Title Page

  • Conducted on

  • Prepared by

  • Location


  • Date:

  • Hospital Name:

  • Surveyor Name:

  • Participants present (e.g. CEO, Infection Control Head, Hospital Officials etc)

Hospital Leadership Support

  • Adequate resources are allocated to infection control Department (e.g., offices, internet access, IT support etc.)

  • Adequate infection control supplies are provided to HCWs for successful IC program (e.g., PPE, disinfectants etc.)

  • Infection control team is given full authority to implement the Infection Control (IC) policies & procedures

  • Hospital leaders support IC personnel supervision when some functions are outsourced (e.g. laundry or dietary services)

Infection Control Department

  • The director of IC department is qualified in infection control through certification, training or experience for two years at least

  • The director of IC program reports directly to the highest administrative authority (General director or medical director of the hospital)

  • At least one full time IC practitioner is assigned for every 100 regular beds including ER, dental units, medical departments, surgical departments, …ect

  • An additional one IC practitioner / 30 ICU beds (at least one)

  • An additional one IC practitioner / 120 dialysis patients per day (at least one)

  • Infection control practitioners are qualified in infection control through certification, training, or experience for one year at least

  • Infection control practitioners have updated infection control skills and knowledge through continuous medical education program and attendance of IC scientific activities

Infection Control Committee

  • IC committee is chaired by the hospital director or the medical director

  • Membership of IC committee includes medical staff, nursing staff, microbiology, OR, CSSD, pharmacy, dietary services, housekeeping, and other departments as needed

  • IC committee meets on a regular basis (at least quarterly)

  • Functions of IC committee include but not limited to (revision and evaluation of the IC yearly plan, review and approval of IC policies & procedures, review of surveillance data,etc)

Infection Control Program

  • There is a program to reduce the risk of (HAIs) which involves patients, staff, trainees, volunteers, families and visitors

  • The program is applied to all areas of the hospital

  • The IC program is based on risk assessment, current scientific knowledge, referenced practice guidelines and applicable national laws and regulations

Infection Control Annual Plan

  • The annual plan addresses the epidemiologically important infections, processes, procedures and devices that are associated with risk of HAIs as identified by the hospital

  • The plan includes goals for patient safety (e.g., standard precautions, transmission based isolation precautions, Healthcare bundles, and patient/family education)

  • The plan includes goals for staff safety (e.g., staff immunization, post exposure management, and staff education)

  • There is a system or a tool to monitor achievements of the annual plan’s goals

Infection Control Manual (IC Policies & Procedures)

  • Infection control policies & procedures are developed by IC department to be approved by IC committee (P&P are based on scientific references approved by MOH ( GCC, CDC, WHO & APIC))

  • Infection control policies & procedures are organized in one manual that is well- distributed and available in all hospital areas

  • Infection control policies & procedures are revised periodically by the infection control department every 2-3 years, or when required

Infection Control Education & Training

  • IC department provides continuous education and training (formal & on- job training) for HCWs on infection control with competency assessment

  • IC department provides orientation and training on basics of infection control for newly hired HCWs within 3 months of joining the work

  • IC department provides education on infection control for patients, families and visitors

Hand Hygiene

  • There are written infection prevention policies and procedures for hand hygiene, including types, indications, supplies, techniques and monitoring

  • Hand washing facilities and supplies are available & easily accessible (sinks with hot & cold water / plain and antimicrobial soap / towels), one for every 2-4 beds in the critical care areas and at least one per patient's room

  • Alcohol - based hand rub dispensers are available in adequate numbers (one dispenser per patient's bed, one at every nursing station and at any service areas)

  • Hand hygiene compliance rates are regularly monitored, Results are discussed in IC committee meetings for corrective actions

  • Reporting of Hand Hygiene Compliance Rates is active and ongoing (i.e., reliable data is passed through regional coordinator to the central body of national hand hygiene program in timely manner)

Personal Protective Equipment (PPE)

  • There are written infection prevention policies and procedures for PPE including types, indications, donning, doffing, disposal and safety

  • PPE is available in all patients care areas in adequate amounts and proper qualities

