MMH TJC - IPC - Mock Survey

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

INFECTION PREVENTION

• HAND HYGIENE

• Team Members know where to access the MMH policy.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Team Members are aware of the monitor and reporting.

  Yes

  No

  N/A

• Team Members are able to recall the MMH HH rate.

  Yes

  No

  N/A

• BLOODBORNE PATHOGENS

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

  Yes

  No

  N/A

• Gloves are worn during vascular access

  Yes

  No

  N/A

• Team Members know what to do if an exposure occurs.

  Yes

  No

  N/A

• Sharps are handled appropriately - no recapping, active vs passive, etc.

  Yes

  No

  N/A

• No unattended sharps noted in area.

  Yes

  No

  N/A

ISOLATION

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Negative and Positive air flow rooms function appropriately.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Isolation signs posted as appropriate.

  Yes

  No

  N/A

• Team Members can locate appropriate PPE equipment.

  Yes

  No

  N/A

• PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>

  Yes

  No

  N/A

NATIONAL PATIENT SAFETY GOAL 7

• Goal 07.01.01 Hand Hygiene Monitors?

  Yes

  No

  N/A

• GOAL 07.03.01 MDRO -How do you prevent drug resistant organism spread?

  Yes

  No

  N/A

• GOAL 07.04.01 CLABSI - Who places central lines?<br> * What criteria do you use.

  Yes

  No

  N/A

• GOAL 07.05.01 SSI - Are Team Members educated on SSI?<br> * Are patients provided educations?

  Yes

  No

  N/A

• GOAL 07.06.01 CAUTI - Do Team Members recieve education as to how to prevent CAUTI?<br> * Are patients/families educated?

  Yes

  No

  N/A

CLEANING

• Equipment cleaning.<br> * Do Team Members know to follow equipment manufacturers instructions for cleaning.

  Yes

  No

  N/A

• Disinfectants are used on surfaces in accordance with manufacturers recommendations.

  Yes

  No

  N/A

• Patient care supplies: (including lab supplies)<br> * Not expired, damaged, soiled.

  Yes

  No

  N/A

• Patient care items: (including WOWs, vitals, PT items, etc. )are wiped down after each use in patient room.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids.<br> * Survey Team Members in the area for opportunities.

  Yes

  No

  N/A

• Air vents: Clean inside and around.

  Yes

  No

  N/A

• Ice machines clean.

  Yes

  No

  N/A

• Water features are cleaned and maintained appropriately.<br>

  Yes

  No

  N/A

REFRIGERATORS

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Patient items are dated and labeled as appropriate.

  Yes

  No

  N/A

• No expired items.

  Yes

  No

  N/A

DESCRIBE THE DEPARTMENTS RESPONSE TO YOUR ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Promptly deliver materials required for review to the tracer team.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Surveyors Signature

  Sign