Healthcare Facility Infection Control Audit

(ICA) 2023
Name of facility Visit Date
Region Auditor 1 Name
Healthcare
City Auditor 1 Email
Facility Tel Auditor 2 Name
Information Email Auditor 2 Email
Head of Infection Control

Domain - A Infection Prevention & Control Administrative Measures

Element # A-1 Leadership Support Activities Score comment
Adequate resources are allocated to infection prevention & control (IPC) department (e.g., offices, internet
A-1.1 O SI 0 1 2
access, IT support ...etc.).
Adequate infection prevention & control supplies are provided to healthcare workers (HCWs) for successful
A-1.2 D O SI 0 1 2
implementation of IPC program (e.g., PPE, disinfectants, etc.).
A-1.3 Infection prevention & control team is given a full authority to implement the IPC policies and procedures. D SI 0 1 2
Hospital leaders' support IPC team and their supervision role when some functions are outsourced (e.g. laundry
A-1.4 D SI 0 2 NA
or dietary services).
Element # A-2 Infection Prevention & Control Department Activities Score comment
For hospitals (≥ 150 beds): the director of IPC department is full-time employee qualified in infection control
A-2.1 PF SI 0 1 2 NA
through certification, training, and experience for a minimum of two years.
For hospitals (< 150 beds): the director of IPC department is a full-time employee qualified in infection control
A-2.2 PF SI 0 1 2 NA
through certification, training, or experience for a minimum of two years.
The director of IPC program reports directly to the highest administrative authority (general director or medical
A-2.3 D SI 0 2
director of the hospital).
The facility has infection prevention & control staffing ratio of not less than 1 full-time practitioner for every 100
A-2.4 D SI 0 2
beds assigned merely for the IPC program in order to accomplish the tasks in an effective manner.
An additional one full-time IPC practitioner is staffed for every 30 beds in critical care units (e.g., ICU, PICU, ER,
A-2.5 Burn Unit …etc) assigned merely for the IPC program in order to accomplish the tasks in an effective D SI 0 2
manner.
An additional one full-time IPC practitioner is staffed for every 120 dialysis patients per day assigned merely for
A-2.6 D SI 0 2 NA
the IPC program in order to accomplish the tasks in an effective manner.
IPC practitioners are qualified in infection control through certification, training, or experience for a minimum of
A-2.7 PF SI 0 1 2
one year.
IPC practitioners have updated infection control skills and knowledge through continuous medical education
A-2.8 PF SI 0 1 2
program and attendance in IPC scientific activities.
Element # A-3 Infection Prevention & Control Committee Activities Score comment
There is written approved terms of reference document for the IPC committee containing structure, rules, duties,
A-3.1 D 0 1 2
and members responsibilities.
Meeting minutes are written in a manner of task force tables with time frame for the actions needed and the
A-3.2 D 0 1 2
documented actions must be followed in the next meeting.
A-3.3 IPC committee is chaired by the hospital director or medical director. D 0 2
Membership of IPC committee includes head of IPC, IPC department members, medical director, head of nursing
services, head of laboratory department (microbiology), head of surgical operating room, head of CSSD,head of
A-3.4 critical care units (ICUs), head of pharmacy department, head of dietary services, head of environmental health D 0 1 2
department, head of houskeeping department, head of adminstartive or financial department , head of medical
supply department, and other guest members as needed.
A-3.5 IPC committee meets on a regular basis (at least quarterly) or when required on urgent demand. D 0 1 2
 Functions of IPC committee include, but not limited to: (revision and evaluation of the IPC yearly plan, review and
A-3.6 approval of IPC policies & procedures, review of surveillance data, & discuss respiratory protection program D SI 0 1 2
related activities & measures, etc) .

Element # A- 4 Infection Prevention & Control Program Activities Score comment

There is a program to reduce the risk of healthcare associated infections (HAIs) that involves patients, staff,
A-4.1 D SI 0 1 2
trainees, volunteers, families, and visitors.