  • PPE is used according to the standard and/or transmission-based precautions through regular training on proper usage, and safety measures by infection control practitioners

  • N95 respirator fit testing is conducted for all HCWs every 2 years or when required

Isolation Precautions

  • There are written policies and procedures for standard and transmission based precautions, including types, duration of isolation, patient transport, and visitors control

  • The entry of AIIR is through an ante-room that serves as a site for hand washing, donning and doffing of PPE

  • Visitors receive proper instructions from assigned personnel before entering into an isolation room, and they comply with recommended PPE

  • A log book is used for HCWs and visitors who had entered the isolation room, when needed

  • Hand washing and toilet facilities are provided for each isolation room (for isolation rooms in ICU, toilet is optional)

  • Non-critical patient-care equipment are single use or dedicated to one patient

  • The signs used to indicate categories of isolation precautions are:1) Clear and visible for HCWs and visitors2) Bilingual (in Arabic & English).3) Color coded and compatible with diagnosis e.g., contact: green, airborne: blue, droplet: pink or red

  • Sputum specimens for tuberculosis are collected in AIIR (Airborne Infection Isolation Room), and any attendant HCW is using a fit tested sealed checked N95 respirator

  • The receiving unit or facility is informed about the required isolation precautions and availability of appropriate PPE is ensured

  • The transfer of patient under isolation precautions is restricted to medically necessary purposes, selecting, whenever possible, low traffic time & route

  • During transfer of a patient under contact isolation precautions, all infected or colonized areas of the patient’s body are contained and covered

  • Patient under droplet / airborne isolation precautions, is transferred wearing surgical mask

  • HCWs who are transferring the patient or handling him/her at the transport destination use proper PPE

  • Portable chest x-ray is available for usage in isolation room when needed

  • Aseptic Technique

  • There is a written policy and procedure for clean, aseptic and sterile techniques

  • Separate clean area is available for preparation of medications (i.e., away from patients’ treatment areas)

  • For invasive procedures, sterile devices and supplies are used after patient’s skin antisepsis (e.g., a sterile syringes, needles and medications are used after skin antisepsis with approved antiseptic wipes)

  • A peripheral venous cannula is properly fixed, with a clearly written date of insertion, and if needed, routinely changed every 72 hours

  • Preparation & dilution of medication are only done by ready-made single-dose sterile solutions

  • Single-dose or single-use vials are used for a single patient and a single procedure/injection (i.e., single-dose vials are not stored for future use even on the same patient)

  • Needles and syringes including prefilled syringes, and vacutainer holders are used for a single procedure/injection

  • Cartridge devices such as insulin pens are used for only one patient

  • Supplies are brought to patient’s care area only when needed and after patient discharge, all remaining single-use items are discarded while reusable ones are sent for reprocessing, even unused items with intact original wrap

  • Multi-dose vials are used for a single patient whenever possible, dated when they have been opened and accessed for the first time, and discarded after 28 days unless the manufacturer specifies a different shorter or a longer date (i.e., reuse life)

  • If multi-dose vials are used for more than one patient, they are be kept and accessed only in a medication preparation area (away from immediate patients’ treatment areas)

  • The rubber self-sealed cap of a medication vial or an IV solution bottle is disinfected with alcohol prior to access

  • IV solution bottles are only accessed through the self-sealed rubber cap

  • Administration of IV sets, including secondary sets and add-on devices, that are continually used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are replaced not more frequently than 96-hour intervals, but at least every 7 days

  • Administration of IV sets that are used to administer blood, blood products, or lipid emulsions, or dextrose/amino acid TPN solutions are replaced within 24 hours of initiating the infusion

  • For a ventilated patient, ventilation circuits are only changed when visibly soiled or mechanically malfunctioning

  • Sterile solutions are used in nebulizers, humidifiers, or any aerosol generator and changed between patients or every 24 hours for the same patient

  • A sterile urine bag is continuously connected to urinary catheter and evacuated with proper technique and appropriate PPE

  • HCWs use mask during insertion a catheter or injection into spinal or epidural space

  • MERS-CoV

  • There is a written policy and procedure for suspected or confirmed MERS-CoV patients based on updated MOH guidelines

