Levels Of

Standards & Monitoring System

7. Sterilization Room
Available
Item Compliance Additi
Quantity (in onal
good working Com
Description Standard Yes No ments
condition)

7. 1 Physical Structure
7.1.1 Space Specification
7.1.2 Cleanliness
7.1.3 Illumination
7.1.4 Ventilation
7.1.5 Electric Current Outlets
7.1.6 Basin
Actual Score
Total Score 6
7. 2 Furniture
7.2.1 Cabinet (Files)
7.2.2 Instrument Table
7.2.3 Waste Receptacle
Actual Score
Total Score 3
7.3 Equipment
7.3.1 Hot Air Oven 1
7.3.2 Autoclave 1
Sterilization Drums(different
7.3.3 3
sizes)
Actual score
Total score 3
Total Sterilization Room
Actual Score
Total Score 12

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Standards & Monitoring System

8. Policies & Procedures

Available
Item Compliance Additio
Quantity (in nal
good working Comm
Description Standard Yes No ents
condition)

8.1 Technical Standards

8.1.1 Is the partograph used to monitor
labor
8.1.2 Are obstetric protocols displayed
and used
8.1.3 Is there a file for each patient
8.1.4 Do staff document every
intervention and services they
provide
8.1.5 Do staff sign after provision of
any service
8.1.6 Are registration books present to
document number and nature of
services provided in the unit
8.1.7 Are registration books completed
and updated daily
8.1.8 Are registration books reviewed
by seniors (every shift)
8.1.9 Are cases of death investigated (by
who, how and what proves it)
8.1.10 Does hospital receive referral cases
8.1.11 Is there an established two way
referral system
8.1.12 Does Perinatal review meetings exist
8.1.13 Is there an Infection Control
Committee
8.1.14 Do ICC follows standards and
regulations
8.1.15 Does waste disposal follow
standards
Total Nurses Office
ActualScore
TotalScore 15

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 Levels Of

Standards & Monitoring System

CSSD
(Central Sterilization and Supply Department)
- The following specifications are required in each service area unless
otherwise specified:
1. Each room should be no less than 15-20 m2.
2. Floors must be covered with porcelain or plastic tiles.
3. Walls must be painted with a washable paint or covered with ceramic
tiles.
4. Paint and ceramic tiles must be light in color so that dirt is easily
visible.
- All equipment must be present in the indicated minimum quantities. The
following conditions must be observed:
1. All equipment must be clean (free of dirt, dust, stains, fluids, etc.).
2. Metal surfaces must be free of rust or stains.
3. All equipment must be sturdy (no loose or unstable parts).
4. Painted surfaces must be intact and free of major scratches.
5. If equipment has wheels, they must all be present and in good working
order.
6. Instruments ready for use must be sterilized.
7. All electrical equipment must be properly operational (working
switches, safe wiring and secure plugs).
- All supplies must be of high quality and be available in sufficient quantities to
meet departmental needs.

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 Levels Of

Standards & Monitoring System

1. CSSD (Clean)
Item Available Compliance Additio
Quantity (in nal
good working Comm
Description Standard condition) Yes No ents

1. 1 Physical Structure
1.1.1 Room specifications
1.1.2 Cleanliness
1.1.3 Illumination
Electric sockets
1.1.4 -The sockets must be suitable
for an autoclave.
1.1.5 Sink
-Ventilation
Air-conditioner and exhaust
1.1.6
fan in working order are
required.
Actual Score
Total Score 6
1. 2 Furniture
Laboratory table
1.2.1 -For the preparation of packing
(linens, instruments, etc.)
1.2.2 Rotating stool
3 cabinets
1.2.3 -For storage of clean and sterile
items
Covered waste receptacle with
1.2.4
plastic bag liners
Actual Score
Total Score 4
1.3. Equipment
Nine perforated trays for
1.3.1
instruments
1.3.2 19 rigid containers (drums)
One stainless steel instrument
1.3.3
basket
1.3.4 Autoclave
1.3.5 Instrument kits prepared

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 Levels Of

Standards & Monitoring System

according to set standards for

cesarean section.
Instrument kit prepared
1.3.6 according to set standards for
abdominal set.
Instrument kit prepared
1.3.7 according to set standards for
D & C set.
Actual Score
Total Score 7
1.4 Supplies
1.4.1 Brush for instruments
1.4.2 Chemical/tape indicator
1.4.3 Clogs/slippers/overshoes
1.4.4 Biological indicator
1.4.5 Apron
1.4.6 Head cover
1.4.7 Thick utility gloves (M and L)
Detergents for instruments
1.4.8
cleaning
Anti-rust solution for
1.4.9
instruments
1.4.10 Lubricant for instruments
1.4.11 Germicide for housekeeping
1.4.12 Decontamination container
1.4.13 Small containers for lubricants
1.4.14 Soap for hand washing
Linens (large and medium
1.4.15
wrappers)
Double thickness sheets
1.4.16
(medium and large)
1.4.17 Hand towels
1.4.18 Fenestrated towels
1.4.19 Surgical gloves
1.4.20 CSSD attire
Actual Score
Total Score 20
Total CSSD (clean)
Actual Score
Total Score 37

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 Levels Of

Standards & Monitoring System

2. CSSD (Dirty)
Available
Item Compliance Additio
Quantity (in nal
good working Comm
Description Standard Yes No ents
condition)

2. 1 Physical Structure
2.1.1 Room specifications
2.1.2 Cleanliness
2.1.3 Illumination
2.1.4 Electric sockets
2.1.5 Sink
Ventilation
2.1.6 -Exhaust fan in working order is
required.
Actual Score
Total Score 6
2. 2 Furniture
Covered waste receptacle with
2.2.1
plastic bag liners
Actual Score
Total Score 1
2.3. Equipment
2.3.1 Perforated trays for instruments
2.3.2 Rigid containers (drums)
2.3.3 Stainless steel instrument baskets
Instrument kits prepared
2.3.4 according to set standards for
caesarian section
Instrument kit prepared according
2.3.5
to set standards for abdominal set
Instrument kit prepared according
2.3.6
to set standards for D & C set
Actual Score
Total Score 6
2.4 Supplies
2.4.1 Brush for instruments
2.4.2 Chemical indicator

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 Levels Of

Standards & Monitoring System

2.4.3 Clogs/slippers/overshoes
2.4.4 Biological indicator
2.4.5 Apron
2.4.6 Head cover
2.4.7 Thick utility gloves (M and L)
2.4.8 Detergents for instrument
cleaning
2.4.9 Anti-rust solution for instruments
2.4.10 Lubricant for instruments
2.4.11 Germicide for housekeeping
2.4.12 Decontamination container
2.4.13 Small containers for lubricants
2.4.14 Soap for hand-washing
2.4.15 Linens (large and medium
wrappers)
2.4.16 Double thickness sheets (large
and medium)
2.4.17 Hand towels
2.4.18 Fenestrated towels
2.4.19 Surgical gloves
2.4.20 CSSD attire
Actual Score
Total Score 20
CSSD (Dirty) Adult score
Total score 33
Total CSSD Score
Actual Score
Total Score 70

82