A-4.2 The program is applied to all areas of the hospital according to the scope of service. D SI O 0 1 2
The IPC program is based on current scientific knowledge, referenced practice guidelines and applicable
A-4.3 D SI 0 1 2
national laws and regulations.
Element # A-5 Infection Prevention & Control Annual Plan Activities Score comment

The annual plan is based on Infection control risk assessment (ICRA) (i.e., addresses processes, procedures,
A-5.1 D SI 0 1 2
resources, and devices that are identified by the IPC practitioners to be associated with risk of HAIs).
The plan includes goals for patient safety (e.g. standard precautions, transmission based isolation precautions,
A-5.2 D SI 0 1 2
healthcare bundles, and patient/family education).
The plan includes goals for healthcare workers (HCWs) safety (e.g., immunization, post exposure management,
A-5.3 D SI 0 1 2
and HCWs education).
A-5.4 The plan includes metrics of required changes in targets and goals to measure achieved proposed activities. D SI 0 1 2

Element # A-6 Infection Prevention & Control Policies & Procedures Activities Score comment
Infection prevention & control policies and procedures are developed by IPC department and to be approved
A-6.1 by IPC committee (policies and procedures are based on approved MOH guidelines and scientific references D 0 1 2
(e.g. GCC, CDC, WHO or APIC).
IPC policies and procedures are organized in one manual that is well- distributed and available in all hospital
A-6.2 D O SI 0 1 2
areas.
Infection prevention & control policies and procedures are revised periodically by the IPC department every 2-3
A-6.3 D 0 1 2
years, or when required.
Element # A-7 Infection Prevention & Control Education & Training Activities Score comment
Annual infection control training program is based on need assessment and include basic and specialized
A-7.1 D SI 0 1 2
infection prevention & control training sessions.
IPC department provides continuous education and training (formal & on- job training) for HCWs on infection
A-7.2 D PF SI 0 1 2
prevention & control with competency assessment.
IPC department provides orientation and training on basics of infection prevention & control for newly hired HCWs
A-7.3 D SI 0 1 2
before or maximum within 1 month of joining their work.
A -7.4 IPC department provides education on infection prevention & control for patients, families, and visitors. D SI 0 1 2
Basic Infection Control Skills License (BICSL) training program is implemented & all HCWs in the hospital have
A -7.5 D SI 0 1 2 NA
been trained and licensed.
Domain - B Infection Prevention & Control Key Measures
Element-B-1 Hand Hygiene Activities Score comment
There is a written infection prevention & control policy and procedure for hand hygiene, including types,
B-1.1 D 0 1 2
indications, supplies, techniques, and monitoring tools.
Hand washing facilities and supplies (sinks with hot and cold water, plain and antimicrobial soap, and towels) are
B-1.2 available and easily accessible (at least one sink for every 2-4 beds in the critical care areas and at least one O 0 1 2
sink per patient's room).
Alcohol - based hand rub dispensers are available in adequate numbers (one dispenser per patient's bed, one
B-1.3 O 0 1 2
at every nursing station, and at any service area).
Hand hygiene compliance rate is regularly monitored and results are discussed in IPC committee meetings for
B-1.4 D 0 1 2
corrective actions.
Visual alerts for hand hygiene are available (WHO 5 moments - hand wash techniques - hand rub techniques)
B-1.5 O SI 0 1 2
and HCWs are oriented about it.
B-1.6 HCWs (8 - 10) are performing hand hygiene properly (appropriate technique and recommended duration). O SI 0 1 2
B-1.7 WHO hand hygiene Improvement strategy tools are applied to improve the quality of hand hygiene. D SI O 0 1 2
Reporting of hand hygiene self-assessment (HHSA) is active and ongoing (WHO HHSA framework - action plan to
B-1.8 D SI 0 1 2
improve the quality of hand hygiene).
Element B-2 Personal Protective Equipment (PPE) Activities Score comment
There is a written infection prevention & control policy and procedure for PPE including types, indications,
B-2.1 D 0 1 2
donning, doffing, & safe disposal techniques.