  • HCWs have received continuous job-specific infection control training on MERS-CoV and comptetency is done

  • Written reminders for updated definitions of suspected cases of MERS-CoV are available in the emergency department & staff are quite familiar with these definitions

  • There is a designated triage areas in the ER, Hemodialysis unit and employee health clinic for suspected MERS-CoV that is physically separated from other areas

  • Visual triage for MERS-CoV is activated in ER and haemodialysis unit.according to updated MOH MERS-CoV guidelines

  • Patients and people accompanying them who have acute respiratory symptoms are instructed to wear surgical masks and placed in a dedicated separated waiting area with distance between them accorrding to updated MOH MERS-CoV guidelines

  • Visual signs for patients and visitors on recommended Hand Hygiene & Respiratory Hygiene/Cough Etiquette practices are posted in the emergency department and inpatient areas

  • The hospital has MOH approved flowchart with policies & procedures for suspected or confirmed cases of MERS-CoV

  • Hospital has log for HCWs who contact with a confirmed case to record the presence of fever, symptoms of acute respiratory illness, diarrhea, vomiting or nausea before starting their shift

  • Nasopharyngeal Swabs from patients is performed by trained personnel

  • HCWs preform aerosol generating procedures (AGP) on any suspected or confirmed MERS-CoV cases in a negative pressure room or single room with a portable HEPA filter using proper PPE (e.g., N95 mask, eye protection, gloves, and gown)

Employee Health Program

  • There is a written policies and procedures for employees’ health related issues (i.e., pre-employment counseling and screening, immunization, post exposure management and work restriction)

  • There is a special clinic for employees’ health that provides pre-employment counseling and screening, immunization, post exposure management and work restriction

  • All employees have a baseline screening for hepatitis B, hepatitis C, HIV and tuberculosis (TB)

  • The immune status of newly hired staff against hepatitis B, measles, mumps, rubella and varicella are determined by documented vaccination, serological evidence of immunity, documented clinical / laboratory evidence of disease with life long immunity). Appropriate vaccine(s) is administered to those who are susceptible

  • The infleunza vaccine is administered annually to all HCWs

  • Newly hired staff are screened for tuberculosis upon contracting with PPD test. The test is repeated annually for those who are non-reactive and PPD conversion rates are monitored and calculated

  • There is an implemented system for reporting, follow up and management of exposure to open pulmonary TB, MERS COV, chicken pox, measles, mumps, and rubella

  • There is an implemented system for reporting, follow up, and management of sharp or needlestick injuries and blood or body fluid exposures

  • The IC team regularly monitors different types of staff exposure and take corrective actions to prevent recurrence, e.g., engineering controls as self-sheathing needles, or safety scalpels are applied

  • Reporting through EPINet system is active and ongoing (i.e., reliable reports of sharp or needlestick injuries and blood or body fluid exposures are sent to GDPIC through the EPINet system in a timely manner)

  • Needles are not bent, broken, separated or recapped

  • There are regular training activities for sharp injuries prevention program

  • The screening, immunization, and post exposure management data are kept in staff medical records

  • Staff accommodation provides facilities for staff isolated (home isolation) or restricted from work due to some infection diseases

  • Applied work restrictions for HCWs are consistent with MOH approved policies

Outbreak Management

  • There is a written policy and procedure for outbreak management. (i.e., determination, investigation and control of outbreaks of infectious diseases)

  • There is a defined outbreak management team

  • The outbreak management team members are qualified, trained, having experience and skills to detect and deal with outbreaks

  • Investigation and control measures of outbreaks are led by the hospital Infection control team that reports as per MOH regulations to the infection control regional directorate and GDIPC simultaneously

  • The results of investigation of an outbreak are discussed in hospital IC committee meetings for corrective and preventive actions

Antimicrobial Resistance Program

  • There is a written policy and procedure for antimicrobial resistance program

  • Antimicrobial committee, which is chaired by the hospital director / the medical director meets on a regular basis (at least biannually)

  • Membership of the antimicrobial committee includes pharmacy, microbiology, infection control, critical care areas, infectious diseases department, OR and surgical department, nursing department, and other departments as needed

