Main Operating Room Environmental Cleaning

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Precautions

• Wears personal protective equipment

  Yes

  No

  N/A

• Follows standard precautions when cleaning

  Yes

  No

  N/A

• Wears proper respiratory protection if cleaning procedures are expected to generate infectious aerosols

  Yes

  No

  N/A

• Cleans and disinfects surfaces or equipment as soon as possible when there is visible soiling by blood, body fluid, or other potentially infectious materials

  Yes

  No

  N/A

Regular Clean Sample #1

• Room number

  Select 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 14
  • 15
  • 16
  • 17
  • 18

Damp Dusting

• Inspect OR for cleanliness before case carts, supplies, instruments, and equipment are brought into the room

  Yes

  No

  N/A

• Damp dusts all horizontal surfaces before the first scheduled surgical or other invasive procedure of the day

  Yes

  No

  N/A

• Performs damp dusting methodically from top to bottom

  Yes

  No

  N/A

• Uses a clean, low-linting cloth moistened with an EPA-registered hospital-grade disinfectant

  Yes

  No

  N/A

Providing a Clean, Safe Environment

• Cleans the environmental surfaces with a detergent prior to disinfection, according to the manufacturer's IFU

  Yes

  No

  N/A

• Labels the cleaning container with the chemical name, concentration, and expiration date if the chemical is removed from the original container

  Yes

  No

  N/A

• Follow manufacturer's IFU for the dwell time of the disinfecting chemical

  Yes

  No

  N/A

• Does not use the spray or misting methods

  Yes

  No

  N/A

• Cleans progressing from clean to dirty areas

  Yes

  No

  N/A

• Cleans progressing from top to bottom areas

  Yes

  No

  N/A

• Cleans clockwise or counter-clockwise in conjunction with clean-to-dirty and top-to-bottom methods

  Yes

  No

  N/A

• Does not use dry methods of cleaning, such as sweeping

  Yes

  No

  N/A

• Cleans and disinfects noncritical items (safety belt, positioning devices) after contact with the floor

  Yes

  No

  N/A

• Does not return used cleaning materials to the cleaning solution container

  Yes

  No

  N/A

• Cleans reusable protective barriers

  Yes

  No

  N/A

• Discards disposable cleaning materials after each use

  Yes

  No

  N/A

• Changes reusable cleaning materials after each use

  Yes

  No

  N/A

Post Procedure Cleaning

• Cleans and disinfects reusable noncritical, nonporous surfaces (mattress covers, pneumatic tourniquets cuffs, blood pressure cuffs) after each patient use

  Yes

  No

  N/A

• Cleans and disinfects high-touch objects after each patient use

  Yes

  No

  N/A

• Cleans and disinfects operating and procedure rooms after the patient has left the area

  Yes

  No

  N/A

• Removes trash and used linen before beginning environmental cleaning

  Yes

  No

  N/A

• Cleans and disinfects items that are used during patient care after every patient use

  Yes

  No

  N/A

• Cleans and disinfects items that are used during a surgical or invasive procedure

  Yes

  No

  N/A

• Cleans and disinfects the floors and walls of the OR and procedure rooms, if soiled or potentially soiled, after each surgical or invasive procedure

  Yes

  No

  N/A

Regular Clean Sample #2

• Room number

  Select 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 14
  • 15
  • 16
  • 17
  • 18

Damp Dusting

• Inspect OR for cleanliness before case carts, supplies, instruments, and equipment are brought into the room

  Yes

  No

  N/A

• Damp dusts all horizontal surfaces before the first scheduled surgical or other invasive procedure of the day

  Yes

  No

  N/A

• Performs damp dusting methodically from top to bottom

  Yes

  No

  N/A

• Uses a clean, low-linting cloth moistened with an EPA-registered hospital-grade disinfectant

  Yes

  No

  N/A

Providing a Clean, Safe Environment

• Cleans the environmental surfaces with a detergent prior to disinfection, according to the manufacturer's IFU

  Yes

  No

  N/A

• Labels the cleaning container with the chemical name, concentration, and expiration date if the chemical is removed from the original container

  Yes

  No

  N/A

• Follow manufacturer's IFU for the dwell time of the disinfecting chemical

  Yes

  No

  N/A

• Does not use the spray or misting methods

  Yes

  No

  N/A

• Cleans progressing from clean to dirty areas

  Yes

  No

  N/A

• Cleans progressing from top to bottom areas

  Yes

  No

  N/A

• Cleans clockwise or counter-clockwise in conjunction with clean-to-dirty and top-to-bottom methods

  Yes

  No

  N/A

• Does not use dry methods of cleaning, such as sweeping

  Yes

  No

  N/A

• Cleans and disinfects noncritical items (safety belt, positioning devices) after contact with the floor