B-2.2 PPE is available in all patients care areas in adequate amounts and proper qualities. D SI O 0 1 2
HCWs are properly trained and demonstrate the appropriate use of PPE (i.e., careful selection in relation to
B-2.3 O SI 0 1 2
indications, proper donning and doffing, correct sequence, and proper disposal)
Respirator fit testing is conducted for all HCWs based on the national regulations needed' frequency or when
B-2.4 D SI 0 1 2
required.
Element # B-3 Isolation Precautions Activities Score comment
There are written policies and procedures for standard and transmission based precautions, including types,
B-3.1 D 0 1 2
duration of isolation, patient transport, and visitors control.
There is a clinical hand washing facility with hands free operation inside the patient's room or in the anteroom (if
B-3.2 O 0 1 2
available).
Patient's room is provided with private toilet and shower (for isolation room in ICU,NICU , CCU toilet and shower
B-3.3 O 0 1 2
are optional).
PPE and alcoholic hand rub are available outside the patient’s room at the corridor or in the anteroom (if
B-3.4 O 0 1 2
available).
All PPEs are doffed inside the patient’s room except N95 respirator which is removed outside airborne infection
B-3.5 O SI 0 1 2
isolation room (AIIR) after closure of the door of patient's room or anteroom (if available).
Visitors receive proper instructions from assigned HCW before entering into an isolation room, and they should
B-3.6 O SI 0 1 2
comply with recommended isolation required precautions.
A log book is available and used for all individuals entering the rooms/cubicles of isolated patient with airborne
B-3.7 D SI 0 1 2
infections (e.g.Pulmonary TB).
Non-Critical patient-care equipments are single use or dedicated to one patient or if not available and shared
B-3.8 O SI 0 1 2
equipments have been used', proper cleaning & disinfection of shared equipments must be strictly followed.
The signs used to indicate categories of isolation precautions are clear and visible for HCWs and visitors, in
B-3.9 bilingual ( Arabic & English), color coded and compatible with diagnosis (e.g; contact: green, airborne: blue, and O SI 0 1 2
droplet: pink or red) (it is preferable to use the MOH approved isolation signs).
The receiving unit or facility is informed about the required isolation precautions and to ensure the availability of
B-3.10 MR SI 0 1 2
appropriate PPE.
The transfer of patient under isolation precautions is restricted to medically necessary purposes,Isolation
transportation cards must be used and should be consistent with the patient diagnosis , colour coded , posted in
B-3.11 O SI 0 1 2
Arabic and English, and indicating the type of precautions required for staff (it is preferable to use the MOH
approved isolation transportation cards) and through less crowded traffic route.
For transport of patient under contact isolation precaution:
B-3.12 •Contain and cover all skin lesions and infected or colonized wound if available with clean bandage/dressing. O SI 0 1 2
•Instruct patient to wear a clean gown, and clean linen should be used.
For transport of patient under droplet/airborne isolation precaution:
B-3.13 • Instruct the patient to wear a surgical mask and follow respiratory hygiene and cough etiquette. O SI 0 1 2
• Cover exposed skin lesions (if any) with clean bandages and/or clean linens.
There is a screening policy for newly admitted or transferred patients to all critical care units (e.g., ICU, CCU,
B-3.14 D SI 0 1 2 NA
NICU...) to identify those who require isolation precautions.
Patients with burns larger than 25% of the total body surface area (TBSA) are kept in a single room or physically
B-3.15 D SI 0 2 NA
separated from other patients .
B-3.16 Portable chest x-ray is available for usage in an isolation room when needed. O SI 0 1 2
The required number of airborne infection isolation room (AIIR) should be predicted in each hospital based on
B-3.17 D SI O 0 1 2
the facility' risk assessment or based on the national approved standard.
Airborne infection isolation rooms specifications' fulfill with MOH required specifications as the following:
*Standard isolation rooms.
B-3.18 *Windows are sealed and fixed (i.e., could not be opened). O 0 1 2
*Openings in walls and ceiling are sealed and airtight.