  • Hospital leaders support AMR program and dedicate necessary human, financial and information technology resources

  • Stewardship program is implemented in hospital for monitoring and tracking of antibiotic prescription (hospital ≥150 beds)

  • Information about the antibiotic use and resistance is regularly reported to doctors, nurses and other relevant staff

  • Education about AMR and optimal prescription of antibiotic is provided repeatedly

  • The antibiogram is prepared by hospital at least every 6 months and reported to GDIPC as per MOH regulations (hospital ≥150 beds)

  • The antibiogram is regularly discussed by antimicrobial committee & action plan developed (hospital ≥150 beds)

Housekeeping &Hospital Environment

  • There is a written policy and procedures for hospital environment & housekeeping

  • There is a written policy and procedures for pest control (regular schedule and pest threshold / pesticides list / time and place of exposure)

  • There is a written policy and procedure for safe handling of blood/body fluids spills

  • Each unit has a schedule of cleaning/ disinfection activities log that records responsible worker, used agents, methods of cleaning and the environmental surfaces intended to be cleaned

  • Cleaning agents and disinfectants are consistent with hospital's policies and MOH specifications and used in the correct method (e.g., dilution and contact time

  • etc.)

  • There are separate clean and dirty utility rooms in each patient care area

  • Allocated staff for housekeeping are trained on hand hygiene, use of PPE, methods of cleaning, and proper and safe mixing of chemicals

  • Hospital environment, lockers, and cabinets are regularly cleaned, dry and dust free

  • Bedside curtains are clean, free of stains and changed regularly & when visibly contaminated

  • Terminal cleaning process is done properly when indicated by using a checklist

  • Terminal cleaning process after discontinuation of isolation is supervised by the in-charge nurse, and in case of an outbreak by infection control practitioner

  • Biological spill kits are available in all patient care units and HCWs are capable of using them properly

  • Random, undirected environmental microbiological cultures (for air, water, or environmental surfaces) are not recommended routinely. Only directed microbiologic sampling is conducted when indicated and approved by the regional IC team

Cleaning/Disinfectionof Medical Equipment

  • Medical equipments are cleaned/disinfected properly as per hospital's policies and manufacturer recommendations (regularity, recommended products, methods,… etc.)

Infectious Medical Waste

  • There is a written policy and procedures that covers infectious waste management (sorting, collection, transport, storage, PPE,… etc.)

  • Except in GENERAL WARDs, supplies and consumables required for waste segregation (waste containers, colored coded bags, and sharp containers) are of appropriate sizes, adequate in number at points of production, and meet the approved national regulations

  • Sharp containers are wall mounted or holded on a stand in critical areas & isolation rooms

  • In GENERAL WARDs, all clinical procedures are performed using procedural trolley equipped with biohazard waste bag and sharp container

  • No infectious medical waste or sharps are observed outside specified containers

  • Medical waste bags are collected after being securely closed when filled to 3/4 of its maximum capacity and labelled with the date and place of production

  • Sharp boxes are collected after being securely closed when filled to 3/4 of its maximum capacity and labelled with the date and place of production

  • Collection & transportation of medical waste are done by allocated workers wearing proper PPE at fixed times and on demand

  • Infectious medical waste is transported in closed and impervious specified carts with biohazard sign. Carts are cleaned after each use or at least daily

  • The medical waste store is consistent with the approved national specifications (adequate in space, away from traffic, secured, well ventilated with temperature <18 °C., provided with water source & adequate drainage, and its walls & floors are easily cleanable)

  • Infectious medical waste is transported outside the hospital every 24 hours to be disposed through the nationally approved system for medical waste management

  • Allocated infectious waste workers are vaccinated against blood borne pathogens and trained on hand hygiene, use of PPE and safe handling of waste

Medical Stores

  • There is a written policy and procedures for the medical storage

  • Medical storage areas are of adequate capacity, regularly cleaned, secured and away from contamination, air vents and direct sunlight

  • Medical storage areas have controlled ventilation with adjusted temperature and humidity (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)

  • Storage shelves are at least, 40 cm from the ceiling, 20 cm from the floor, and 5 cm from the wall