  Yes

  No

  N/A

• Does not return used cleaning materials to the cleaning solution container

  Yes

  No

  N/A

• Cleans reusable protective barriers

  Yes

  No

  N/A

• Discards disposable cleaning materials after each use

  Yes

  No

  N/A

• Changes reusable cleaning materials after each use

  Yes

  No

  N/A

Post Procedure Cleaning

• Cleans and disinfects reusable noncritical, nonporous surfaces (mattress covers, pneumatic tourniquets cuffs, blood pressure cuffs) after each patient use

  Yes

  No

  N/A

• Cleans and disinfects high-touch objects after each patient use

  Yes

  No

  N/A

• Cleans and disinfects operating and procedure rooms after the patient has left the area

  Yes

  No

  N/A

• Removes trash and used linen before beginning environmental cleaning

  Yes

  No

  N/A

• Cleans and disinfects items that are used during patient care after every patient use

  Yes

  No

  N/A

• Cleans and disinfects items that are used during a surgical or invasive procedure

  Yes

  No

  N/A

• Cleans and disinfects the floors and walls of the OR and procedure rooms, if soiled or potentially soiled, after each surgical or invasive procedure

  Yes

  No

  N/A

Regular Clean Sample #3

• Room number

  Select 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 14
  • 15
  • 16
  • 17
  • 18

Damp Dusting

• Inspect OR for cleanliness before case carts, supplies, instruments, and equipment are brought into the room

  Yes

  No

  N/A

• Damp dusts all horizontal surfaces before the first scheduled surgical or other invasive procedure of the day

  Yes

  No

  N/A

• Performs damp dusting methodically from top to bottom

  Yes

  No

  N/A

• Uses a clean, low-linting cloth moistened with an EPA-registered hospital-grade disinfectant

  Yes

  No

  N/A

Providing a Clean, Safe Environment

• Cleans the environmental surfaces with a detergent prior to disinfection, according to the manufacturer's IFU

  Yes

  No

  N/A

• Labels the cleaning container with the chemical name, concentration, and expiration date if the chemical is removed from the original container

  Yes

  No

  N/A

• Follow manufacturer's IFU for the dwell time of the disinfecting chemical

  Yes

  No

  N/A

• Does not use the spray or misting methods

  Yes

  No

  N/A

• Cleans progressing from clean to dirty areas

  Yes

  No

  N/A

• Cleans progressing from top to bottom areas

  Yes

  No

  N/A

• Cleans clockwise or counter-clockwise in conjunction with clean-to-dirty and top-to-bottom methods

  Yes

  No

  N/A

• Does not use dry methods of cleaning, such as sweeping

  Yes

  No

  N/A

• Cleans and disinfects noncritical items (safety belt, positioning devices) after contact with the floor

  Yes

  No

  N/A

• Does not return used cleaning materials to the cleaning solution container

  Yes

  No

  N/A

• Cleans reusable protective barriers

  Yes

  No

  N/A

• Discards disposable cleaning materials after each use

  Yes

  No

  N/A

• Changes reusable cleaning materials after each use

  Yes

  No

  N/A

Post Procedure Cleaning

• Cleans and disinfects reusable noncritical, nonporous surfaces (mattress covers, pneumatic tourniquets cuffs, blood pressure cuffs) after each patient use

  Yes

  No

  N/A

• Cleans and disinfects high-touch objects after each patient use

  Yes

  No

  N/A

• Cleans and disinfects operating and procedure rooms after the patient has left the area

  Yes

  No

  N/A

• Removes trash and used linen before beginning environmental cleaning

  Yes

  No

  N/A

• Cleans and disinfects items that are used during patient care after every patient use

  Yes

  No

  N/A

• Cleans and disinfects items that are used during a surgical or invasive procedure

  Yes

  No

  N/A

• Cleans and disinfects the floors and walls of the OR and procedure rooms, if soiled or potentially soiled, after each surgical or invasive procedure

  Yes

  No

  N/A

Terminal Clean Sample #1

• Room number

  Select 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 14
  • 15
  • 16
  • 17
  • 18

• Terminally cleans and disinfects perioperative areas daily when the areas are being used and according to facility policy and procedure

  Yes

  No

  N/A

• Disinfects all floors in the perioperative and sterile processing areas

  Yes

  No

  N/A

• Terminally cleans floors with either a wet vacuum or a single-use mo and a disinfectant

  Yes

  No

  N/A

• Cleans from the cleanest to the dirtiest areas of the floor

  Yes

  No

  N/A

• Disinfects floors surfaces at the perimeter of the room before floor surfaces in the center of the room

  Yes

  No

  N/A

• Disinfects the entire floor surface, including areas under the OR bed and mobile equipment

  Yes

  No

  N/A

• Terminally cleans and disinfects all exposed surfaces, including wheels and casters of all items