*Doors are properly designed and well sealed.
Airborne Infection Isolation Rooms (AIIRs) are under negative pressure (minimum -2.5 Pascal) with air totally
B-3.19 exhausted to outside (100%) through High-Efficiency Particulate Air (HEPA) filters. The exhaust air ducts including D 0 1 2
that from the bathroom are independent of the building exhaust air system.
 There is 100% fresh air supply (i.e. return of air is not permitted) from central AC or concealed separate unit. All
B-3.20 components of AIIR ventilation unit (supply & exhaust) are connected to emergency power supply to maintain air D O 0 1 2
pressurization in the event of power failure.
There is a fixed monitor outside the patient room in the corridor to continuously monitor the pressure difference
B-3.21 O 0 1 2
between the patient room and corridor, with activation of audiovisual alarm when the ventilation system failed.
There is evidence of regular monitoring of negative pressure difference of AIIRs:
• Daily when in use (i.e., a patient isolated inside).
B-3.22 D O 0 1 2
• Weekly when not in use (i.e., no patient isolated).
• Monthly check by maintenance personals.
B-3.23 Air exchange of AIIR is ≥ 12 air changes per hour (≥ 12 ACH) with monthly monitoring. D 0 1 2
B-3.24 AIIRs are used only for isolation of suspected or confirmed cases with airborne infectious diseases. D O SI 0 1 2
Bronchoscopy should be performed only in a room with negative air pressure, a minimum of 12 air exchanges
B-3.25 D O SI 0 2 NA
per hour, and discharged through HEPA filtration system (refer to AIIR specifications).
Element # B-4 Aseptic Technique Activities Score comment
B-4.1 There is a written policy and procedure for clean, and aseptic techniques. D 0 1 2
Separate clean area is available and maintained for preparation of medications (i.e., away from patients’
B-4.2 O SI 0 2
treatment areas).
For invasive procedures, sterile devices and supplies are used after patient’s skin antisepsis (e.g., sterile syringes,
B-4.3 O SI 0 1 2
needles and medications are used after skin antisepsis with approved antiseptics).
A peripheral venous catheter is properly fixed, with a clearly written date of insertion, and to reduce risk of
infection and phlebitis, it is replaced - if still needed - as follows:
B-4.4 O SI 0 1 2
In adults: it is not replaced more frequently than every 72 to 96 hours.
In children: it is replaced only when clinically indicated.
B-4.5 Preparation & dilution of medications are only done by ready-made single-dose sterile solutions. O SI 0 1 2
Single-dose or single-use vial is used for a single procedure/injection in a single patient and it is not stored for
B-4.6 O SI 0 2
future use even for the same patient.
Needles and syringes including prefilled syringes, and vacutainer holders are used for a single
B-4.7 O SI 0 2
procedure/injection.
B-4.8 Cartridge devices such as insulin pens are used for only one patient. O SI 0 2 NA
Supplies are brought to patient’s care area only when needed and after patient discharge, all remaining single-
B-4.9 use items are discarded while reusable ones are sent to CSSD for reprocessing (even unused items with intact O SI 0 1 2
original wrap).
Whenever possible, multi-dose vial is used for a single patient, with recorded patient's name and date of the first
B-4.10 use (when it has been accessed for the first time), and discarded after 28 days, unless the manufacturer specifies O SI 0 1 2 NA
a different shorter or a longer date (i.e., reuse life).
If multi-dose vial is used for more than one patient, they should only be kept and accessed in a dedicated clean
B-4.11 O SI 0 1 2 NA
medication preparation area away from immediate patient treatment areas.
The self-sealed rubber cap of a medication vial or an IV solution bottle is disinfected with approved antiseptic
B-4.12 O SI 0 2
wipes (e.g., alcohol wipes) prior to any access.
IV sets (including secondary sets and add-on devices) that are continually used to infuse crystalloid solutions
B-4.13 (hypotonic, isotonic, or hypertonic), are replaced at least every 7 days, but not more frequently than 96-hour O SI 0 1 2
intervals.