  • Storage shelves are made of easily cleanable material, e.g., fenestrated stainless steel, Aluminium or hard plastic

  • Sterile and clean items are completely separated from personal items, foods and drinks

  • No Items are kept in the original shipping boxes, especially in the clinical areas

  • Construction & Renovation

  • There is a written policy and procedures for IC considerations during demolition, renovation, and construction projects

  • IPC team is involved prior to, during, and after any construction, demolition, and renovation project (Planning, ICRA, IC permit, continuous follow - up and authority to stop the project)

  • IPC measures are followed during the construction, demolition, and renovation projects by using infection control risk assessment (ICRA)

Airborne Infection Isolation Rooms (AIIRs)

  • There is at least one AIIR for every 25 beds in general wards

  • At least one AIIR for each 8 beds in the ICU/NICU departments

  • At least one AIIR for each 12 beds in the emergency room

  • Airborne Infection Isolation Rooms (AIIRs) are under negative pressure (minimum -2.5 Pascal) with air totally exhausted to outside (100%) through High-Efficiency Particulate Air (HEPA) filter

  • There is 100% fresh air supply from central AC or cocealed separate unit

  • There is a fixed monitor outside the patient room in the corridor to continuously monitor the pressure difference between the patient room and corridor, with activation of audiovisual alarm when the ventilation system failed

  • There is evidence of regular monitoring of negative pressure difference of AIIRs:• Daily when in use (i.e., a patient is isolated inside).• Weekly when not in use (i.e., no patient is isolated).• Monthly check by biomedical personals

  • HEPA filter is changed on a regular basis and according to manufacturer's recommendations

  • There is evidence that air exchange of AIIR is ≥ 12 air changes per hour (12 ACH) with regular monitoring (at least quarterly)

  • AIIRs are used only for isolation of suspected or confirmed cases with airborne infectious diseases

Disinfectants and Antiseptics Supplies

  • Infection control team is involved in the evaluation and purchase of antiseptics and disinfectant supplies

  • Antiseptics and disinfectants are used in accordance with current scientific guidelines and recommended practices

Single Use Items (SUI)

  • According to MOH regulations, no reuse for single use items

Infection Control Surveillance

  • There is a written policy and procedures for health care associated infection surveillance, including the updated CDC-NHSN definitions (e.g., VAP, CLABSI, CAUTI, SSI and MDROs according to the scope of service)

  • There are written policies and procedures for VAP, CLABSI, CAUTI, SSI and MDROs care bundles

  • There are adequate numbers of computers and available.internet service for surveillance to be carried out

  • IC practitioners are well trained and familiar with updated CDC-NHSN surveillance definitions

  • Surveillance is carried out in all critical care units

  • The hospital implements an active, targeted, patient based and prospective surveillance

  • Surveillance data are regularly collected & reported to the regional directorate and GDIPC-MOH through IC-HESN electronic surveillance System

  • The results of surveillance are regularly analyzed, interpreted and communicated to staff and concern departments

  • The results of surveillance are used to reduce HAI through well design quality improvement projects

  • The results of surveillance are regularly reviewed by the infection control committee and an action plan is developed accordingly

Ventilator Associated Pneumonia Care Bundle

  • The hospital adopts and implements care bundle for prevention of (VAP) and data are regularly collected, analyzed, evaluated and corrective interventions are considered (or taken) accordingly

Surgical Site Infection Care Bundle

  • The hospital adopts and implements care bundle for prevention of (SSI) and data are regularly collected, analyzed, evaluated and corrective interventions are considered (or taken) accordingly

Catheter Associated Urinary Tract Infection Care Bundle

  • The hospital adopts and implements care bundle for prevention of (CAUTI) and data are regularly collected, analyzed, evaluated and corrective interventions are considered (or taken) accordingly

Central Line Associated Blood Stream Infection Care Bundle

  • The hospital adopts and implements care bundle for prevention of (CLABSI) and data are regularly collected, analyzed, evaluated and corrective interventions are considered (or taken) accordingly

  • MultiDrug Resistant Organisms Bundle

  • The hospital adopts and implements care bundle for prevention of (MDROs) and data are regularly collected, analyzed, evaluated and corrective interventions are considered (or taken) accordingly

