Title Page
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Inspection - Homecare Healthcare worker
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Conducted on
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Prepared by
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Location
Infection Control - Hand Hygiene - 5 Moments Observations
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Staff Interviewed Name, Title, Department:
Infection Control - Hand Hygiene - 5 Moments Observation
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Is the patient on isolation precautions?
NON-ISOLATED HOME CARE/HOME SUPPORT PATIENT
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What type of patient?
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MOMENT 1: Did staff member perform hand hygiene when entering the patient room/before patient contact?
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Coached?
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Did staff member create or use a clean surface to place patient care items prior to use on the patient?
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Coached?
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MOMENT 2: Did staff member perform hand hygiene before performing a clean and/or aseptic procedure? (ex. medication pass, dressing change, etc).<br>See Sterile technique question at the bottom.
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Coached?
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If any items became contaminated did the staff member discard or clean the item as appropriate? (ex. items falls on floor or dirty surface)
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Coached?
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MOMENT 3: Did staff member clean their hands in between providing ‘dirty’ and ‘clean’ patient care - immediately after an exposure to bodily fluid and after removing gloves?
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Coached?
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Were observed glove changes done correctly? (hand hygiene before and between glove changes)
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Coached?
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Did staff member clean reusable equipment prior to storage or use on the next patient? (ex. glucometer, pulse oximetry, vital signs machine, etc.)
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Coached?
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MOMENT 4: Did staff member perform hand hygiene after any patient contact, such as assisting them with putting on their clothes or emptying catheter bag?
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Coached?
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MOMENT 5: Did staff member perform hand hygiene after touching unclean inanimate objects or themselves before approaching the patient?
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Coached?
PERFORMANCE IMPROVEMENT PLAN (if applicable)
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Does the staff member require additional training for improvement of skill?
Isolation Patient
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Upon entering the patient’s room, did staff member perform hand hygiene and apply the appropriate PPE correctly for the level of isolation? (moment 1)
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Coached?
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Did staff member create or use a clean surface to place patient care items prior to use on the patient?
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Coached?
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Did staff member perform hand hygiene after touching unclean inanimate objects or themselves before approaching the patient? (moment 5)
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Coached?
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Did staff member perform hand hygiene before performing a clean and/or aseptic procedure? (ex. medication pass, dressing change, etc) (moment 2)<br>See Sterile technique question at the bottom.
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Coached?
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Did staff member clean their hands in between providing ‘dirty’ and ‘clean’ patient care? (moment 3)
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Coached?
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If any items became contaminated did the staff member discard or clean the item as appropriate? (ex. items falls on floor or dirty surface)
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Coached?
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Were observed glove changes done correctly? (hand hygiene before and between glove changes)
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Coached?
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Did staff member clean reusable equipment prior to storage or use on the next patient? (ex. glucometer, pulse oximetry, vital signs machine, etc.)
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Coached?
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Did staff member perform hand hygiene upon exiting the patient room? (moment 4)
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Coached?
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Ask the assigned nurse/caregiver if there is documentation in the chart that the patient/family received education on Isolation Practices and if the patient/family refused education.
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Coached?
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Sterile technique: Observe a staff member performing a sterile technique; did the staff member appropriately maintain sterile technique? (Ex. Did not touch non-sterile objects during procedure without removing gloves, glove changes with hand hygiene in between)
Completion
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What sterile technique procedure did you observe?
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Comments/Coaching/Equipment observed:
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Observer Name & Signature:
SIGN OFF (NURSING SUPERVISOR)
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NAME AND DESIGNATION
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SIGNATURE