IV sets that are used to administer blood, blood products, lipid emulsions, or dextrose/amino acid TPN solutions
B-4.14 O SI 0 1 2 NA
are replaced within 24 hours of initiating the infusion.
B-4.15 For a ventilated patient, ventilation circuit is only changed when visibly soiled or mechanically malfunctioning. D SI 0 1 2 NA
Sterile solutions are used in nebulizers, humidifiers, or any aerosol generating system and changed between
B-4.16 patients and every 24 hours for the same patient, unless the manufacturer of ready-made sterile solutions O SI 0 1 2
specifies different dates.
Hand hygiene practiced before breastmilk expression and sterile container is used for breastmilk collection and
B-4.17 O SI 0 1 2 NA
preservation.
B-4.18 HCW wears mask during insertion of a catheter or injection into spinal or epidural space. O SI 0 1 2 NA
Element # B-5 Single Use Items (SUIs) Activities Score comment
B-5.1 The facility has an implemented policy for No Reuse of single use items based on the national regulations. D O SI 0 2
Element # B-6 Respiratory Protection Program (RPP) Activities Score comment
There is a written policy and procedure for RPP with well designed programs' components & activities and
B-6.1 D 0 1 2
based on current scientific knowledge, approved MOH guideline, reference practice, and regulations.
There is a written policy and procedure for dealing with suspected or confirmed respiratory illnesses patients
B-6.2 based on updated national guidelines. It contains early detection, management, and transfer of respiratory D 0 1 2
illness patients.
The IPC committee regularly discusses RPP program’s activities, progress, and any issues with potential to
B-6.3 D SI 0 1 2
impede the effective implementation of the program
There is a designated respiratory triage facing the entrance of the Emergency and Hemodialysis units of the
B-6.4 O 0 1 2
hospital. i.e., First area to be reached by any patients.
Written reminders in the emergency department for updated definitions of respiratory illnesses of national alert
B-6.5 O SI 0 1 2
are available and based on updated national guidelines and staff are quite familiar with these definitions
Flowchart is available in Emergency and Hemodialysis Units for early detection& management of respiratory
B-6.6 D SI 0 1 2
illness patients
Patients who have acute infectious respiratory symptoms are instructed to wear surgical masks and placed in a
B-6.7 O SI 0 1 2
dedicated and separated waiting area with at least 1.2 meter distance between them.
The facility conducts a tracing for all HCWs who have exposed to a confirmed respiratory illnesses (e.g: TB or
B-6.8 D SI 0 1 2
MERS-CoV) cases as per the latest national guidelines.
There is an implemented system for reporting, follow up, and management of exposure to open pulmonary TB,
B-6.9 D SI 0 1 2
MERS-CoV, chicken pox, measles, mumps, and rubella.
Aerosol generating procedures (AGPs) (e.g; nasopharyngeal swabs, tracheal aspirate, etc)of suspected
B-6.10 infectious respiratory patients are performed by trained HCWs , and there must be schedule for assigned trained D MR SI
HCWs to cover all shifts.
HCWs must perform aerosol generating procedures (AGPs) on any suspected or confirmed respiratory illnesses
cases in a negative pressure room or single room with a portable high-efficiency particulate air (HEPA) filter
B-6.11 D O SI 0 1
machine (if the negative pressure room is not available) and by using proper PPE (e.g., N95 fitted mask, eye
protection, gloves, and gown).
There is a proper maintenance of all portable HEPA filter machines and all HEPA filters are changed on a regular
B-6.12 D 0 1 2
basis and according to the manufacturer’s recommendations.
Element # B-7 Employee Health Program Activities Score comment
There is a written policy and procedure for employees’ health (i.e., pre-employment counseling and screening,
B-7.1 D 0 1 2
immunization, post exposure management, and work restriction).
There is a special clinic for employees’ health that provides pre-employment counseling and screening,
B-7.2 O SI 0 1 2
immunization, post exposure management and work restriction.