  • Endoscopy

  • There is a written policy and procedures for infection control in the endoscopy unit

  • The procedure room(s) and the decontamination area are physically separated

  • Procedure room is equipped with a separate, dedicated hand washing sink with hand free controls

  • Endoscopes are kept moist and free of visible contamination after the procedure until the start of decontamination process (flushed & wiped with a special detergent)

  • Soiled endoscopes are transported safely in a suitable closed container to the reprocessing area

  • Reusable heat-stable accessories that break the mucosa (critical high risk items e.g., biopsy forceps) are sent to CSSD for sterilization after each use

  • Reprocessed endoscopes and accessories are stored safely and securely (uncoiled, hanging vertically in a clean, dry, and well ventilated storage cabinet)

  • There is effective manual or computer-based tracking system that records details of endoscopes usage, reprocessing & storage

  • Bronchoscopy is performed only in a room with negative air pressure (-2.5 Pa), a minimum of 12 air exchanges per hour, and discharged through HEPA filtration system

  • Haemodialysis Unit (HD)

  • There is a written policy and procedures for infection control in haemodialysis unit

  • Special room for central venous line insertion equipped with hand washing facility and PPE

  • For preparation of medications a central area (clean) is specified, which is physically separated from patient’s treatment areas (contaminated)

  • The distance separating adjacent dialysis chairs/beds is not less than 1.2 m

  • Easy accessible hand washing sinks are available in adequate number (one for every 2-4 chair/beds)

  • An Alcohol hand rub device is available for every patient's chair/bed

  • Appropriate PPE (gloves: clean/sterile, gowns, goggles or facesheild and N95 respirators) are available and used according to standard and/or transmission based precautions

  • Haemodialysis patient’s environment (surfaces of machines including the control panels, chairs/beds,

  • etc.) is cleaned and disinfected after each treatment session with an approved disinfectant

  • Supplies and equipment such as blood pressure cuffs, stethoscopes, scissors and thermometers are allocated to a single patient and are disposed (if single use) or cleaned and disinfected (if reusable) at the end of each patient treatment session

  • Centeral line catheter maintenance, connection and disconnection are done according to CDC guidelines

  • The process of internal cleaning and disinfection of dialysis machines in-between patients is performed according to manufacture's recommendations

  • Water treatment system is regularly maintened with change of filters according to the manufacturer’s instructions. Cleaning and disinfection of the water treatment and distribution system is performed at least once weekly

  • Treated water is regularly subjected to chemical testing at least once per year

  • Microbiological testing for water and dialysite is conducted monthly, if standards are exceeded, testing is done weekly until meeting standards.(maximum acceptable level is 100 (CFU) per milliliter of water and the action level is 50 CFU)

  • Endotoxin testing for water is performed at least once per month, and if not up to standards, testing is repeated weekly until the problem is resolved (maximum acceptable level is 0.25 EU/ml action level is 0.1 EU/ml)

  • The results of chemical and microbiological testing of water are available and reviewed by responsible nephrologist and infection control practitioners, and an action is taken accordingly

  • Patients are tested for HBV and HCV, HIV at the beginning of dialysis, and those with negative results are rescreened every 3 - 6 months. Hepatitis B susceptible patients are vaccinated

  • HCWs are tested for HBV and HCV upon hiring and annually, and vaccine is given for those who are susceptible to hepatitis B

  • HVB +ve patients are strictly segregated in a separate room(s), treated by dedicated staff during dialysis sessions using designated machines, equipment, instruments, supplies, and medications which are used only for them

  • Patients –ve for HBV, but +ve for HCV and/or HIV are treated in separate areas /rooms using dedicated machines, supplies and instrument

Compound Sterile Preparation (CSP) / Pharmacy

  • There is a written IC policy and procedures for compound sterile preparation (CSP)

  • Compound sterile preparation (CSP) is restricted to competent pharmaceutical staff (except during emergency situations), who are familiar with aseptic techniques and proper use of appropriate PPE

  • Compound sterile preparation (CSP) room/area is a functionally separate facility which is under positive pressure

