A Self-Assessment Guide for Health Care Organizations - IFC
A Self-Assessment Guide for Health Care Organizations - IFC
A Self-Assessment Guide for Health Care Organizations - IFC
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Measurable Element Look <strong>for</strong> Score Observations<br />
What is required<br />
9) Kitchen sanitation and<br />
food preparation and<br />
handling are appropriate<br />
to minimize infection risk.<br />
10) The risks and impact<br />
of any renovation or<br />
construction on air quality<br />
and infection control<br />
activities is assessed and<br />
managed.<br />
11) Patients with known<br />
or suspected contagious<br />
diseases are isolated in<br />
accordance with<br />
organization policy and<br />
recommended guidelines. 46<br />
12) Universal procedures,<br />
including <strong>for</strong> gloves, masks,<br />
eye protection and hand<br />
disinfection, are<br />
appropriately<br />
47, 48<br />
implemented.<br />
13) All staff are oriented<br />
to the policies, procedures,<br />
and practices of the<br />
infection prevention and<br />
control program.<br />
How is this element<br />
assessed<br />
Policies and procedures are written<br />
<strong>for</strong> kitchen sanitation. Staff are<br />
trained (document in file).<br />
Observation monitoring shows that<br />
staff carry out the procedures<br />
according to policy.<br />
Minutes of meetings regarding<br />
construction projects indicate that<br />
infection control is considered and<br />
actions planned to reduce the<br />
potential <strong>for</strong> infection. During<br />
construction, safety rounds are<br />
made to observe whether safety<br />
practices are adhered to.<br />
Isolation policies and procedures<br />
are in place. Observation of<br />
practice indicates proper<br />
implementation of isolation<br />
precautions.<br />
Observations show that staff use<br />
gloves and masks etc according to<br />
the defined policy and procedures.<br />
Infection control procedures are<br />
incorporated into the general<br />
orientation program <strong>for</strong> staff.<br />
Annual training is provided <strong>for</strong><br />
targeted staff groups.<br />
0 5 10 Why did you give this score<br />
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14) Patients and their<br />
families are educated<br />
about reducing the<br />
transmission of infectious<br />
diseases, e.g.<br />
immunizations, personal<br />
hygiene, hand washing,<br />
cough etiquette, as<br />
appropriate.<br />
Policies and procedures describe<br />
expectations <strong>for</strong> educating patients<br />
and families regarding hygiene<br />
measures. In<strong>for</strong>mational materials<br />
are made available to them and<br />
implementation of the policy is<br />
monitored.<br />
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46<br />
Coia JE, Duckworth GJ, et al. (2006) <strong>Guide</strong>lines <strong>for</strong> the control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities.<br />
Journal of Hospital Infection, 63S, S1-S44. Available at: www.his.org.uk/_db/_documents/MRSA_<strong>Guide</strong>lines_PDF.pdf<br />
47<br />
Joint Commission (2009). Measuring Hand Hygiene Adherence: Overcoming the Challenges. Available at:<br />
www.jointcommission.org/NR/rdonlyres/68B9CB2F-789F-49DB-9E3F-2FB387666BCC/0/hh_monograph.pdf<br />
48<br />
WHO (2009). WHO <strong>Guide</strong>lines on Hand Hygiene in <strong>Health</strong> <strong>Care</strong>. Available at http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf<br />
<strong>IFC</strong> <strong>Self</strong>-<strong>Assessment</strong> <strong>Guide</strong> <strong>for</strong> <strong>Health</strong> <strong>Care</strong> <strong>Organizations</strong> 47