B-7.3 All employees have a baseline screening for hepatitis B, hepatitis C, HIV, and tuberculosis (TB). D MR 0 1 2
The immune status of newly hired HCWs against hepatitis B, measles, mumps, rubella, COVID-19, and varicella
are determined by documented vaccination, serological evidence of immunity, documented clinical /
B-7.4 D MR SI 0 1 2
laboratory evidence of disease with life long immunity). Appropriate vaccine(s) are administered to those who
are susceptible.
B-7.5 The influenza vaccine is administered annually to targeted HCWs as per MOH recommendations. D MR SI 0 1 2
Newly hired HCWs are screened for tuberculosis upon contracting with Purified Protein Derivative based
B-7.6 Tuberculin Skin Test (PPD-based TST). The test is repeated annually for those who are non-reactive and PPD-based D MR SI 0 1 2
TST conversion rates are monitored and calculated.
There is an implemented system for reporting, follow up, and management of sharp or needlestick injuries and of
B-7.7 D MR SI 0 1 2
blood/body fluid exposures.
Reporting is active and ongoing (i.e., reliable reports of sharp or needlestick injuries and blood/body fluid
B-7.8 D SI 0 1 2
exposures are sent through approved national platform or other approved reporting system in a timely manner).
The Employee health clinic team regularly monitors different types of HCWs exposure and recommend corrective
B-7.9 actions to prevent recurrence, e.g., devices with safety mechanisms (self-sheathing needles-retractable needles D SI 0 1 2
and scalpels ... etc.).
Updated medical records (or copies) are available for all HCWs of supportive services (i.e., kitchen, laundry,
B-7.10 D MR 0 1 2
housekeeping, waste management …etc.)
B-7.11 The screening, immunization, and post exposure management data are kept in HCWs medical records. MR 0 1 2
There are regular training activities for employee health program.(an active annual education and training plan
B-7.12 D PF SI 0 1 2
for the employee health program targeting healthcare worker)
 Exposed health care workers are isolated when needed (either home isolation in staff accommodation or in their
B-7.13 D O SI 0 1 2
home or in identified rooms at the hospital).
B-7.14 Approved national/MOH protocol for work restriction is strictly applied. D SI MR 0 1 2
Domain - C HAIs Surveillance & Outbreak Management
Element # C-1 Outbreak Management Measures Activities Score comment
There is a written policy and procedure for dealing with the outbreak in the facility based on the approved
C -1.1 D 0 1 2
scientific reference and national MOH guidelines.
There is a defined outbreak management team (OMT) chaired by hospital director or medical director with clear
C -1.2 D 0 1 2
roles & responsibilities and include all key members involved in outbreak management.
Investigation and control measures of suspected HAIs outbreak are led by the director of IPC department in the
C -1.3 D SI 0 1 2
hospital.
The outbreak management team members are trained and having experience and skills in management of
C -1.4 D PF 0 1 2
outbreaks based on the latest national MOH guidelines & regulations.
If an outbreak is suspected, the IPC department alerts the hospital director through approved channel of
C -1.5 D 0 1 2 NA
communication and the OMT will be activated consequently and will be discussed in the nearest committee.
If an outbreak is suspected, the infection prevention & control department activate the notification through
C -1.6 D SI 0 1 2 NA
approved national platform based on the national MOH guidelines and regulations.
If an outbreak is suspected, the OMT members meet weekly or as required and the meeting recommended
C -1.7 D 0 1 2 NA
actions' will be implemented and followed.
If an outbreak is suspected, the facility implements outbreak management approaches (investigation forms, line
C -1.8 list, contact tracing, & outbreak management action plan (OMAP), & final report) based on the national MOH D SI 0 1 2 NA
guidelines & regulations.
There is a well designed notification system between the IPC department, laboratory, and all departments in the
C -1.9 D SI O 0 1 2
hospital for any critical values (i.e MDROs, positive cultures..), and all these values' must be monitored regularly.

