CLEANPASS Hygiene Audit

CLEANPASS Hygiene Audit

The scope of the audit will be confined to structural and equipment issues pertinent to hygiene and infection prevention & control. Processes and practices will be audited; management and supervisory staff will be interviewed in relation to specific issues as part of the audit.

Audit Tool

The audit will be conducted using the - National Standards for the prevention and Control of Healthcare Associated Infections - Observation Tool for Unannounced Monitoring Inspections and guidance from The Monitoring Programme for unannounced inspections undertaken against the National Standards for the prevention and control of Healthcare associated infections. HIQA 2015

Costs

Hygiene Audit includes one day spent on - site and provision of comprehensive full colour pictorial report for each facility. €900

The Audit Plan

Terms of reference

The terms of reference applied to the process will be to undertake a hygiene audit of a range of areas relating to patient care. Issues relating to hygiene and Infection Prevention and Control practices will be audited. The audit will be conducted with limited prior notification so that staff at ward and unit levels should not be aware of the planned visit.

Patient areasThe following areas will be assessed:

• Bathrooms / washrooms
• Patient equipment
• Clean utility (treatment room / drug room)
• Dirty utility
• Waste disposal
• Isolation rooms
• Housekeeping and equipment room
• Linen
• Hans hygiene practices

CLEANPASS Environmental Hygiene Audit

Please read carefully

A selected number of areas will be chosen in which to carry out the audit. These facilities will be selected at random. Auditing will take place between 8am and 6pm Monday to Friday.

In order for each facility to be fully prepared prior to audit please see below for list of requirements:

• Exclusion of facilities from the audit
• Identification and role of the contact/liaison person for each facility
• Documentation required at each site (see appendices)
  • Exclusion of Facilities from Audit

A pre-planned audit will not take place if a facility has an:-

• Outbreak of infection requiring a restriction in public visiting arrangements
• Extensive renovations ongoing resulting in the facility not substantially functioning
• Other issues that may restrict visiting or health and safety reasons
• Industrial relations issues or
• Any other issues that should be considered by the audit team regarding the possible exclusion of specific facilities.

The decision as to whether any facility will be excluded from the Audit will ultimately be decided by the Independent Auditors.

Facilities will need to have a nominated liaison person.

The role of the liaison person will include to:-

• Be available from 8 a.m. – 6 p.m. if necessary (contact number and lead name required)
• Have a contingency plan for their own non-availability, and contact number for substitute
• Meet and greet the auditor
• Have available and provide if necessary a list of wards and departments
• Where there are children / vulnerable adults – ensure the ward manager is aware that auditor(s) will need to be accompanied in that area.
• Be available to the auditors when the audit of an area has been completed. It is not necessary for the liaison person to accompany the auditor(s) for the duration of the audit.

The external auditor, on arrival, will require documentation to be available. If there are additional policies and training records in place in the residential facility, these can also be included but there must be evidence to show that these policies are being actioned on site.

National documents, central policies and training records that are required for reference and recording purposes should be held together in a central location. However, there should be evidence that staff are aware that these documents are held in a central location and that they have access to these documents if they require them i.e. on wards. Policies in the form of notices and posters etc. For implementation on wards such as those related to hand hygiene, waste disposal and sharps injuries should be clearly available on wards.

Photographs – Photographs will be taken as part of the audit; however they will be non-identifiable to the facility or persons.

Evaluation forms – Each facility will be asked to complete an evaluation form in relation to the audit.

Availability of Results – a comprehensive pictorial report will be compiled and made available to the designated person(s) within one week of audit.