  • The doors of the compound sterile preparation (CSP) room/area are equipped with an auto-closure mechanism

  • Mixing IV medications is performed in laminar air flow hood or safety cabinet, with air supplied through High-Efficiency Particulate Air (HEPA) filter

  • Compound sterile preparation (CSP) room/area is cleaned and disinfected with an approved detergent/disinfectant

  • Working surface (under the laminar air flow hood) is regularly disinfected by an approved disinfectant using non-linting wipes

  • Maintenance records for hoods and safety cabinets are available

  • All supplies and containers used in CSPs preparations are sterile

  • Operating Room (OR)

  • There is a written policies and procedures for infection control in OR including a clear policy to handle patients under Air-borne Infection Isolation Precautions inside OR (e.g., TB)

  • There is a clear demarcation between unrestricted, semirestricted and restricted zones of OR with restrictions and special precautions for movement between these zones

  • Floors, walls, ceiling are: formed of one piece without connections, cracks, or decorative parts, with minimal openings that are completely sealed, and withstand repeated cleaning and disinfection

  • At least one large scrubbing sink is available at entry to each operating theater

  • Storage areas in the OR is organized and well maintained

  • Only necessary items are kept in the restricted area of the OR

  • Doors are kept closed and only necessary personnel are allowed in the theater

  • OR environment is maintained clean and there are clear procedures for cleaning and disinfection by allocated housekeeping staff after each surgical procedure and at least daily

  • Ventilation system operates all the time and never shuts down even in long holidays, and air is introduced from the ceiling and exhausted near the floor

  • All re-circulated or fresh air is filtered through High-Efficiency Particulate Air (HEPA) filters that are maintained and replaced as per the manufacturer recommendations

  • Operating Room is maintained at positive pressure (at least +2.5 Pascal) with respect to corridors

  • Operating Room is maintained at ≥ 15 air changes per hour (ACH) with 20% fresh air

  • Operating Room itemperature ranges from 21 °C to 24 °C and relative humidity from 20% to 60%

  • Patients with infectious transmissible diseases are scheduled towards the end of the operating list


  • There is a written policies and procedures for IC in the laboratory

  • Access is restricted with a sign incorporating the universal biohazard symbol posted at the entrance

  • Eating, drinking, handling contact lenses, and storing food are not permitted

  • All manipulations of infectious materials that may generate aerosols are properly contained or conducted in a biological safety cabinet (BSC - class II-B)

  • Biological Safety Cabinets (BSC - class II-B) dedicated for aerosols generating procedures are tested and certified at least annually

  • Whenever possible, glass tubes are replaced by plastic ones

  • Emergency shower and eyewash station is available for immediate decontamination after exposure to hazardous chemicals

  • Specimen collection and receiving area are equipped with hand washing facilities and proper PPEs

  • Tuberculosis laboratory is at least biosafety level III (BL-3) that is separated from other parts of building by an anteroom and equipped with Biological Safety Cabinet (BSC - class II-B)

  • Cultures plates are autoclaved in appropriate autoclave bags and then contained inside yellow coloured bags with a biohazard symbol before disposal as infectious medical waste

  • Working surfaces and equipment are regulaly cleaned and disinfected

  • Laboratory personnel perform hand hygiene and wear appropriate PPE when indicated

Dental Services

  • There are written IC policies and procedures for the dental setting

  • No reprocessing of instruments is carried inside the dental clinic (all the contaminated items are sent to the central sterilization department)

  • Single-use devices (e.g., disposable examination set, anesthesia carpule/cartidge, etc. …) are discarded immedialtely after each patient

  • All reusable dental instruments (critical and semicritical dental items) are sent to CSSD after each patient

  • Contaminated dental instruments including dental handpieces are transferred to the central sterilization department in a closed, sealed, puncture- resistant containers

  • If reprocessing of instruments will not be carried within two hours, transportation gel/spray is applied before sending them to CSSD

  • Engineering controls (e.g., self-sheathing anesthetic needles, safety scalpels) are used to prevent injuries

  • If needles with self-sheathing mechanism and recapping devices are not available, dental care personnel use one-handed recapping (scoop technique) for recapping needles

