patient safety information is communicated to staff. QPS.1.4

  Yes

  No

  N/A

• Staff are trained to participate in the program. QPS.1.5

  Yes

  No

  N/A

Data Collection for Quality Measurement

• The organization's leaders identify key measures in the organization's structures, processes, and outcomes to be used night organization-wide quality improvement and patient safety plan. QPS.3

  Yes

  No

  N/A

• The organization's leaders identify key measures for each of the organization's clinical structures, processes, and outcomes. QPS.3.1

  Yes

  No

  N/A

• The organization's leaders identity key measures for each of the organizations managerial structures, processes, and outcomes.QPS.3.2

  Yes

  No

  N/A

• The organization's leaders identify key measures for each of grow International Patient Goals. QPS.3.3

  Yes

  No

  N/A

Analysis of Measurement Data

• Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization. QPS.4

  Yes

  No

  N/A

• The frequency of data analysis is appropriate to the process being studied and meets organization requirements. QPS.4.1

  Yes

  No

  N/A

• The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices. QPS.4.2

  Yes

  No

  N/A

• The organization uses an internal process to validate data. QPS.5

  Yes

  No

  N/A

• Data are analyzed when undesirable trends and variation are evident from the data. QPS.7

  Yes

  No

  N/A

Improvement

• Improvement in quality and safety is achieved and sustained. QPS.9

  Yes

  No

  N/A

Governance, Leadership, and Direction (GLD)

Direction of Departments and Services

• One or more qualified individuals provide direction for each department or service in the organization. GLD.5

  Yes

  No

  N/A

Care of Patients (COP)

Food and Nutrition Therapy

• A variety of food choices,appropriate for the patient's nutritional status and indigent with his or her clinical care, is regularly available. COP.4

  Yes

  No

  N/A

• Food preparation, handling, storage, and distribution are safe and comply with laws, regulations, and current acceptable practices. COP.4.1

  Yes

  No

  N/A

Staff Qualifiations and Educations (SQE)

Standards

• Organization leaders define the desired education, skills, knowledge, and other requirements of all staff members. SQE.1

  Yes

  No

  N/A

Management of Communication and Information (MCI)

Communication Between Practitioners Within and Outside of the Organization

• Information related to the patient's care is transferred with the patient. MCI.8

  Yes

  No

  N/A