Team Members know where to access the MMH policy.

HH is practiced consistent with "the 5 moments" campaign.

Team Members are aware of the monitor and reporting.

Team Members are able to recall the MMH HH rate.


No food, drink, or cosmetics in patient care, specimen, or med areas.

Gloves are worn during vascular access

Team Members know what to do if an exposure occurs.


Contain only those items designed for that refrigerator (specimen, medications or patient food)

If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.

Patient items are dated and labeled as appropriate.

No expired items.


Equipment cleaning.
* Does staff know to follow manufacturers instructions for cleaning?

Disinfectants are used on surfaces in accordance with manufacturers recommendations.

Patient care supplies:
* Not expired, damaged, soiled.

Linen and Linen Carts: Covered and carts have solid bottoms.

General Cleanliness:
* Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms
* No blood or bodily fluids

Air vents: Clean inside and around.

Ice machines clean.

Water features are cleaned and maintained appropriately.

Survey Team Members for input on general cleanliness opportunities


Team Members know how to access the Isolation policy and appendix.

Team Members are familiar with types of isolation, how to institute, and the Infection Control Admission Assessment.

Negative and Positive air flow rooms function appropriately.

Team Members are knowledgable of AII (negative pressure) room controls and know where and when to document readouts.

Team Members are aware of contingency measures in AII rooms lose pressure.

Isolation signs posted as appropriate.

Team Members can locate appropriate PPE equipment.

* Readily available
* Clearly marked
* Worn correctly


Greet the team with smiles and introductions.

Have a space designated for the team to conduct interviews and file reviews.

Promptly deliver materials required for review to the tracer team.

Any additional comments regarding positive or suboptimal issues observed during the tracer.

Surveyors Signature
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.