Infection Prevention and Control Assessment Tool for Acute Care Hospitals

This tool is intended to assist in the assessment of infection control programs and practices in acute care hospitals. If feasible, direct observations of infection control practices are encouraged. To facilitate the assessment, health departments are encouraged to share this tool with hospitals in advance of their visit.

Overview

Section 1: Facility Demographics

Section 2: Infection Control Program and Infrastructure

Section 3: Direct Observation of Facility Practices (optional)

Section 4: Infection Control Guidelines and Other Resources

Infection Control Domains for Gap Assessment

Infection Control Program and Infrastructure

Infection Control Training, Competency, and Implementation of Policies and Practices

Hand Hygiene

Personal Protective Equipment (PPE)

Prevention of Catheter-associated Urinary Tract Infection (CAUTI)

Prevention of Central Line-associated Bloodstream Infection (CLABSI)

Prevention of Ventilator-associated Event (VAE)

Injection Safety

Prevention of Surgical Site Infection

Prevention of Clostridium difficile Infection (CDI)

Environmental Cleaning

Device Reprocessing

Systems to Detect, Prevent, and Respond to Healthcare-Associated Infections and Multidrug-Resistant Organisms (MDROs)

Section 1. Facility Demographics v1

Facility Name (for health department use only)	Click here to enter text.
NHSN Facility Organization ID (for health department use only)	Click here to enter text.
State-assigned Unique ID	Click here to enter text.
Date of Assessment	Click here to enter a date.
Type of Assessment	☐ On-site ☐ Other (specify): Click here to enter text.
Rationale for Assessment (Select all that apply)	☐ Outbreak ☐ Input from accrediting organization or state survey agency ☐ NHSN data If YES, specify: ☐ CAUTI ☐ CLABSI ☐ SSI ☐ CDI ☐ Other (specify: Click here to enter text.) ☐ Collaborative (specify partner[s]): Click here to enter text.) ☐ Other (specify): Click here to enter text.
Facility type	☐ Acute Care Hospital ☐ Critical Access Hospital ☐ Long-term Acute Care Hospital (LTACH) ☐ Other (specify): Click here to enter text.
Number of Licensed Beds	Click here to enter text.
Number of Infection Preventionist Full-Time Equivalents	Click here to enter text.