  • Clinical contact surfaces (contaminated and frequently touched surfaces in the patient-care area): light handles, bracket trays, switches on dental units, computer equipment are either barrier protected or cleaned and disinfected after each patient

  • Housekeeping surfaces (e.g., floors, walls, and sinks) cleaned with water and detergent or disinfectant/detergent on a routine basis or when they are visibly dusty or soiled

  • Dental unit waterline treatment products / devices are used to ensure that water quality meets regulatory standards for drinking water for routine dental treatment (i.e., ≤ 500 CFU / ml of heterotrophic water bacteria) and this is tested at least semiannualy

  • During surgical procedures, only sterile solutions are used as a coolant / irrigant using an appropriate delivery device

  • Dental care personnel apply standard precautions while performing dental x-rays

  • Dental lab personnel adhere to standard precautions while performing dental lab procedures

  • Before handling dental prostheses and prosthodontics materials in the dental lab (e.g., impressions, bite registrations, and occlusal rims), they are cleaned and disinfected according to manufacturers' instructions

Dietary Services

  • There is a written policies and procedures addressing dietary services and kitchen staff hygiene

  • Kitchen staff practice hand hygiene properly and use suitable PPE while handling food

  • Kitchen staff with respiratory infections, gastroenteritis, diareaha or hand infections or wounds are restricted from handling food

  • Stool tests and cultures are performed routinely upon hiring, every 6 months and after returning from long vacation. Results are reviewed by the employee health clinic and the IC team

  • Kitchen is designed as physically separated areas with specified equipment & supplies (e.g., Mixers, juicers, knives, etc

  • ) for different types of food

  • Adequate numbers of hand washing facilities and/or hand rub antiseptic devices are available

  • Temperature requirements and protection from contamination are considered during receiving, storage, preparation, display and transportation of food

  • Garbage containers or receptacles are adequate in number, well distributed, insect and rodent proof and with covers controlled by foot

  • Boards and knives used to cut meat, poultry, fish or vegetables are identifiably separated (color- coded) and immediately washed after use

  • Food containers are properly labelled with expiry dates noted. Expiry dates of food stuffs are checked before use

  • Fruits and vegetables are washed and disinfected thoroughly

  • Freezers & fridges temperatures are continuously monitored and documented on log sheets and relevant actions are taken

  • Food containers and cooking utensils are washed immediately after being emptied

  • There is an Insect and rodent control plan that is strictly implemented

  • The kitchen environment is clean (i.e., frequently cleaned, dry and dust free)


  • There is a written policies and procedures for linen management, (e.g., collection, transportation, sorting, washing, storing and dispensing)

  • Work flow is unidirectional from a soiled area to clean area with complete physical separation between them

  • Hand hygiene facilities and supplies are available & easily accessible, especially in the dirty area

  • Clean and dirty linen are separated during transport, linen carts used for clean and dirty linen are clearly identified

  • Soiled linen (visibly contaminated with patient’s blood, excreta, or other body fluids), and linen from patients under isolation precautions are handled as little as possible, with appropriate PPE, and special color-coded and leak-proof laundry bags are used

  • During high temperature washing cycle, water temperature is at a minimum of 71°C for 25 minutes (heat disinfection), and this is recorded

  • During low temperature washing cycle (22°C - 50°C), sodium hypochlorite is added as a disinfectant during bleach wash cycle (chemical disinfection: residual bleach is 50 - 150 ppm), this is monitored and controlled

  • Routine inspection is conducted after washing, and linen with blood or/and body fluid stains is washed again

The Mortuary

  • There is a written policies and procedures that address safe handling of dead bodies, including postmortem handling of patients under isolation precautions and bodies with open wounds

  • Hand hygiene facilities and supplies are available & easily accessible

  • The mortuary is generally clean, well ventilated, and well organised. There is a regular schedule of cleaning activities (cleaning and disinfection) that includes all environmental surfaces and equipments

  • The temperature of the morgue refrigerator is kept at 2-4°C and logged daily

  • For long-term preservation of dead bodies, the facility must provide a deep freezing compartment (temp < -15°C)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.