A Self-Assessment Guide for Health Care Organizations - IFC

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Measurable Element Look for Score Observations What is required 5) Equipment cleaning and sterilization methods are appropriate for the type of equipment. 42 How is this element assessed Policies and procedures for sterilization are based on manufacturer’s recommendations and current practice. Staff performing sterilization are trained (documented in their file) and competency verified. The effectiveness of sterilization is monitored. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ 6) Laundry and linen management are appropriate to minimize risk to staff and patients. 43 7) Disposal of infectious waste and body fluids are managed to minimize transmission risk. 44 8) Sharps and needles are collected in dedicated, puncture-proof containers which are not re-used. 45 Laundry department policies and procedures include infection prevention practices. Staff are trained (documented in their file). Compliance with these practices is recorded. Policies and procedures describe the disposal of infectious waste. All staff that deal with waste are trained to carry out these procedures correctly (documented in their file). Observation and monitoring of compliance is recorded. Observations made during safety rounds indicate that appropriate containers are used for sharps disposal. These may be heavy plastic or thick cardboard containers. The opening does not allow withdrawal of items. The container is no more than 2/3 full. Containers are never emptied, but are sealed and put in a protected location until final disposal. ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 42 Center for Disease Control (2008), Guideline for Disinfection and Sterilization in Healthcare Facilities. Available at: www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf 43 Healthcare Laundry Accreditation Council (2006) Accreditation Standards for Processing Reusable Textiles for use in Healthcare Facilities. Frankfort, IL, USA. Available at www.hlacnet.org 44 Center for Disease Control (2003) Guidelines for Environmental Infection Control in Health-Care Facilities. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm 45 WHO Safe Injection Global Network. www.who.int/injection_safety/sign/en 46 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 9) Kitchen sanitation and food preparation and handling are appropriate to minimize infection risk. 10) The risks and impact of any renovation or construction on air quality and infection control activities is assessed and managed. 11) Patients with known or suspected contagious diseases are isolated in accordance with organization policy and recommended guidelines. 46 12) Universal procedures, including for gloves, masks, eye protection and hand disinfection, are appropriately 47, 48 implemented. 13) All staff are oriented to the policies, procedures, and practices of the infection prevention and control program. How is this element assessed Policies and procedures are written for kitchen sanitation. Staff are trained (document in file). Observation monitoring shows that staff carry out the procedures according to policy. Minutes of meetings regarding construction projects indicate that infection control is considered and actions planned to reduce the potential for infection. During construction, safety rounds are made to observe whether safety practices are adhered to. Isolation policies and procedures are in place. Observation of practice indicates proper implementation of isolation precautions. Observations show that staff use gloves and masks etc according to the defined policy and procedures. Infection control procedures are incorporated into the general orientation program for staff. Annual training is provided for targeted staff groups. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 14) Patients and their families are educated about reducing the transmission of infectious diseases, e.g. immunizations, personal hygiene, hand washing, cough etiquette, as appropriate. Policies and procedures describe expectations for educating patients and families regarding hygiene measures. Informational materials are made available to them and implementation of the policy is monitored. ........................................................ ........................................................ ........................................................ ........................................................ 46 Coia JE, Duckworth GJ, et al. (2006) Guidelines for the control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection, 63S, S1-S44. Available at: www.his.org.uk/_db/_documents/MRSA_Guidelines_PDF.pdf 47 Joint Commission (2009). Measuring Hand Hygiene Adherence: Overcoming the Challenges. Available at: www.jointcommission.org/NR/rdonlyres/68B9CB2F-789F-49DB-9E3F-2FB387666BCC/0/hh_monograph.pdf 48 WHO (2009). WHO Guidelines on Hand Hygiene in Health Care. Available at http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf IFC Self-Assessment Guide for Health Care Organizations 47
Page 1 and 2: PROMOTING STANDARDS IN THE PRIVATE
Page 3 and 4: Contents Foreword 2 Acknowledgement
Page 5 and 6: Acknowledgements This Guide was dev
Page 7 and 8: introduction IFC Self-Assessment Gu
Page 9 and 10: Why are Standards Important Why sho
Page 11 and 12: Leadership Systems Data Where to Be
Page 13 and 14: Preparing for the self-assessment I
Page 15 and 16: Facility Safety and Emergency Manag
Page 17 and 18: The self -assessment template IFC S
Page 19 and 20: Clinical Governance and Leadership
Page 21 and 22: Measurable Element Look for Score O
Page 25 and 26: Standard CGL.6 [Staff recruitment,
Page 27 and 28: Standard EPR.2 [Patient and family
Page 29 and 30: Standard EPR.3 [Informed consent] P
Page 31 and 32: Standard EPR.4 [Ethical management]
Page 33 and 34: Standard EPR.5 [Organ and tissue do
Page 35 and 36: Standard EPR.6 [Reproductive health
Page 37 and 38: Standard EPR.7 [Termination of preg
Page 41 and 42: Quality Measurement and Improvement
Page 43 and 44: Standard QMI.2 [Leaders’ collabor
Page 47: Measurable Element Look for Score O
Page 51 and 52: Standard QMI.4 [Medications use] Me
Page 57 and 58: Patient Safety (PS) Standard PS.1 [
Page 59 and 60: Standard PS.2 [Effective communicat
Page 61 and 62: Standard PS.4 [Correct site, proced
Page 63 and 64: Standard PS.5 [Health care associat
Page 65 and 66: Facility Safety and Emergency Manag
Page 73 and 74: Standard FSE.6 [Utilities managemen
Page 75 and 76: IFC Self-Assessment Guide for Healt
Page 77 and 78: After the self-assessment Next Step
Page 79 and 80: Baseline Score Score Score Clinical
Page 81 and 82: EPR.6 Reproductive health policies
Page 83 and 84: QMI.4 Medications use 1 Medication
Page 85 and 86: Baseline Score Score Score Facility
Page 87 and 88: STEP 5: Develop an Action Plan The
Page 89 and 90: IFC Self-Assessment Guide for Healt
Page 91 and 92: Appendices IFC Self-Assessment Guid
Page 93 and 94: 11. Organ donation and transplant T
Page 95 and 96: Clinical Privileging Committee The
Page 97 and 98: emergency 1. An unanticipated or su
Page 99 and 100:
privileging The process whereby a s
Page 102:
Contact Information Health and Educ
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A Self-Assessment Guide for Health Care Organizations - IFC

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