Section 2: Infection Control Program and Infrastructure

Infection Control Program and Infrastructure
Elements to be assessed	Assessment	Notes/Areas for Improvement
Hospital provides fiscal and human resource support for maintaining the infection prevention and control program.	Yes No
The person(s) charged with directing the infection prevention and control program at the hospital is/are qualified and trained in infection control. Verify qualifications, which should include: (Check all that apply) ☐ Successful completion of initial and recertification exams developed by the Certification Board for Infection Control & Epidemiology (CIC) AND/OR ☐ Participation in infection control courses organized by recognized professional societies (e.g., APIC, SHEA)	Yes No
Infection prevention and control program performs an annual facility infection risk assessment that evaluates and prioritizes potential risks for infections, contamination, and exposures and the program’s preparedness to eliminate or mitigate such risks. Note: Example of Facility Infection Risk Assessment Report and Plan is available in Section 4.	Yes No
Written infection control policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards. Verify the following: Respondent can describe the process for reviewing and updating policies (e.g., policies are dated and reviewed annually and when new guidelines are issued)	Yes No a. Yes No
Infection prevention and control program provides infection prevention education to patients, family members, and other caregivers. Verify the following: Respondent can describe how this education is provided (e.g., information included in the admission or discharge packet, videos, signage, in-person training)	Yes No a. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Hand Hygiene
Hospital has a competency-based training program for hand hygiene. Verify the following: Training is provided to all healthcare personnel, including all ancillary personnel not directly involved in patient care but potentially exposed to infectious agents (e.g., food tray handlers, housekeeping, volunteer personnel). Training is provided upon hire, prior to provision of care at this hospital. Training is provided at least annually. Personnel are required to demonstrate competency with hand hygiene following each training. Hospital maintains current documentation of hand hygiene competency for all personnel.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No
Hospital regularly audits (monitors and documents) adherence to hand hygiene. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their hand hygiene performance. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in patient care areas.	Yes No
Hand hygiene policies promote preferential use of alcohol-based hand rub over soap and water except when hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus.	Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Personal Protective Equipment (PPE)
Hospital has a competency-based training program for use of personal protective equipment (PPE). Verify the following: Training is provided to all personnel who use PPE. Training is provided upon hire, prior to provision of care at this hospital. Training is provided at least annually. Training is provided when new equipment or protocols are introduced. Training includes 1) appropriate indications for specific PPE components, 2) proper donning, doffing, adjustment, and wear of PPE, and 3) proper care, maintenance, useful life, and disposal of PPE. Personnel are required to demonstrate competency with selection and use of PPE (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of PPE competency for all personnel who use PPE.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No
Hospital regularly audits (monitors and documents) adherence to proper PPE selection and use, including donning and doffing. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback to personnel regarding their performance with selection and use of PPE. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Supplies necessary for adherence to personal protective equipment recommendations specified under Standard and Transmission-based Precautions (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use.	Yes No
The hospital’s respiratory protection program provides annual respiratory fit testing for all personnel who are anticipated to require respiratory protection. Verify the following: Hospital maintains supplies of respiratory protection devices (e.g., Powered air purifying respirator) to be used by personnel who cannot be fitted. Healthcare personnel are educated about factors that may compromise proper fit and function of respiratory protection devices (e.g., weight gain/loss, facial hair).	Yes No a. Yes No b. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Prevention of Catheter-associated Urinary Tract Infection (CAUTI)
Hospital has physician and/or nurse champions for CAUTI prevention activities.	Yes No
Hospital has a competency-based training program for insertion of urinary catheters. Verify the following: Training is provided to all personnel who are given responsibility for insertion of urinary catheters. Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and physicians. Training is provided upon hire, prior to being allowed to perform urinary catheter insertion. Training is provided at least annually. Training is provided when new equipment or protocols are introduced. Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of competency with urinary catheter insertion for all personnel who insert urinary catheters.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No
Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of urinary catheters. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their performance for insertion of urinary catheters. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Prevention of Catheter-associated Urinary Tract Infection (CAUTI), continued
Hospital has a competency-based training program for maintenance of urinary catheters. Verify the following: Training is provided to all personnel who are given responsibility for urinary catheter maintenance (e.g., perineal care, emptying the drainage bag aseptically, maintaining the closed drainage system, maintaining unobstructed urine flow). Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and transport personnel. Training is provided upon hire, prior to being allowed to perform urinary catheter maintenance. Training is provided at least annually. Training is provided when new equipment or protocols are introduced Personnel are required to demonstrate competency with catheter maintenance (i.e., correct technique is observed by trainer) following each training Hospital maintains current documentation of competency with urinary catheter maintenance for all personnel who maintain urinary catheters.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No
Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of urinary catheters. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their performance for maintenance of urinary catheters. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Patients with urinary catheters are assessed, at least daily, for continued need for the catheter. Verify the following: Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, nurse directed protocol, reminders or stop orders). Hospital routinely audits adherence to daily assessment of urinary catheter need.	Yes No a. Yes No b. Yes No
II. Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Prevention of Catheter-associated Urinary Tract Infection (CAUTI), continued
Hospital monitors CAUTI data and uses it to direct prevention activities. Verify the following: Respondent is familiar with National Healthcare Safety Network (NHSN) CAUTI data. Respondent can describe how CAUTI data are used to direct prevention activities.	Yes No a. Yes No b. Yes No
Hospital provides feedback of CAUTI data to frontline personnel. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Prevention of Central line-associated Bloodstream Infection (CLABSI)
Hospital has physician and/or nurse champions for CLABSI prevention activities.	Yes No
Hospital has a competency-based training program for insertion of central venous catheters. Verify the following: Training is provided to all personnel who are given responsibility for insertion of central venous catheters. Personnel may include, but are not limited to, physicians, physician assistants, and members of line insertion teams. Training is provided upon hire, prior to being allowed to perform central venous catheter insertion. Training is provided at least annually. Training is provided when new equipment or protocols are introduced. Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of competency with central venous catheter insertion for all personnel who insert central venous catheters.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No
Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of central venous catheters. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their performance for insertion of central venous catheters. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Prevention of Central line-associated Bloodstream Infection (CLABSI), continued
Hospital has a competency-based training program for maintenance of central venous catheters. Verify the following: Training is provided to all personnel who maintain central venous catheters (e.g., scrub the hub, accessing the catheter, dressing changes). Personnel may include, but are not limited to, nurses, nursing assistants, physicians, and physician assistants. Training is provided upon hire, prior to being allowed to perform central venous catheter maintenance. Training is provided at least annually. Training is provided when new equipment or protocols are introduced. Personnel are required to demonstrate competency with maintenance (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of competency with central venous catheter maintenance for all personnel who maintain central venous catheters.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No
Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of central venous catheters. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their performance for maintenance of central venous catheters. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Patients with central venous catheters are assessed, at least daily, for continued need for the catheter. Verify the following: Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, reminders). Hospital routinely audits adherence to daily assessment of central venous catheter need.	Yes No a. Yes No b. Yes No
II. Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
D. Prevention of Central line-associated Bloodstream Infection (CLABSI), continued
Hospital monitors CLABSI data and uses it to direct prevention activities. Verify the following: Respondent is familiar with National Healthcare Safety Network (NHSN) CLABSI data. Respondent can describe how CLABSI data are used to direct prevention activities.	Yes No a. Yes No b. Yes No
Hospital provides feedback of CLABSI data to frontline personnel. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
E. Prevention of Ventilator-associated Event (VAE)
Hospital has physician and/or nurse champions for VAE prevention activities.	Yes No Check if facility does not provide care to ventilated patients and move to item F. Injection Safety.
Hospital has a competency-based training program addressing prevention of VAEs. Verify the following: Training is provided to all personnel who provide respiratory therapy for ventilated patients (e.g., suctioning, administration of aerosolized medications). Personnel may include, but are not limited to, respiratory therapists and nurses. Training is provided upon hire, prior to being allowed to provide respiratory therapy for ventilated patients. Training is provided at least annually. Training is provided when new equipment or protocols are introduced. Personnel are required to demonstrate competency with respiratory therapy practices (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of competency with respiratory practices for all personnel who provide respiratory therapy for ventilated patients.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No
Hospital regularly audits (monitors and documents) adherence to recommended practices for management of ventilated patients (e.g., suctioning, administration of aerosolized medications). Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their performance for management of ventilated patients. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
E. Prevention of Ventilator-associated Event (VAE), continued
Patients requiring invasive ventilation are assessed, at least daily, for continued need for the ventilator. Verify the following: Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, reminders) Hospital routinely audits adherence to daily assessment of ventilator need.	Yes No a. Yes No b. Yes No
Hospital has a program that includes daily spontaneous breathing trials and lightening of sedation in eligible patient.	Yes No
Hospital has an oral-hygiene program.	Yes No
Hospital monitors VAE data and uses it to direct prevention activities. Verify the following: Respondent can describe how VAE data are used to direct prevention activities. If the hospital reports VAE data to NHSN, verify the following: Respondent is familiar with NHSN VAE data. If the hospital does not report VAE data to NHSN, verify the following: Respondent can describe how VAE data are collected.	Yes No a. Yes No b. Yes No Not Applicable c. Yes No Not Applicable
Hospital provides feedback of VAE data to frontline personnel. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Injection Safety (This element does not include assessment of pharmacy practices)
Hospital has a competency-based training program for preparation and administration of parenteral medications (e.g., SQ, IM, IV) outside of the pharmacy. Verify the following: Training is provided to all personnel who prepare and/or administer injections and parenteral infusions. Training is provided upon hire, prior to being allowed to prepare and/or administer injections and parenteral infusions. Training is provided at least annually. Training is provided when new equipment or protocols are introduced. Personnel are required to demonstrate competency with preparation and/or administration of injections and parenteral infusions following each training. Hospital maintains current documentation of competency with preparation and/or administration procedures for all personnel who prepare and/or administer injections and parenteral infusions.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No
Hospital regularly audits (monitors and documents) adherence to safe injection practices. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their adherence to safe injection practices. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Hospital has a drug diversion prevention program that includes consultation with the IP program when drug tampering (involving alteration or substitution) is suspected or identified to assess patient safety risks. Verify the following: Respondent can describe how the hospital would assess risk to patients if tampering is suspected or identified.	Yes No a. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Prevention of Surgical Site Infection (SSI)
Hospital has a surgical care improvement program. Verify the following: The surgical care improvement program addresses appropriate prophylactic antibiotic use including: Preoperative timing of prophylactic antibiotic administration (within 1 hour prior to incision or 2 hours for vancomycin or fluoroquinolones). Appropriate prophylactic antibiotic selection based on procedure type. Discontinuation of prophylactic antibiotics within 24 hours (48 hours for CABG or other cardiac surgery) after surgical end time. The surgical care improvement program addresses prompt removal of urinary catheter on post-op day 1 or 2, unless there is a documented appropriate reason for continued use.	Yes No Check if facility does not perform surgeries and move to item H. Clostridium difficile Infection. a. Yes No b. Yes No c. Yes No d. Yes No
Hospital regularly audits (monitors and documents) adherence to elements of surgical care improvement program. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their adherence to elements of the surgical care improvement program. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
II. Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
G. Prevention of Surgical Site Infection (SSI) , continued
Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for SSI prevention. Verify the following: Auditing includes: Adherence to preoperative surgical scrub and hand hygiene Appropriate use of surgical attire and drapes Adherence to aseptic technique and sterile field Proper ventilation requirements in surgical suites Minimization of traffic in the operating room Adherence to cleaning and disinfection of environmental surfaces Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No h. Yes No i. Yes No
Hospital provides feedback from audits to personnel regarding their adherence to surgical infection control practices. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Hospital monitors SSI data and uses it to direct prevention activities. Verify the following: Respondent is familiar with NHSN SSI data. Respondent can describe how SSI data are used to direct prevention activities.	Yes No a. Yes No b. Yes No
Hospital provides feedback of SSI data to surgeons and other surgical personnel. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Prevention of Clostridium difficile Infection (CDI)
Hospital has physician and/or nurse champions for CDI prevention activities.	Yes No
Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for CDI prevention. Verify the following: Auditing includes: Adherence to hand hygiene Appropriate use of PPE Compliance with Contact Precautions, including use of dedicated or disposable equipment Adherence to cleaning and disinfection procedures, including use of sporicidal disinfectants if part of hospital policy Respondent can describe process used for audits. Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No
Hospital provides feedback from audits to personnel regarding their adherence to recommended infection control practices for CDI prevention. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Hospital has specific antibiotic stewardship strategies in place to reduce CDI. Note: Please see section III.8 for full assessment of antibiotic stewardship program. Verify the following: Hospital has strategies to reduce unnecessary use of antibiotics that are high-risk for CDI (e.g., fluoroquinolones, 3rd/4th generation cephalosporins). Hospital reviews appropriateness of antibiotics prescribed for treatment of other conditions (e.g., urinary tract infection) for patients with new or recent CDI diagnosis. Hospital educates providers about the risk of CDI with antibiotics. Hospital educates patients and family members about the risk of CDI with antibiotics.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No
Hospital monitors CDI data and uses it to direct prevention activities. Verify the following: Respondent is familiar with NHSN CDI data. Respondent can describe how CDI data are used to direct prevention activities.	Yes No a. Yes No b. Yes No
Hospital provides feedback of CDI data to frontline personnel. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No

Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Environmental Cleaning
Hospital has a competency-based training program for environmental cleaning. Verify the following: Training is provided to all personnel who clean and disinfect patient care areas. Personnel may include, but are not limited to, environmental services staff, nurses, nursing assistants, and technicians. Training is provided upon hire, prior to being allowed to perform environmental cleaning. Training is provided at least annually. Training is provided when new equipment or protocols are introduced. Personnel are required to demonstrate competency with environmental cleaning (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of competency with environmental cleaning procedures for all personnel who clean and disinfect patient care areas. If the hospital contracts environmental services, the contractor has a comparable training program.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No Not Applicable
Hospital has policies that clearly define responsibilities for cleaning and disinfection of non-critical equipment, mobile devices, and other electronics (e.g., ICU monitors, ventilator surfaces, bar code scanners, point-of-care devices, mobile work stations, code carts, airway boxes).	Yes No
Hospital has protocols to ensure that healthcare personnel can readily identify equipment that has been properly cleaned and disinfected and is ready for patient use (e.g., tagging system, placement in dedicated clean area).	Yes No
Hospital regularly audits (monitors and documents) adherence to cleaning and disinfection procedures, including use of products in accordance with manufacturers’ instructions (e.g., dilution, storage, shelf-life, contact time). Verify the following: Respondent can describe process used for audits (e.g., monitoring technology, direct observation). Respondent can describe frequency of audits. Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No
Hospital provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Device Reprocessing This section refers to all medical devices that may be reused in the hospital. Device categories include: Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior to use. Semi-critical items (e.g., endoscopes for upper endoscopy and colonoscopy, laryngoscope blades) are objects that contact mucous membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse. Non-critical items (e.g., blood pressure cuffs, point-of-care devices) are objects that may come in contact with intact skin but not mucous membranes and should undergo cleaning and low- or intermediate-level disinfection depending on the nature and degree of contamination (See Environmental Cleaning Section I. above). Single-use devices (SUDs) are labeled by the manufacturer for a single use and do not have reprocessing instructions. They may not be reused unless they have been reprocessed for reuse by entities which have complied with FDA regulatory requirements and have received FDA clearance to reprocess specific SUDs.
Hospital has a competency-based training program for reprocessing of critical devices. Verify the following: Training is provided to all personnel who reprocess critical devices. Training is provided upon hire, prior to being allowed to reprocess critical devices. Training is provided at least annually. Training is provided when new devices or protocols are introduced. Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess critical devices. If the hospital contracts reprocessing of critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No Not Applicable
Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for critical devices. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Audits occur in all locations where critical devices are reprocessed (e.g., central sterile reprocessing, operating suites), including locations where initial cleaning steps are performed (e.g., point of use). Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No
Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
Device Reprocessing, continued
Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for critical devices. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
Hospital has a competency-based training program for reprocessing of semi-critical devices. Verify the following: Training is provided to all personnel who reprocess semi-critical devices. Training is provided upon hire, prior to being allowed to reprocess semi-critical devices. Training is provided at least annually. Training is provided when new devices or protocols are introduced. Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training. Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess semi-critical devices. If the hospital contracts reprocessing of semi-critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No Not Applicable
Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for semi-critical devices. Verify the following: Respondent can describe process used for audits. Respondent can describe frequency of audits. Audits occur in all locations where semi-critical devices are reprocessed (e.g., central sterile reprocessing, endoscopy suites), including locations where initial cleaning steps are performed (e.g., point of use). Respondent can describe process for improvement when non-adherence is observed.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No
Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for semi-critical devices. Verify the following: Respondent can describe how feedback is provided. Respondent can describe frequency of feedback.	Yes No a. Yes No b. Yes No
II. Infection Control Training, Competency, and Implementation of Policies and Procedures
Elements to be assessed	Assessment	Notes/Areas for Improvement
J. Device Reprocessing, continued
If hospital reuses single-use devices, the devices are reprocessed by an FDA-approved entity.	Yes No Not Applicable (hospital does not reuse single-use devices)
Hospital maintains documentation of reprocessing activities. Verify the following: Hospital maintains logs for each sterilizer cycle that include the results from each load. Hospital has documentation that the chemicals used for high-level disinfection are routinely tested for appropriate concentration and replaced appropriately. Hospital maintains documentation of reprocessing activities.	Yes No a. Yes No b. Yes No c. Yes No
Hospital allows adequate time for reprocessing to ensure adherence to all steps recommended by the device manufacturer, including drying and proper storage. Verify the following: Hospital has an adequate supply of instruments for the volume of procedures performed to allow sufficient time for all reprocessing steps Scheduling of procedures allows sufficient time for all reprocessing steps Hospital does not routinely use immediate-use steam sterilization (IUSS).	Yes No a. Yes No b. Yes No c. Yes No
IP program is consulted whenever new devices or products will be purchased or introduced to ensure implementation of appropriate reprocessing policies and procedures.	Yes No
Hospital has policies and procedures outlining hospital response (i.e., risk assessment and recall of device) in the event of a reprocessing error or failure. Verify the following: The IP can describe how the risk assessment would be performed including how the hospital would identify which patients may have been exposed to an improperly reprocessed device.	Yes No a. Yes No

Systems to Detect, Prevent, and Respond to Healthcare-Associated Infections and Multidrug-Resistant Organisms (MDROs)
Elements to be assessed	Assessment	Notes/Areas for Improvement
Hospital has system in place for early detection and management of potentially infectious persons at initial points of entry to the hospital, including rapid isolation as appropriate. Verify the following: Travel and occupational history is included as part of admission and triage protocols. Hospital has system to identify (flag) patients with targeted MDROs upon readmission so appropriate precautions can be applied. The hospital has a respiratory/hygiene cough etiquette program that includes: Posting signs at entrances Providing tissues and no-touch receptacles for disposal of tissues Providing hand hygiene supplies in or near waiting areas Offering facemasks to coughing patients and other symptomatic individuals upon entry to the facility Providing space in patient waiting areas (e.g., ED waiting room) and encouraging individuals with symptoms of respiratory infections to sit as far away from others as possible	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No
Hospital has systems in place for early detection and isolation of infectious patients identified during the hospital stay, including rapid isolation of patients as appropriate. Verify the following: There is a mechanism for prompt notification of the IP by the clinical microbiology laboratory when novel resistance patterns and/or targeted antimicrobial-resistant pathogens are detected.	Yes No a. Yes No
Hospital has system in place for INTER-facility communication of infectious status and isolation needs of patients prior to transfer to other facilities. Verify the following: Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving facilities. The hospital has system to notify receiving facilities of microbiological tests (e.g., cultures) that are pending at the time of transfer.	Yes No a. Yes No b. Yes No

Systems to Detect, Prevent, and Respond to Healthcare-Associated Infections and Multidrug-Resistant Organisms (MDROs)
Elements to be assessed	Assessment	Notes/Areas for Improvement
Hospital has system in place for INTER-facility communication to identify infectious status and isolation needs of patients prior to accepting patients from other facilities. Verify the following: Respondent can describe methods employed to ensure infectious status and isolation needs are obtained from transferring facilities. The hospital has system to follow-up on microbiological results (e.g., cultures) that are pending at the time of transfer. If the hospital identifies an infection that may be related to care provided at another facility (e.g., hospital, nursing home, clinic), the facility is notified.	Yes No a. Yes No b. Yes No c. Yes No
Hospital has system in place for INTRA-facility communication to identify infectious status and isolation needs of patients prior to transfer to other units or shared spaces (e.g., radiology, physical therapy, emergency department) within the hospital. Verify the following: Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving units.	Yes No a. Yes No
Hospital has a surveillance program to monitor incidence of epidemiologically-important organisms (e.g., CRE) and targeted healthcare-associated infections. Verify the following: Respondent can describe how the hospital determines which organisms and HAIs to track.	Yes No a. Yes No
Hospital uses surveillance data to implement corrective actions rapidly when transmission of epidemiologically-important organisms (e.g., CRE) or increased rates or persistently elevated rates of healthcare-associated infections are detected. Verify the following: Data collection method allows for timely response to identified problems.	Yes No a. Yes No

Systems to Detect, Prevent, and Respond to Healthcare-Associated Infections and Multidrug-Resistant Organisms (MDROs)
Elements to be assessed	Assessment	Notes/Areas for Improvement
Hospital has an antibiotic stewardship program that meets the 7 CDC core elements listed below (a – g). Note: The antibiotic stewardship program should be assessed in consultation with personnel knowledgeable about antibiotic stewardship activities (e.g., physician or pharmacist stewardship lead). Responses can be obtained from or cross-checked with the NHSN Annual Hospital Survey Antibiotic Stewardship Practice questions (Q 23 – 34) if available. Verify the following: Hospital leadership commitment Hospital has a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship) AND/OR Hospital provides salary support for dedicated time for antibiotic stewardship activities. Program leadership (accountability) There is a leader responsible for outcomes of stewardship activities at the hospital. Drug expertise There is at least one pharmacist responsible for improving antibiotic use at the hospital. Act (at least one prescribing improvement action below) Hospital has a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry. Hospital has hospital-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions. There is a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g., antibiotic time out). Hospital has specified antibiotic agents that need to be approved by a physician or pharmacist prior to dispensing at the hospital. Physician or pharmacist reviews courses of therapy for specified antibiotic agents and communicates results with prescribers. Track Hospital monitors antibiotic use (consumption). Report Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing. Educate Stewardship program provides education to clinicians and other relevant staff on improving antibiotic use.	Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No

III. Systems to Detect, Prevent, and Respond to Healthcare-Associated Infections and Multidrug-Resistant Organisms (MDROs)
Elements to be assessed	Assessment	Notes/Areas for Improvement
Hospital has occupational health program that, in addition to complying with state and federal requirements (e.g., OSHA), has policies regarding contact of personnel with patients when personnel have potentially transmissible conditions. Verify the following: The program has work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits or job status. Personnel are educated regarding prompt reporting of illness to their supervisor and the occupational health programs.	Yes No a. Yes No b. Yes No
Hospital follows recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunization of healthcare personnel, including offering Hepatitis B and influenza vaccination.	Yes No
Hospital is compliant with mandatory reporting requirements for notifiable diseases, healthcare-associated infections (as appropriate), and potential outbreaks. Verify the following: Hospital can identify point(s) of contact at the local or state health department for HAI concerns.	Yes No a. Yes No
Hospital implements infection control measures relevant to construction, renovation, demolition, and repairs including performance of an infection control risk assessment (ICRA) before a project gets underway. Verify the following: IP program is consulted anytime construction, renovation, demolition, or repairs will be performed. ICRA elements are included in all contracts related to construction, renovation, demolition, and repairs.	Yes No a. Yes No b. Yes No

Section 3: Direct Observation of Facility Practices (optional)

Certain infection control lapses (e.g., reuse of syringes on more than one patient or to access a medication container that is used for subsequent patients; reuse of lancets) can result in bloodborne pathogen transmission and should be halted immediately. Identification of such lapses warrants appropriate notification and testing of potentially affected patients.

