WORKSHEET FOR BASE LINE ASSESSMENT OF INFECTION CONTROL SYSTEM

Prepared by Prof. Ossama Rasslan

12/03/2011
Instructions: The following is a list of items that must be assessed during the on-site survey, in
order to determine the current situation of the infection control system in a healthcare facility.
Items are to be assessed primarily by surveyor observation, with interviews used to provide
additional confirming evidence of observations.
The interviews and observations should be performed with the most appropriate staff person(s) for
the items of interest
When performing interviews and observations, any single instance of a breach in infection control
would constitute a breach for that practice.

PART 1 - Facility CHARACTERISTICS

1) Facility name:----------------------------------------------------------------------------------
2a) Type of healthcare provided :……….1ry…………2ry…………3ry…………….
2b) Number of Beds:……………………………………………………………………
2c) Number of employees:
Doctors………………………………………
Nurses……………………………………….
Other healthcare workers………………….
Administrative staff………………………….
Ancillary services……………………………

3) What year did the facility open for operation?

4) Please list date(s) of site visit: (mm/dd/yyyy) to (mm/dd/yyyy)………………………
5) What is the ownership of the facility?
a. Government -owned
b. Private Hospital
c. Charity Hospital
d. Other (please specify) …………………………………………………………………

6) What is the primary procedure performed at the Facility (i.e., what procedure type reflects the
majority of procedures performed at the Facility). Check only ONE:
1 Dental
2 Endoscopy
3 Ear/Nose/Throat
4 OB/Gyn
5 Ophthalmologic
6 Orthopedic
7 Pain
8 Plastic/reconstructive
9 Podiatry
10 Other (please specify): _______________________

7) What additional procedures are performed at the Facility (Check all that apply)?
1 Dental
2 Endoscopy
3 Ear/NoseThroat
4 OB/Gyn
5 Ophthalmologic

1
 6 Orthopedic
7 Pain
8 Plastic/reconstructive
9 Podiatry
10 Other (please specify): __________________

8) Who does the facility perform procedures on? (Check only ONE):
1 Pediatric patients only
2 Adult patients only
3 Both pediatric and adult patients

9) What is the average number of procedures performed at the facility per month?

10) How many Operating Rooms does the facility have?

Number of rooms:-------------------------------------------------------------------------------------------------

11) Please indicate how the following services are provided (check all that apply):
Anesthesia: a. Contract b. Employee c Other (please specify)__________
Environmental Cleaning: a. Contract b. Employee c Other (please specify)__________
Nursing: a. Contract b. Employee c Other (please specify)__________
Pharmacy: a. Contract b. Employee c Other (please specify)__________
Sterilization/Reprocessing: a. Contract b. Employee c Other (please specify)__________
Waste Management : a. Contract b. Employee c Other (please specify)__________

INFECTION CONTROL PROGRAM

12) Does the Facility have an explicit infection control program? YES NO

12a) Does the facility have an infection control organizational structure? YES NO ;
Infection control committee comprising ;------------------------------------------------------
------------------------------------------------------
--------------------------------------------------------
--------------------------------------------------------
Infection control team comprising ----------------------------------------------------------
------------------------------------------------------------
12b) Is there a top management commitment and support for the infection control program?
YES NO
If YES………….Very good……………….Good…………………….Fair……………………

12c) Does the facility specify an annual budget for the running of the I C program? YES NO
If Yes …………..Good…………………Reasonable (Basic Resources)……………………....

13) Does the Facility’s infection control program follow a recognized infection control guidelines ?
YES NO

14) Is there documentation that the Facility considered and selected a recognized infection control
guidelines for its program? YES NO

15) Which recognized infection control guidelines has the Facility selected for its program (Check all
that apply)?

2
1. National Guidelines
2. CDC Guidelines:
a Guideline for Isolation Precautions
b Hand hygiene
c Disinfection and Sterilization in Healthcare Facilities
d Environmental Infection Control in Healthcare Facilities
e Guidelines for prevention of surgical site infections
f Others ( please specify)-------------------------------------------------------------
------------------------------------------------------------------------------------

3. Guidelines issued by a specialty society / organization (List)

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4.Others (please specify) ____________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

16) Does the Facility have a licensed health care professional qualified through training in infection
control and designated to direct the Facility’s infection control program? YES NO

If YES,
17a) is this person an: (check only ONE):
1Facility employee
2 Faciity contractor_____________________________________

17b) Is this person certified in infection control ? YES NO

17c) If this person is NOT certified in infection control, what type of infection control training has this
person received? ___________________________________________________________

17d) On average how many hours per week does this person spend in the Facility directing the
infection control program? (it is expected that the designated individual spends sufficient time on-
site directing the program, taking into consideration the size of the facility and the volume of its
surgical activity.)
__________________________________________________________

18) Does the Facility have a system to actively identify infections that may have been related to
procedures performed at the Facility? YES NO

18a) If YES, how does the Facility obtain this information? (Check ALL that apply)
1 The facility sends e-mails to patients after discharge
2 The facility follows-up with their patients’ primary care providers after discharge
3 The facility relies on the physician performing the procedure to obtain this information at a
follow-up visit after discharge, and report it to the Facility
4 Other (please specify…………………………………………………………………………………..

18b) Is there supporting documentation confirming this tracking activity? YES NO

19) Do staff members receive infection control training? YES NO

If YES,

3
19a) How do they receive infection control training (check all that apply)?
1 In-service
2 Computer-based training
3 Other (specify):________________________________

19b) Which staff members receive infection control training? (check all that apply):
1 Medical staff
2 Nursing staff
3 Other staff providing direct patient care
4 Staff responsible for on-site sterilization/high-level disinfection
5 Cleaning staff
6 Other (specify):________________________________

19c) Is training:
1 the same for all categories of staff
2 different for different categories of staff

19d) Indicate frequency of staff infection control training (check all that apply):
1 Upon hire
2 Annually
3 Periodically/as needed
4 Other (specify):________________________________

20) Is there documentation confirming that training is provided to all categories of staff listed above?
YES NO

------------------------------------------------------------------------------------------------------------------------------------------