Title Page

  • UCLA SMH Infection Prevention Audit - Non Clinical Staff

  • Conducted on

  • Prepared by:

  • Personnel attending the IP Audit-Rounds

  • Department: (i.e. Transport and Lift Team; Chaplain; Volunteers)


  • 1. Staff able to find or state the location of the hospital's Infection Control Policies & Procedures<br>

  • 2. Able to name three types of isolation / precautions and their indications.<br>

  • 3. Able to state the CDC recommended personal protective equipment (PPE) for a specific type of isolation / precaution: (name one of the isolation precautions)<br>

  • 4. TRANSPORT TEAM: Able to verbalize / demonstrate cleaning/disinfection of side rails and removal of gloves prior to transporting an isolation patient to another part of the hospital.<br>

  • 5. Able to describe which way the air flows in a negative airflow room and anteroom. <br>

  • 6. State who checks negative pressure rooms? How often? Where is this recorded?<br><br>

  • 7. Staff able to articulate steps to check a negative airflow room for correct operation. What is the correct procedure if the room doesn't check out?<br><br>

  • 8. Able to state the Hand Hygiene policy including the fingernail standards for healthcare workers.<br><br>

  • 9. Able to name steps to cleanup a biohazard spill of blood or body fluids.<br><br>

  • 10. Able to identify biohazardous waste containers; list three examples of biohazard waste.<br><br>

  • 11. Able to articulate the department's performance improvement activities to reduce hospital onset infections happening in the unit? In the hospital?<br><br>

  • 12. Able to describe three actions to take if exposed to blood or body fluids.<br><br><br>

  • 13. Able to state three steps to take if a patient or visitor in a waiting area is suspected of having a contagious respiratory disease.<br><br>

  • 14. Able to state the the contact/dwell time or both hydrogen peroxide and bleach wipes.<br>

  • 15. Staff able to articulate contact/dwell times for hospital approved disinfectants. (Bleach and Hydrogen peroxide)


  • 16. Staff is observed performing correct hand hygiene: a) washing hands for at least 15 seconds with alcohol foam or soap and water, b) using towel to turn off faucets and touch door handles, and c) between patient contacts.<br><br>

  • 17. Direct patient care staff have no artificial fingernails; nails extend < 1/4" from fingertip.<br><br>

  • 18. Staff correctly observed isolation precautions posted for patients.<br><br>

  • 19. Correct contact/dwell times observed for hospital approved disinfectants. (Bleach and Hydrogen peroxide)


  • 20. Storage area is clean and organized with no outside shipping containers

  • 21. Sterile items are stored in a manner that will not compromise sterility

  • 22. Storage shelving/carts are: 18" from the ceiling, 8-10" above the floor, and at least 2 " from the outside walls

  • 23. Sterile supplies are rotated on the "first in, first out" concept.

  • 24. No outdated supplies found.

  • 25. Staff is able to articulate decontamination process of dirty equipment.

  • 26. Clean Equipment Storage Room only contains clean equipment.


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