Examples of Auditing Tools for Direct Observations:

General Infection Control

Centers for Medicare & Medicaid Services Hospital Infection Control Worksheet: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-1.pdf

Auditing checklists available for observations of:

☐ Hand hygiene

☐ Personal protective equipment use

☐ Indwelling urinary catheter insertion and maintenance

☐ Central venous catheter insertion and maintenance

☐ Injection safety

☐ Environmental services

☐ Equipment reprocessing (non-critical, semi-critical, critical reusable and single-use devices)

☐ Ventilator/respiratory therapy

☐ Spinal injection procedures

☐ Point of care devices

☐ Transmission-based precautions (Contact, Droplet, Airborne)

☐ Surgical procedures

Hand Hygiene Auditing Tools

☐ Measuring Hand Hygiene Adherence: Overcoming the Challenges: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf

☐ iScrub: http://compepi.cs.uiowa.edu/index.php/Research/IScrub

Personal Protective Equipment (PPE) Donning and Doffing

☐ CDC Sequence for Donning and Removing Personal Protective Equipment http://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

Urinary Catheter Appropriate Use, Insertion, and Maintenance

☐ American Nurses Association CAUTI Prevention Tool: http://nursingworld.org/CAUTI-Tool

☐ CDC TAP CAUTI Toolkit Implementation Guide: http://www.cdc.gov/hai/prevent/tap/resources.html

Central Venous Catheter Appropriate Use, Insertion, and Maintenance

☐ CDC Checklist for Prevention of Central Line-Associated Blood Stream Infections: http://www.cdc.gov/HAI/pdfs/bsi/checklist-for-CLABSI.pdf

☐ AHRQ Tools for Reducing CLABSI: http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html

Safe Injection Practices

☐ Injection Safety Checklist: http://www.oneandonlycampaign.org/sites/default/files/upload/pdf/Injection%20Safety%20Checklist-508.pdf

Environmental Infection Control

☐ CDC Environmental Checklist for Monitoring Terminal Cleaning: http://www.cdc.gov/HAI/toolkits/Environmental-Cleaning-Checklist-10-6-2010.pdf

☐ CDC Environmental Cleaning Evaluation Worksheet: http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html

☐ Infection Control Risk Assessment (ICRA) Matrix of Precautions for Construction & Renovation: http://www.ashe.org/advocacy/organizations/CDC/pdfs/assessment_icra.pdf

Section 4: Infection Control Guidelines and Other Resources

General Infection Prevention

☐ CDC/HICPAC Guidelines and recommendations: http://www.cdc.gov/HAI/prevent/prevent_pubs.html

Facility Infection Risk Assessment

☐ Infection Prevention Annual Report and Plan: http://apicchapter26.org/Data%20files/Minutes%202011/IC%20Risk%20Assessment%20guide.pdf

Hand Hygiene

☐ Guideline for Hand Hygiene in Healthcare Settings: http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

☐ Hand Hygiene in Healthcare Settings: http://www.cdc.gov/handhygiene

Personal Protective Equipment

☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation2007.pdf

☐ Guidance for the Selection and Use of Personal Protective Equipment in Healthcare Settings: http://www.cdc.gov/HAI/prevent/ppe.html

Catheter-associated Urinary Tract Infection (CAUTI)

☐ Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009: http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

Central line-associated Bloodstream Infection (CLABSI)

☐ Guideline for Prevention of Intravascular Catheter-related Infections, 2011: http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Ventilator-associated Event (VAE)

☐ Guidelines for Preventing Healthcare-associated Pneumonia, 2003: http://www.cdc.gov/hicpac/pdf/guidelines/CDCpneumo_guidelines.pdf

Surgical Site Infection (SSI)

☐ Guidelines for the Prevention of Surgical Site Infection, 1999: http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf

Safe Injection Practices

☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

☐ CDC Injection Safety Web Materials: http://www.cdc.gov/injectionsafety

☐ CDC training video and related Safe Injection Practices Campaign materials: http://oneandonlycampaign.org

Clostridium difficile Infection (CDI) and Multidrug-Resistant Organisms (MDRO), including antimicrobial stewardship

☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

☐ Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006: http://www.cdc.gov/hicpac/pdf/guidelines/MDROGuideline2006.pdf

☐ SHEA-IDSA Strategies to Prevention Clostridium difficile Infections in Acute Care Hospitals: 2014 Update: http://www.jstor.org/stable/10.1086/676023

☐ SHEA-IDSA Guideline: http://www.cdc.gov/HAI/pdfs/cdiff/Cohen-IDSA-SHEA-CDI-guidelines-2010.pdf

☐ CDC’s Core Elements of Hospital Antibiotic Stewardship Program: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

☐ CDC Implementation Resources for Antibiotic Stewardship: http://www.cdc.gov/getsmart/healthcare/implementation.html

☐ EPA Listing of disinfectant products with sporicidal activity against C. difficile: http://www.epa.gov/oppad001/list_k_clostridium.pdf

Environmental Infection Control, including Infection Control Risk Assessment (ICRA)

☐ Guidelines for Environmental Infection Control in Healthcare Facilities: http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

☐ 2014 Facility Guidelines Institute (FGI) Guidelines for Hospitals and Outpatient Facilities: http://www.fgiguidelines.org/guidelines2014_HOP.php

Equipment Reprocessing

☐ Guideline for Disinfection and Sterilization in Healthcare Facilities: http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

☐ FDA regulations on reprocessing of single-use devices: http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm071434

Point-of-Care Testing

☐ Infection Prevention during Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html

☐ Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html

Respiratory Hygiene/Cough Etiquette

☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

☐ Recommendations for Preventing the Spread of Influenza: http://www.cdc.gov/flu/professionals/infectioncontrol/

Healthcare Personnel Safety

☐ Guideline for Infection Control in Healthcare Personnel: http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

☐ Immunization of Healthcare Personnel: http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html

☐ Occupational Safety & Health Administration (OSHA) Bloodborne Pathogen and Needlestick Prevention Standard: https://www.osha.gov/SLTC/bloodbornepathogens/index.html

☐ Hospital Respiratory Protection Program Toolkit: http://www.cdc.gov/niosh/docs/2015-117/pdfs/2015-117.pdf

Resources to assist with evaluation and response to breaches in infection control

☐ Patel PR, Srinivasan A, Perz JF. Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control 2008; 36(10):685-90. http://www.ajicjournal.org/article/S0196-6553(08)00683-4/abstract

☐ Steps for Evaluating an Infection Control Breach: http://www.cdc.gov/hai/outbreaks/steps_for_eval_IC_breach.html

☐ Patient Notification Toolkit: http://www.cdc.gov/injectionsafety/pntoolkit/index.html

