INFECTION CONTROL AUDIT TOOL

FACILITY NAME:

Instructions: Kindly complete the IPC audit tool objectively with relevant information as per each section. Aggregate each section
independently to get the overall score.
FC-Full compliant (required threshold has been met (2 points)
PC-Partially compliant (Some bit of the measured indicator has been met but there are recommendations to be addressed (1 point)
NC-The threshold of the required task has not been met or very little effort is observed (0 point.)

Name and designation of auditor(s):

Date:

Audited Unit:

Number of Clinical staff

Number of support staff

Number of beds/Bed capacity:

Number of admissions per month:

Number of outpatients per month

Type of admissions

ITEM FC PC NC COMMENT

Planning and coordination

The hospital has a documented infection control

program

The hospital leadership support the IPC practices

through budgeting, training and review of these
procedures?

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A situational analysis has been conducted on IPC
and projection of supplies been documented

The hospital has sufficient bed space and

ventilation in all areas

Mechanisms for controlling access to unauthorized

departments are in place and monitored

Hygiene

Functional hand hygiene stations with adequately

displayed posters in
key places

Sufficient hand washing facilities are placed in

relevant departments?

Reusable items are decontaminated and cleaned

according to policy with right ratio of disinfectants
across all departments.

Health care workers (HCWs) are knowledgeable

as to how and when to clean their hands.

Hand hygiene posters are placed in appropriate

areas.

The hospital has a program for regular training

HCW on hand hygiene

A cleaning checklist for each equipment and is the

level of compliance met.

The hospital has developed an environmental

cleaning program which defines who cleans
various areas.

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The hospital has sufficient sinks in clinical and

support areas?

The hospital has an organized clean and lockable

utility room that is organized,

Health workers appropriately clean their hands

appropriately and this is observed.

Hand washing taps have no rust and have running

water all the time. (Buckets could be improvised).

Decontamination and disinfection procedures

There are written disinfection procedures and are

they followed according to policy?

Disinfection procedures are consistently followed

and monitored.

Relevant staff trained on disinfection procedures

for various departments and correct ratios of
disinfectants preparation

Mops are disinfected and stored appropriately after

use.

Relevant equipment are disinfected and cleaned

according to manufacturer’s requirements.

There filled checklists showing how and frequency

of cleaning equipment parts in various
departments.

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Vital signs equipment are cleaned/wiped in
between patient use.

Breathing and emergency care instruments are

cleaned after each use.

Staff consistently disinfect both clinical and non-

clinical areas as per IPC guidelines

Waste management

The hospital has identified a waste management

plan including training, supply management, audit,
segregation, storage and disposal.

Are the waste management procedures monitored

with evidence?

There are containers for confining soiled articles

prior to pick- up?

Garbage containers covered and emptied at regular

times. Waste logs are filled during waste
collection.

Linen, utility and equipment management and

housekeeping

A linen management manual which defines how

linen processing is conducted and evidence of
correct implementation observed is available

Adequate storage for contaminated supplies

/equipment is available.

Mops and buckets are cleaned, coded, and stored

appropriately. These procedures are monitored and

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documented

Utility room and laundry area have a clean

orderly appearance. There is clear demarcation
showing linen flow from dirty to clean linen and
evidence of mix up is not observed.

Linen are ironed prior to storage .

A specified area for holding and sluicing soiled

linen awaiting collection to laundry department

Housekeeping staff are trained on infection control

measures.

Disinfectants or cleaning agents are clearly

labelled

A linen receptacle is consistently and correctly

used.

A clear separation of clean and soiled storage

areas is observed.

Clean supplies are stored above the floor.

All mattresses have Makin tosh and the linen

register filled every day.

There is a schedule for cleaning curtains and other

hospital linen as per required policy.

PPE use and OHS

There is a defined procedures on how PPE should

be used and are staff trained on this process.

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Personal protection equipment are available,
sufficient and used appropriately.

Staff are vaccinated against communicable

diseases and is there mechanism for monitoring
completion of this process.

Gowns are available and are worn for the

appropriate tasks

Gloves are being worn for appropriate tasks. They

are changed as appropriate if they become soiled
during a procedure?

Staff are knowledgeable about TB precautions

/Respiratory isolation? Are particulate respirator
mask available?

STERILIZATION

There are SOPs showing how sterilization

procedures are conducted and evidence of
implementation is observed.

Each pack has a checklist/catalog of its content.

Sterilization time monitored.

Instruments are stored in an aerated cupboard with

spaces in between them.

The flow of sterilization procedure is consistent

with the required guidelines.

Personnel are trained on sterilization technique.

Are there evidence of training in reports and
skills?

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There is an indicator tapes label for the sterile
packs.

Medication Room/dispensing area:

The area have a clean orderly appearance

There is no evidence of inappropriate activities

such as food preparation/storage where medication
is stored.

Open containers of sterile solutions are dated.

Multi-dose vials are labeled and appropriately

stored in between use.

The refrigerator is clean and free of frost build-up.

Tub /Shower Room(s):

The shower areas have a clean orderly in

appearance.

There is policy that designates who clean the tub

between patients.

There are protocol posted for cleaning tubs and

showers.

There is a regular cleaning schedule which is

regularly filled.

There is a laundry hamper for used towels and

shelving for supplies.

Patient/Resident Rooms and Isolation areas :

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Isolations or private rooms for isolation are
available

The rooms are clean orderly in appearance.

Staff are trained on the isolation procedures linked

to infection control.

Injection safety Precautions

Hospital staff know what to do in the event of

sharps injury.

A sharps exposure protocol posted in the patient

care area.

Provisions are in place for immediate reporting

and assessment of sharps injury.

There a policy designating responsibility of sharps

disposal.

Sharps containers are sealed for disposal when

approximately ¾ full.

Sharps containers are available at point –of-use.

Needles used on patients are correctly re-capped

and disposed.

If multi-dose vials are used, a separate needle and

syringe used for each re-entry.

There a protocol prescribing or prohibiting food

consumption in patient /resident care areas.

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Staff (HCWs) know the difference between
biomedical, radioactive and regular waste.

Biomedical and radioactive waste are disposed

off appropriately

Specimen Handling

HCWs have knowledgeable about safe handling of

body fluid specimens.

Specimens are properly wrapped prior to sending

to the laboratory.

Specimens are appropriately labelled and stored

Sharps are removed from samples prior to

transport.

There is a written policy for specimen collection

and transport available and implementation is
observed.

Decontamination Of Fluid Spillage

There a written policy for decontamination of

spills of body fluids.

Supplies are readily available for

decontaminations? i.e spill kit and eye wash in
relevant departments

Incidents of such spillage are reported through

biosafety team and occurrence forms

Scrub days adhered to for various departments e.g.

theater

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Disease Surveillance & Vaccination

There are tools for reporting diseases in various

departments-clinical and food handling areas

Disease surveillance reports are file regularly.

Incident reporting done for food handlers on

disease outbreaks

There are records showing personnel reporting of

incidences of communicable diseases

Food handlers have recent copy of health

assessment

Dressing Changes & Asepsis

The HCW observed to clean their hands prior to

gathering supplies.

Aseptic technique are maintained throughout the

equipment set-up

“Clean to dirty “flow technique maintained

throughout the procedure.

Sterile equipment are used during procedures

Sterility of the autoclave machine is monitored

e.g. swabs for culture and sensitivity

GENERAL APPEARANCE

The hospital dress code is adhered to

Staff consume food and beverages in patient care

areas.

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Skin lesions are covered.

Key findings

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RECOMMENDATIONS:

ACTION BY WHO WHEN EVALUATION STATUS

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