  Yes

  No

  N/A

• Uses a checklist and documents that terminal cleaning was performed

  Yes

  No

  N/A

Terminal Clean Sample #2

• Room number

  Select 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 14
  • 15
  • 16
  • 17
  • 18

• Terminally cleans and disinfects perioperative areas daily when the areas are being used and according to facility policy and procedure

  Yes

  No

  N/A

• Disinfects all floors in the perioperative and sterile processing areas

  Yes

  No

  N/A

• Terminally cleans floors with either a wet vacuum or a single-use mo and a disinfectant

  Yes

  No

  N/A

• Cleans from the cleanest to the dirtiest areas of the floor

  Yes

  No

  N/A

• Disinfects floors surfaces at the perimeter of the room before floor surfaces in the center of the room

  Yes

  No

  N/A

• Disinfects the entire floor surface, including areas under the OR bed and mobile equipment

  Yes

  No

  N/A

• Terminally cleans and disinfects all exposed surfaces, including wheels and casters of all items

  Yes

  No

  N/A

• Uses a checklist and documents that terminal cleaning was performed

  Yes

  No

  N/A

Terminal Clean Sample #3

• Room number

  Select 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 14
  • 15
  • 16
  • 17
  • 18

• Terminally cleans and disinfects perioperative areas daily when the areas are being used and according to facility policy and procedure

  Yes

  No

  N/A

• Disinfects all floors in the perioperative and sterile processing areas

  Yes

  No

  N/A

• Terminally cleans floors with either a wet vacuum or a single-use mo and a disinfectant

  Yes

  No

  N/A

• Cleans from the cleanest to the dirtiest areas of the floor

  Yes

  No

  N/A

• Disinfects floors surfaces at the perimeter of the room before floor surfaces in the center of the room

  Yes

  No

  N/A

• Disinfects the entire floor surface, including areas under the OR bed and mobile equipment

  Yes

  No

  N/A

• Terminally cleans and disinfects all exposed surfaces, including wheels and casters of all items

  Yes

  No

  N/A

• Uses a checklist and documents that terminal cleaning was performed

  Yes

  No

  N/A

Sterile Processing Areas-Centercore (pods)

• Terminally cleans and disinfects sterile processing areas daily when the area is being used

  Yes

  No

  N/A

• Cleans the clean work areas (packaging areas, sterile storage areas) before the dirty work areas (decontamination area)

  Yes

  No

  N/A

• Damp dust all horizontal surfaces (sterilizers, countertops, shelving) daily

  Yes

  No

  N/A

• Does not commence terminal cleaning when personnel are actively decontaminating instruments

  Yes

  No

  N/A

• Cleans disinfects all work surfaces and high-touch objects

  Yes

  No

  N/A

• Removes trash from receptacles in sterile processing areas when they are full, but at least daily

  Yes

  No

  N/A

Scheduled Cleaning

Cleans areas and items that are not terminally cleaned on an established schedule:

• Sterile storage areas

  Yes

  No

  N/A

• Shelving and storage bins

  Yes

  No

  N/A

• Corridors, including stairwells and elevators

  Yes

  No

  N/A

• Walls and ceilings

  Yes

  No

  N/A

• Privacy curtains

  Yes

  No

  N/A

• Pneumatic tubes and carriers

  Yes

  No

  N/A

• Sterilizer and loading carts

  Yes

  No

  N/A

• Sterilizer service access rooms

  Yes

  No

  N/A

• Unrestricted areas lounges

  Yes

  No

  N/A

• Waiting rooms, offices

  Yes

  No

  N/A

• Environmental services closets

  Yes

  No

  N/A

• Cleans ventilation ducts, linen chutes, refrigerators, ice machines, sinks, wash basins, aerators, and faucets on a schedule per facility policy and procedure

  Yes

  No

  N/A

Enhanced Cleaning Procedures, if applicable

• Follows enhanced environmental cleaning procedures on high-touch surfaces after care of patients who are infected or colonized with multi drug-resistant organisms

  Yes

  No

  N/A

• In addition to high-touch surfaces, cleans and disinfects objects cleaned as part of routine cleaning, after the patient leaves the room or area

  Yes

  No

  N/A

• In addition to standard precautions, wears a gown and gloves

  Yes

  No

  N/A

• Uses and EPA-registered disinfectant that is effective against C-difficile to clean following the care of patients diagnosed with or suspected of infection with C-difficile

  Yes

  No

  N/A

• Does not clean rooms following the care of patients diagnosed or suspected of infection with an airborne transmissible disease (tuberculosis) until a complete air exchange occurs or wears respiratory protection (N95 mask)

  Yes

  No

  N/A

• Follow procedures for environmental cleaning after contamination with high-risk tissue per policy and procedure

  Yes

  No

  N/A

• Performs cleaning and disinfection of environmental surfaces to remove dust and debris caused by construction, renovation, remediation, repair, or demolition, if applicable, per policy and procedure

  Yes

  No

  N/A