Assessment Summary

Infection Control Program and Infrastructure
Incomplete Elements
Hospital provides fiscal and human resource support for maintaining the infection prevention and control program.
The person(s) charged with directing the infection prevention and control program at the hospital is/are qualified and trained in infection control.
Infection prevention and control program performs an annual facility infection risk assessment that evaluates and prioritizes potential risks for infections, contamination, and exposures and the program’s preparedness to eliminate or mitigate such risks.
Written infection control policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards.
Respondent can describe the process for reviewing and updating policies (e.g., policies are dated and reviewed annually and when new guidelines are issued)
Infection prevention and control program provides infection prevention education to patients, family members, and other caregivers.
Respondent can describe how this education is provided (e.g., information included in the admission or discharge packet, videos, signage, in-person training)
Summary of ‘No’ Responses
Hospital provides fiscal and human resource support for maintaining the infection prevention and control program.
The person(s) charged with directing the infection prevention and control program at the hospital is/are qualified and trained in infection control.
Infection prevention and control program performs an annual facility infection risk assessment that evaluates and prioritizes potential risks for infections, contamination, and exposures and the program’s preparedness to eliminate or mitigate such risks.
Written infection control policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards.
Respondent can describe the process for reviewing and updating policies (e.g., policies are dated and reviewed annually and when new guidelines are issued)
Infection prevention and control program provides infection prevention education to patients, family members, and other caregivers.
Respondent can describe how this education is provided (e.g., information included in the admission or discharge packet, videos, signage, in-person training)
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Hand Hygiene
Incomplete Elements
Hospital has a competency-based training program for hand hygiene.
Training is provided to all healthcare personnel, including all ancillary personnel not directly involved in patient care but potentially exposed to infectious agents (e.g., food tray handlers, housekeeping, volunteer personnel).
Training is provided upon hire, prior to provision of care at this hospital.
Training is provided at least annually.
Personnel are required to demonstrate competency with hand hygiene following each training.
Hospital maintains current documentation of hand hygiene competency for all personnel.
Hospital regularly audits (monitors and documents) adherence to hand hygiene.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their hand hygiene performance.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in patient care areas.
Hand hygiene policies promote preferential use of alcohol-based hand rub over soap and water except when hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus.
Summary of ‘No’ Responses
Hospital has a competency-based training program for hand hygiene.
Training is provided to all healthcare personnel, including all ancillary personnel not directly involved in patient care but potentially exposed to infectious agents (e.g., food tray handlers, housekeeping, volunteer personnel).
Training is provided upon hire, prior to provision of care at this hospital.
Training is provided at least annually.
Personnel are required to demonstrate competency with hand hygiene following each training.
Hospital maintains current documentation of hand hygiene competency for all personnel.
Hospital regularly audits (monitors and documents) adherence to hand hygiene.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their hand hygiene performance.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in patient care areas.
Hand hygiene policies promote preferential use of alcohol-based hand rub over soap and water except when hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Personal Protective Equipment (PPE)
Incomplete Elements
Hospital has a competency-based training program for use of personal protective equipment (PPE).
Training is provided to all personnel who use PPE.
Training is provided upon hire, prior to provision of care at this hospital.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Training includes 1) appropriate indications for specific PPE components, 2) proper donning, doffing, adjustment, and wear of PPE, and 3) proper care, maintenance, useful life, and disposal of PPE.
Personnel are required to demonstrate competency with selection and use of PPE (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of PPE competency for all personnel who use PPE.
Hospital regularly audits (monitors and documents) adherence to proper PPE selection and use, including donning and doffing.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance with selection and use of PPE.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Supplies necessary for adherence to personal protective equipment recommendations specified under Standard and Transmission-based Precautions (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use.
The hospital’s respiratory protection program provides annual respiratory fit testing for all personnel who are anticipated to require respiratory protection.
Hospital maintains supplies of respiratory protection devices (e.g., Powered air purifying respirator) to be used by personnel who cannot be fitted.
Healthcare personnel are educated about factors that may compromise proper fit and function of respiratory protection devices (e.g., weight gain/loss, facial hair).
Summary of ‘No’ Responses
Hospital has a competency-based training program for use of personal protective equipment (PPE).
Training is provided to all personnel who use PPE.
Training is provided upon hire, prior to provision of care at this hospital.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Training includes 1) appropriate indications for specific PPE components, 2) proper donning, doffing, adjustment, and wear of PPE, and 3) proper care, maintenance, useful life, and disposal of PPE.
Personnel are required to demonstrate competency with selection and use of PPE (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of PPE competency for all personnel who use PPE.
Hospital regularly audits (monitors and documents) adherence to proper PPE selection and use, including donning and doffing.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance with selection and use of PPE.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Supplies necessary for adherence to personal protective equipment recommendations specified under Standard and Transmission-based Precautions (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use.
The hospital’s respiratory protection program provides annual respiratory fit testing for all personnel who are anticipated to require respiratory protection.
Hospital maintains supplies of respiratory protection devices (e.g., Powered air purifying respirator) to be used by personnel who cannot be fitted.
Healthcare personnel are educated about factors that may compromise proper fit and function of respiratory protection devices (e.g., weight gain/loss, facial hair).
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Prevention of Catheter-associated Urinary Tract Infection (CAUTI)
Incomplete Elements
Hospital has physician and/or nurse champions for CAUTI prevention activities.
Hospital has a competency-based training program for insertion of urinary catheters.
Training is provided to all personnel who are given responsibility for insertion of urinary catheters. Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and physicians.
Training is provided upon hire, prior to being allowed to perform urinary catheter insertion.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with urinary catheter insertion for all personnel who insert urinary catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of urinary catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for insertion of urinary catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a competency-based training program for maintenance of urinary catheters.
Training is provided to all personnel who are given responsibility for urinary catheter maintenance (e.g., perineal care, emptying the drainage bag aseptically, maintaining the closed drainage system, maintaining unobstructed urine flow). Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and transport personnel.
Training is provided upon hire, prior to being allowed to perform urinary catheter maintenance.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with catheter maintenance (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with urinary catheter maintenance for all personnel who maintain urinary catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of urinary catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for maintenance of urinary catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Patients with urinary catheters are assessed, at least daily, for continued need for the catheter.
Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, nurse directed protocol, reminders or stop orders).
Hospital routinely audits adherence to daily assessment of urinary catheter need.
Hospital monitors CAUTI data and uses it to direct prevention activities.
Respondent is familiar with National Healthcare Safety Network (NHSN) CAUTI data.
Respondent can describe how CAUTI data are used to direct prevention activities.
Hospital provides feedback of CAUTI data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Summary of ‘No’ Responses
Hospital has physician and/or nurse champions for CAUTI prevention activities.
Hospital has a competency-based training program for insertion of urinary catheters.
Training is provided to all personnel who are given responsibility for insertion of urinary catheters. Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and physicians.
Training is provided upon hire, prior to being allowed to perform urinary catheter insertion.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with urinary catheter insertion for all personnel who insert urinary catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of urinary catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for insertion of urinary catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a competency-based training program for maintenance of urinary catheters.
Training is provided to all personnel who are given responsibility for urinary catheter maintenance (e.g., perineal care, emptying the drainage bag aseptically, maintaining the closed drainage system, maintaining unobstructed urine flow). Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and transport personnel.
Training is provided upon hire, prior to being allowed to perform urinary catheter maintenance.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with catheter maintenance (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with urinary catheter maintenance for all personnel who maintain urinary catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of urinary catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for maintenance of urinary catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Patients with urinary catheters are assessed, at least daily, for continued need for the catheter.
Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, nurse directed protocol, reminders or stop orders).
Hospital routinely audits adherence to daily assessment of urinary catheter need.
Hospital monitors CAUTI data and uses it to direct prevention activities.
Respondent is familiar with National Healthcare Safety Network (NHSN) CAUTI data.
Respondent can describe how CAUTI data are used to direct prevention activities.
Hospital provides feedback of CAUTI data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Prevention of Central line-associated Bloodstream Infection (CLABSI)
Incomplete Elements
Hospital has physician and/or nurse champions for CLABSI prevention activities.
Hospital has a competency-based training program for insertion of central venous catheters.
Training is provided to all personnel who are given responsibility for insertion of central venous catheters. Personnel may include, but are not limited to, physicians, physician assistants, and members of line insertion teams.
Training is provided upon hire, prior to being allowed to perform central venous catheter insertion.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with central venous catheter insertion for all personnel who insert central venous catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of central venous catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for insertion of central venous catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a competency-based training program for maintenance of central venous catheters.
Training is provided to all personnel who maintain central venous catheters (e.g., scrub the hub, accessing the catheter, dressing changes). Personnel may include, but are not limited to, nurses, nursing assistants, physicians, and physician assistants.
Training is provided upon hire, prior to being allowed to perform central venous catheter maintenance.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with maintenance (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with central venous catheter maintenance for all personnel who maintain central venous catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of central venous catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for maintenance of central venous catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Patients with central venous catheters are assessed, at least daily, for continued need for the catheter.
Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, reminders).
Hospital routinely audits adherence to daily assessment of central venous catheter need.
Hospital monitors CLABSI data and uses it to direct prevention activities.
Respondent is familiar with National Healthcare Safety Network (NHSN) CLABSI data.
Respondent can describe how CLABSI data are used to direct prevention activities.
Hospital provides feedback of CLABSI data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Summary of ‘No’ Responses
Hospital has physician and/or nurse champions for CLABSI prevention activities.
Hospital has a competency-based training program for insertion of central venous catheters.
Training is provided to all personnel who are given responsibility for insertion of central venous catheters. Personnel may include, but are not limited to, physicians, physician assistants, and members of line insertion teams.
Training is provided upon hire, prior to being allowed to perform central venous catheter insertion.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with central venous catheter insertion for all personnel who insert central venous catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of central venous catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for insertion of central venous catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a competency-based training program for maintenance of central venous catheters.
Training is provided to all personnel who maintain central venous catheters (e.g., scrub the hub, accessing the catheter, dressing changes). Personnel may include, but are not limited to, nurses, nursing assistants, physicians, and physician assistants.
Training is provided upon hire, prior to being allowed to perform central venous catheter maintenance.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with maintenance (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with central venous catheter maintenance for all personnel who maintain central venous catheters.
Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of central venous catheters.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for maintenance of central venous catheters.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Patients with central venous catheters are assessed, at least daily, for continued need for the catheter.
Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, reminders).
Hospital routinely audits adherence to daily assessment of central venous catheter need.
Hospital monitors CLABSI data and uses it to direct prevention activities.
Respondent is familiar with National Healthcare Safety Network (NHSN) CLABSI data.
Respondent can describe how CLABSI data are used to direct prevention activities.
Hospital provides feedback of CLABSI data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Prevention of Ventilator-associated Event (VAE)
Incomplete Elements
Hospital has physician and/or nurse champions for VAE prevention activities.
Hospital has a competency-based training program addressing prevention of VAEs.
Training is provided to all personnel who provide respiratory therapy for ventilated patients (e.g., suctioning, administration of aerosolized medications). Personnel may include, but are not limited to, respiratory therapists and nurses.
Training is provided upon hire, prior to being allowed to provide respiratory therapy for ventilated patients.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with respiratory therapy practices (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with respiratory practices for all personnel who provide respiratory therapy for ventilated patients.
Hospital regularly audits (monitors and documents) adherence to recommended practices for management of ventilated patients (e.g., suctioning, administration of aerosolized medications).
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for management of ventilated patients.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Patients requiring invasive ventilation are assessed, at least daily, for continued need for the ventilator.
Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, reminders).
Hospital routinely audits adherence to daily assessment of ventilator need.
Hospital has a program that includes daily spontaneous breathing trials and lightening of sedation in eligible patient.
Hospital has an oral-hygiene program.
Hospital monitors VAE data and uses it to direct prevention activities.
Respondent can describe how VAE data are used to direct prevention activities.
If the hospital reports VAE data to NHSN, verify the following: Respondent is familiar with NHSN VAE data.
If the hospital does not report VAE data to NHSN, verify the following: Respondent can describe how VAE data are collected
Hospital provides feedback of VAE data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Summary of ‘No’ Responses
Hospital has physician and/or nurse champions for VAE prevention activities.
Hospital has a competency-based training program addressing prevention of VAEs.
Training is provided to all personnel who provide respiratory therapy for ventilated patients (e.g., suctioning, administration of aerosolized medications). Personnel may include, but are not limited to, respiratory therapists and nurses.
Training is provided upon hire, prior to being allowed to provide respiratory therapy for ventilated patients.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with respiratory therapy practices (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with respiratory practices for all personnel who provide respiratory therapy for ventilated patients.
Hospital regularly audits (monitors and documents) adherence to recommended practices for management of ventilated patients (e.g., suctioning, administration of aerosolized medications).
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their performance for management of ventilated patients.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Patients requiring invasive ventilation are assessed, at least daily, for continued need for the ventilator.
Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, reminders).
Hospital routinely audits adherence to daily assessment of ventilator need.
Hospital has a program that includes daily spontaneous breathing trials and lightening of sedation in eligible patient.
Hospital has an oral-hygiene program.
Hospital monitors VAE data and uses it to direct prevention activities.
Respondent can describe how VAE data are used to direct prevention activities.
If the hospital reports VAE data to NHSN, verify the following: Respondent is familiar with NHSN VAE data.
If the hospital does not report VAE data to NHSN, verify the following: Respondent can describe how VAE data are collected
Hospital provides feedback of VAE data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Injection Safety
Incomplete Elements
Hospital has a competency-based training program for preparation and administration of parenteral medications outside of the pharmacy.
Training is provided to all personnel who prepare and administer injections and parenteral infusions.
Training is provided upon hire, prior to being allowed to prepare and administer injections and parenteral infusions.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with preparation and administration of injections and parenteral infusions following each training.
Hospital maintains current documentation of competency with preparation and administration procedures for all personnel who prepare and administer injections and parenteral infusions.
Hospital regularly audits (monitors and documents) adherence to safe injection practices.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to safe injection practices.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a drug diversion prevention program that includes consultation with the IP program when drug tampering (involving alteration or substitution) is suspected or identified to assess patient safety risks.
Respondent can describe how the hospital would assess risk to patients if tampering is suspected or identified.
Summary of ‘No’ Responses
Hospital has a competency-based training program for preparation and administration of parenteral medications outside of the pharmacy.
Training is provided to all personnel who prepare and administer injections and parenteral infusions.
Training is provided upon hire, prior to being allowed to prepare and administer injections and parenteral infusions.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with preparation and administration of injections and parenteral infusions following each training.
Hospital maintains current documentation of competency with preparation and administration procedures for all personnel who prepare and administer injections and parenteral infusions.
Hospital regularly audits (monitors and documents) adherence to safe injection practices.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to safe injection practices.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a drug diversion prevention program that includes consultation with the IP program when drug tampering (involving alteration or substitution) is suspected or identified to assess patient safety risks.
Respondent can describe how the hospital would assess risk to patients if tampering is suspected or identified.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Prevention of Surgical Site Infection
Incomplete Elements
Hospital has a surgical care improvement program.
Preoperative timing of prophylactic antibiotic administration (within 1 hour of incision or 2 hours for vancomycin or fluoroquinolones).
Appropriate prophylactic antibiotic selection based on procedure type.
Discontinuation of prophylactic antibiotics within 24 hours (48 hours for cardiovascular surgery) after surgical end time.
The surgical care improvement program addresses prompt removal of urinary catheter on post-op day 1 or 2, unless there is a documented appropriate reason for continued use.
Hospital regularly audits (monitors and documents) adherence to elements of surgical care improvement program.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to elements of the surgical care improvement program.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for SSI prevention.
Adherence to preoperative surgical scrub and hand hygiene
Appropriate use of surgical attire and drapes
Adherence to aseptic technique and sterile field
Proper ventilation requirements
Minimization of traffic in the operating room
Adherence to cleaning and disinfection of environmental surfaces
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to surgical infection control practices.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital monitors SSI data and uses it to direct prevention activities.
Respondent is familiar with NHSN SSI data.
Respondent can describe how SSI data are used to direct prevention activities.
Hospital provides feedback of SSI data to surgeons.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Summary of ‘No’ Responses
Hospital has a surgical care improvement program.
Preoperative timing of prophylactic antibiotic administration (within 1 hour of incision or 2 hours for vancomycin or fluoroquinolones).
Appropriate prophylactic antibiotic selection based on procedure type.
Discontinuation of prophylactic antibiotics within 24 hours (48 hours for cardiovascular surgery) after surgical end time.
The surgical care improvement program addresses prompt removal of urinary catheter on post-op day 1 or 2, unless there is a documented appropriate reason for continued use.
Hospital regularly audits (monitors and documents) adherence to elements of surgical care improvement program.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to elements of the surgical care improvement program.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for SSI prevention.
Adherence to preoperative surgical scrub and hand hygiene
Appropriate use of surgical attire and drapes
Adherence to aseptic technique and sterile field
Proper ventilation requirements
Minimization of traffic in the operating room
Adherence to cleaning and disinfection of environmental surfaces
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to surgical infection control practices.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital monitors SSI data and uses it to direct prevention activities.
Respondent is familiar with NHSN SSI data.
Respondent can describe how SSI data are used to direct prevention activities.
Hospital provides feedback of SSI data to surgeons.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Prevention of Clostridium difficile Infection (CDI)
Incomplete Elements
Hospital has physician and/or nurse champions for CDI prevention activities.
Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for CDI prevention.
Adherence to hand hygiene
Appropriate use of PPE
Compliance with Contact Precautions, including use of dedicated or disposable equipment
Adherence to cleaning and disinfection procedures, including use of sporicidal disinfectants if part of hospital policy
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to recommended infection control practices for CDI prevention.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has specific antibiotic stewardship strategies in place to reduce CDI.
Hospital has strategies to reduce unnecessary use of antibiotics that are high-risk for CDI (e.g., fluoroquinolones, 3rd/4th generation cephalosporins).
Hospital reviews appropriateness of antibiotics prescribed for treatment of other conditions (e.g., urinary tract infection) for patients with new or recent CDI diagnosis.
Hospital educates providers about the risk of CDI with antibiotics.
Hospital educates patients and family members about the risk of CDI with antibiotics.
Hospital monitors CDI data and uses it to direct prevention activities.
Respondent is familiar with NHSN CDI data.
Respondent can describe how CDI data are used to direct prevention activities.
Hospital provides feedback of CDI data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Summary of ‘No’ Responses
Hospital has physician and/or nurse champions for CDI prevention activities.
Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for CDI prevention.
Adherence to hand hygiene
Appropriate use of PPE
Compliance with Contact Precautions, including use of dedicated or disposable equipment
Adherence to cleaning and disinfection procedures, including use of sporicidal disinfectants if part of hospital policy
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to recommended infection control practices for CDI prevention.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has specific antibiotic stewardship strategies in place to reduce CDI.
Hospital has strategies to reduce unnecessary use of antibiotics that are high-risk for CDI (e.g., fluoroquinolones, 3rd/4th generation cephalosporins).
Hospital reviews appropriateness of antibiotics prescribed for treatment of other conditions (e.g., urinary tract infection) for patients with new or recent CDI diagnosis.
Hospital educates providers about the risk of CDI with antibiotics.
Hospital educates patients and family members about the risk of CDI with antibiotics.
Hospital monitors CDI data and uses it to direct prevention activities.
Respondent is familiar with NHSN CDI data.
Respondent can describe how CDI data are used to direct prevention activities.
Hospital provides feedback of CDI data to frontline personnel.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Environmental Cleaning
Incomplete Elements
Hospital has a competency-based training program for environmental cleaning.
Training is provided to all personnel who clean and disinfect patient care areas. Personnel may include, but are not limited to, environmental services staff, nurses, nursing assistants, and technicians.
Training is provided upon hire, prior to being allowed to perform environmental cleaning.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with environmental cleaning (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with environmental cleaning procedures for all personnel who clean and disinfect patient care areas.
If the hospital contracts environmental services, the contractor has a comparable training program.
Hospital has policies that clearly define responsibilities for cleaning and disinfection of non-critical equipment, mobile devices, and other electronics (e.g., ICU monitors, ventilator surfaces, bar code scanners, point-of-care devices, mobile work stations, code carts, airway boxes).
Hospital has protocols to ensure that healthcare personnel can readily identify equipment that has been properly cleaned and disinfected and is ready for patient use (e.g., tagging system, placement in dedicated clean area).
Hospital regularly audits (monitors and documents) adherence to cleaning and disinfection procedures, including use of products in accordance with manufacturers’ instructions (e.g., dilution, storage, shelf-life, contact time).
Respondent can describe process used for audits (e.g., monitoring technology, direct observation).
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Summary of ‘No’ Responses
Hospital has a competency-based training program for environmental cleaning.
Training is provided to all personnel who clean and disinfect patient care areas. Personnel may include, but are not limited to, environmental services staff, nurses, nursing assistants, and technicians.
Training is provided upon hire, prior to being allowed to perform environmental cleaning.
Training is provided at least annually.
Training is provided when new equipment or protocols are introduced.
Personnel are required to demonstrate competency with environmental cleaning (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with environmental cleaning procedures for all personnel who clean and disinfect patient care areas.
If the hospital contracts environmental services, the contractor has a comparable training program.
Hospital has policies that clearly define responsibilities for cleaning and disinfection of non-critical equipment, mobile devices, and other electronics (e.g., ICU monitors, ventilator surfaces, bar code scanners, point-of-care devices, mobile work stations, code carts, airway boxes).
Hospital has protocols to ensure that healthcare personnel can readily identify equipment that has been properly cleaned and disinfected and is ready for patient use (e.g., tagging system, placement in dedicated clean area).
Hospital regularly audits (monitors and documents) adherence to cleaning and disinfection procedures, including use of products in accordance with manufacturers’ instructions (e.g., dilution, storage, shelf-life, contact time).
Respondent can describe process used for audits (e.g., monitoring technology, direct observation).
Respondent can describe frequency of audits.
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Device Reprocessing
Incomplete Elements
Hospital has a competency-based training program for reprocessing of critical devices.
Training is provided to all personnel who reprocess critical equipment.
Training is provided upon hire, prior to being allowed to reprocess critical equipment.
Training is provided at least annually.
Training is provided when new devices or protocols are introduced.
Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess critical devices.
If the hospital contracts reprocessing of critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital.
Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for critical devices.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Audits occur in all locations where critical devices are reprocessed (e.g., central sterile reprocessing, operating suites), including locations where initial cleaning steps are performed (e.g., point of use).
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for critical devices.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a competency-based training program for reprocessing of semi-critical equipment.
Training is provided to all personnel who reprocess semi-critical devices.
Training is provided upon hire, prior to being allowed to reprocess semi-critical devices.
Training is provided at least annually.
Training is provided when new devices or protocols are introduced.
Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess semi-critical devices.
If the hospital contracts reprocessing of semi-critical equipment, the contractor has a comparable training program which includes the specific equipment used by the hospital.
Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for semi-critical equipment.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Audits occur in all locations where semi-critical equipment is reprocessed (e.g., central sterile reprocessing, endoscopy suites), including locations where initial cleaning steps are performed (e.g., point of use).
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for semi-critical equipment.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
If hospital reuses single-use devices, the devices are reprocessed by an FDA-approved entity.
Hospital maintains documentation of reprocessing activities.
Hospital maintains logs for each sterilizer cycle that include the results from each load.
Hospital has documentation that the chemicals used for high-level disinfection are routinely tested for appropriate concentration and replaced appropriately.
Hospital maintains documentation of reprocessing activities.
Hospital allows adequate time for reprocessing to ensure adherence to all steps recommended by the device manufacturer, including drying and proper storage.
Hospital has an adequate supply of instruments for the volume of procedures performed to allow sufficient time for all reprocessing steps
Scheduling of procedures allows sufficient time for all reprocessing steps
Hospital does not routinely use immediate-use steam sterilization (IUSS).
IP program is consulted whenever new equipment or products will be purchased or introduced to ensure implementation of appropriate reprocessing policies and procedures.
Hospital has policies and procedures outlining hospital response (i.e., risk assessment and recall of device) in the event of a reprocessing error or failure.
The IP can describe how the risk assessment would be performed including how the hospital would identify which patients may have been exposed to an improperly reprocessed instrument.
Summary of ‘No’ Responses
Hospital has a competency-based training program for reprocessing of critical devices.
Training is provided to all personnel who reprocess critical equipment.
Training is provided upon hire, prior to being allowed to reprocess critical equipment.
Training is provided at least annually.
Training is provided when new devices or protocols are introduced.
Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess critical devices.
If the hospital contracts reprocessing of critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital.
Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for critical devices.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Audits occur in all locations where critical devices are reprocessed (e.g., central sterile reprocessing, operating suites), including locations where initial cleaning steps are performed (e.g., point of use).
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for critical devices.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
Hospital has a competency-based training program for reprocessing of semi-critical equipment.
Training is provided to all personnel who reprocess semi-critical devices.
Training is provided upon hire, prior to being allowed to reprocess semi-critical devices.
Training is provided at least annually.
Training is provided when new devices or protocols are introduced.
Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training.
Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess semi-critical devices.
If the hospital contracts reprocessing of semi-critical equipment, the contractor has a comparable training program which includes the specific equipment used by the hospital.
Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for semi-critical equipment.
Respondent can describe process used for audits.
Respondent can describe frequency of audits.
Audits occur in all locations where semi-critical equipment is reprocessed (e.g., central sterile reprocessing, endoscopy suites), including locations where initial cleaning steps are performed (e.g., point of use).
Respondent can describe process for improvement when non-adherence is observed.
Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for semi-critical equipment.
Respondent can describe how feedback is provided.
Respondent can describe frequency of feedback.
If hospital reuses single-use devices, the devices are reprocessed by an FDA-approved entity.
Hospital maintains documentation of reprocessing activities.
Hospital maintains logs for each sterilizer cycle that include the results from each load.
Hospital has documentation that the chemicals used for high-level disinfection are routinely tested for appropriate concentration and replaced appropriately.
Hospital maintains documentation of reprocessing activities.
Hospital allows adequate time for reprocessing to ensure adherence to all steps recommended by the device manufacturer, including drying and proper storage.
Hospital has an adequate supply of instruments for the volume of procedures performed to allow sufficient time for all reprocessing steps
Scheduling of procedures allows sufficient time for all reprocessing steps
Hospital does not routinely use immediate-use steam sterilization (IUSS).
IP program is consulted whenever new equipment or products will be purchased or introduced to ensure implementation of appropriate reprocessing policies and procedures.
Hospital has policies and procedures outlining hospital response (i.e., risk assessment and recall of device) in the event of a reprocessing error or failure.
The IP can describe how the risk assessment would be performed including how the hospital would identify which patients may have been exposed to an improperly reprocessed instrument.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Systems for Healthcare Associated Infections and Multidrug-Resistant Organisms (MDROs)
Incomplete Elements
Hospital has system in place for early detection and management of potentially infectious persons at initial points of entry to the hospital, including rapid isolation as appropriate.
Travel and occupational history is included as part of triage protocols.
Hospital has system to identify (flag) patients with targeted MDROs upon readmission so appropriate precautions can be applied.
Posting signs at entrances
Providing tissues and no-touch receptacles for disposal of tissues
Providing hand hygiene supplies in or near waiting areas
Offering facemasks to coughing patients and other symptomatic individuals upon entry to the facility
Providing space in patient waiting areas (e.g., ED waiting room) and encouraging individuals with symptoms of respiratory infections to sit as far away from others as possible
Hospital has systems in place for early detection and isolation of infectious patients identified during the hospital stay, including rapid isolation of patients as appropriate.
There is a mechanism for prompt notification of the IP by the clinical microbiology laboratory when novel resistance patterns and/or targeted antimicrobial-resistant pathogens are detected.
Hospital has system in place for INTER-facility communication of infectious status and isolation needs of patients prior to transfer to other facilities.
Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving facilities.
The hospital has system to notify receiving facilities of microbiological tests (e.g., cultures) that are pending at the time of transfer.
Hospital has system in place for INTER-facility communication to identify infectious status and isolation needs of patients prior to accepting patients from other facilities.
Respondent can describe methods employed to ensure infectious status and isolation needs are obtained from transferring facilities.
The hospital has system to follow-up on microbiological results (e.g., cultures) that are pending at the time of transfer.
If the hospital identifies an infection that may be related to care provided at another facility (e.g., hospital, nursing home, clinic), the facility is notified.
Hospital has system in place for INTRA-facility communication to identify infectious status and isolation needs of patients prior to transfer to other units or shared spaces (e.g., radiology, physical therapy, emergency department) within the hospital.
Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving units.
Hospital has a surveillance program to monitor incidence of epidemiologically-important organisms (e.g., CRE) and targeted healthcare-associated infections.
Respondent can describe how the hospital determines which organisms and HAIs to track.
Hospital uses surveillance data to implement corrective actions rapidly when transmission of epidemiologically-important organisms (e.g., CRE) or increased rates or persistently elevated rates of healthcare-associated infections are detected.
Data collection method allows for timely response to identified problems.
Hospital has an antibiotic stewardship program that meets the 7 CDC core elements listed below (a – g).
Hospital leadership commitment Hospital has a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship) AND/OR Hospital provides salary support for dedicated time for antibiotic stewardship activities.
Program leadership (accountability) There is a leader responsible for outcomes of stewardship activities at the hospital.
Drug expertise There is at least one pharmacist responsible for improving antibiotic use at the hospital.
Act (at least one prescribing improvement action below) Hospital has a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry. Hospital has hospital-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions. There is a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g., antibiotic time out). Hospital has specified antibiotic agents that need to be approved by a physician or pharmacist prior to dispensing at the hospital. Physician or pharmacist reviews courses of therapy for specified antibiotic agents and communicates results with prescribers.
Track Hospital monitors antibiotic use (consumption).
Report Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing.
Educate Stewardship program provides education to clinicians and other relevant staff on improving antibiotic use.
Hospital has occupational health program that, in addition to complying with state and federal requirements (e.g., OSHA), has policies regarding contact of personnel with patients when personnel have potentially transmissible conditions.
The program has work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits or job status.
Personnel are educated regarding prompt reporting of illness to their supervisor and the occupational health programs.
Hospital follows recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunization of healthcare personnel, including offering Hepatitis B and influenza vaccination.
Hospital is compliant with mandatory reporting requirements for notifiable diseases, healthcare-associated infections (as appropriate), and potential outbreaks.
Hospital can identify point(s) of contact at the local or state health department for HAI concerns.
Hospital implements infection control measures relevant to construction, renovation, demolition, and repairs including performance of an infection control risk assessment (ICRA) before a project gets underway.
IP program is consulted anytime construction, renovation, demolition, or repairs will be performed.
ICRA elements are included in all contracts related to construction, renovation, demolition, and repairs.
Summary of ‘No’ Responses
Hospital has system in place for early detection and management of potentially infectious persons at initial points of entry to the hospital, including rapid isolation as appropriate.
Travel and occupational history is included as part of triage protocols.
Hospital has system to identify (flag) patients with targeted MDROs upon readmission so appropriate precautions can be applied.
Posting signs at entrances
Providing tissues and no-touch receptacles for disposal of tissues
Providing hand hygiene supplies in or near waiting areas
Offering facemasks to coughing patients and other symptomatic individuals upon entry to the facility
Providing space in patient waiting areas (e.g., ED waiting room) and encouraging individuals with symptoms of respiratory infections to sit as far away from others as possible
Hospital has systems in place for early detection and isolation of infectious patients identified during the hospital stay, including rapid isolation of patients as appropriate.
There is a mechanism for prompt notification of the IP by the clinical microbiology laboratory when novel resistance patterns and/or targeted antimicrobial-resistant pathogens are detected.
Hospital has system in place for INTER-facility communication of infectious status and isolation needs of patients prior to transfer to other facilities.
Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving facilities.
The hospital has system to notify receiving facilities of microbiological tests (e.g., cultures) that are pending at the time of transfer.
Hospital has system in place for INTER-facility communication to identify infectious status and isolation needs of patients prior to accepting patients from other facilities.
Respondent can describe methods employed to ensure infectious status and isolation needs are obtained from transferring facilities.
The hospital has system to follow-up on microbiological results (e.g., cultures) that are pending at the time of transfer.
If the hospital identifies an infection that may be related to care provided at another facility (e.g., hospital, nursing home, clinic), the facility is notified.
Hospital has system in place for INTRA-facility communication to identify infectious status and isolation needs of patients prior to transfer to other units or shared spaces (e.g., radiology, physical therapy, emergency department) within the hospital.
Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving units.
Hospital has a surveillance program to monitor incidence of epidemiologically-important organisms (e.g., CRE) and targeted healthcare-associated infections.
Respondent can describe how the hospital determines which organisms and HAIs to track.
Hospital uses surveillance data to implement corrective actions rapidly when transmission of epidemiologically-important organisms (e.g., CRE) or increased rates or persistently elevated rates of healthcare-associated infections are detected.
Data collection method allows for timely response to identified problems.
Hospital has an antibiotic stewardship program that meets the 7 CDC core elements listed below (a – g).
Hospital leadership commitment Hospital has a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship) AND/OR Hospital provides salary support for dedicated time for antibiotic stewardship activities.
Program leadership (accountability) There is a leader responsible for outcomes of stewardship activities at the hospital.
Drug expertise There is at least one pharmacist responsible for improving antibiotic use at the hospital.
Act (at least one prescribing improvement action below) Hospital has a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry. Hospital has hospital-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions. There is a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g., antibiotic time out). Hospital has specified antibiotic agents that need to be approved by a physician or pharmacist prior to dispensing at the hospital. Physician or pharmacist reviews courses of therapy for specified antibiotic agents and communicates results with prescribers.
Track Hospital monitors antibiotic use (consumption).
Report Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing.
Educate Stewardship program provides education to clinicians and other relevant staff on improving antibiotic use.
Hospital has occupational health program that, in addition to complying with state and federal requirements (e.g., OSHA), has policies regarding contact of personnel with patients when personnel have potentially transmissible conditions.
The program has work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits or job status.
Personnel are educated regarding prompt reporting of illness to their supervisor and the occupational health programs.
Hospital follows recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunization of healthcare personnel, including offering Hepatitis B and influenza vaccination.
Hospital is compliant with mandatory reporting requirements for notifiable diseases, healthcare-associated infections (as appropriate), and potential outbreaks.
Hospital can identify point(s) of contact at the local or state health department for HAI concerns.
Hospital implements infection control measures relevant to construction, renovation, demolition, and repairs including performance of an infection control risk assessment (ICRA) before a project gets underway.
IP program is consulted anytime construction, renovation, demolition, or repairs will be performed.
ICRA elements are included in all contracts related to construction, renovation, demolition, and repairs.
Action Items/Plans for Improvement: (check all that apply) ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: (check all that apply) ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Follow Up Activities:	☐ Repeat on-site assessment planned (date: Click here to enter a date.)
☐ Repeat remote (phone/email) assessment planned (date: Click here to enter a date.)
☐ Other (specify): Click here to enter text.

☐ IC Program and Infrastructure ☐ Hand Hygiene

☐ PPE ☐ CAUTI ☐ CLABSI ☐ VAE ☐Injection Safety

☐ SSI ☐ CDI ☐ Environmental Cleaning

☐ Device Reprocessing ☐ MDRO