Emergency Preparedness & Response to the National Infectious Diseases’

Element # C-2 Activities Score comment
Threats
There is a policy and procedure for the current defined infectious disease based on the national guidelines and
C -2.1 D 0 1 2 NA
references.
Active surveillance is implemented for monitoring HCWs with signs & symptoms of suspected current infectious
C -2.2 D SI 0 1 2 NA
disease.
All HCWs, patients, and visitors must follow the national recommended preventive measures of the current
C -2.3 D SI O 0 1 2 NA
infectious disease with public threat at all times while in their respective clinical settings.
C -2.4 All HCWs must receive continuous job specific training on the current national infectious disease. D SI 0 1 2 NA
Element # C-3 Antimicrobial Stewardship / Antibiogram Activities Score comment
There is a written policy and procedure for antimicrobial stewardship program (ASP) and authorized ASP
committee formulated & approved by ASP committee members that is chaired by clinical pharmacist or
C -3.1 D 0 1 2 NA
infectious disease (ID) consultant with a clear roles and responsibilities and meets on regular basis (at least bi-
annually).
There is a written restricted antibiotics policy implemented in the facility, and it should be developed & followed
C -3.2 D 0 1 2 NA
up by the pharmacy and infectious disease department.
There is an Interventional policy implemented to Improve antibiotic usage which is developed & approved by
C -3.3 D 0 1 2 NA
the pharmacy department.
The ASP committee members include: infectious disease physician, pharmacist, microbiologist, IPC practitioner,
C -3.4 head of critical care units, head of operating room, head of surgical department, head of nursing services and D SI 0 1 2 NA
other departments as needed.
Antibiogram is regularly discussed by antimicrobial stewardship committee with action plan and interventions to
C -3.5 D 0 1 NA
improve the use of antimicrobials and prevent resistance.
Hospital leaders dedicate necessary human, financial, and information technology resources to the ASP
C -3.6 committee(support training ASP/MDROs program- participating in the world awareness antimicrobial week D 0 1 2 NA
celebrations(WAAW) , assign ID consultant, etc)
The antibiogram report is prepared & interpreted annually by hospital microbiologist and reported to the hospital
C -3.7 D 0 1 2 NA
IPC department (hospital ≥100 beds) and to the ASP team chairman.
Education about AMR & optimal antimicrobial prescription are provided regularly to the HCWs at least biannually
C -3.8 D SI 0 1 2 NA
by the ASP team members (each per their role).
Element # C- 4 HAIs Surveillance Activities Score comment

There are written policies and procedures for surveillance of health care associated infections, using CDC-NHSN
C - 4.1 definitions approved by natuonal MOH guidelines (e.g., VAP/VAE, CLABSI, CAUTI, SSI and MDROs according to D 0 1 2 NA
the hospital's scope of services).
There is a written policy and procedure for surveillance of dialysis event, using CDC-NHSN definitions which are
C - 4.2 D 0 1 2 NA
approved by national MOH guideline.
Adequate number of computers and a reliable internet service are available for effective implementation of
C - 4.3 O 0 1 2 NA
surveillance program without any interruption.
IPC practitioners are well trained regarding the national approved electronic surveillance platform and familiar
C - 4.4 D SI 0 1 2 NA
with CDC-NHSN definitions approved by national MOH guideline.
Surveillance system is carried out in all critical care units (active, prospective, targeted and patient based
C - 4.5 D SI 0 1 2 NA
surveillance).
SSI surveillance is applied according to national MOH guideline (i.e. selecting only 1 - 3 types of high risk
C - 4.6 D SI 0 1 2 NA
procedures or most common surgeries during at least 6 months).
Hospital has a system for post operative follow up and communication with post surgical patients regularly after
C - 4.7 D SI 0 1 2 NA
discharge for any signs and symptoms of surgical site infections including patients with implants.
Surveillance data (targeted patients, numerators, denominators, and device utilization ratio) are validated by IPC
C - 4.8 D SI 0 1 2 NA
practitioners at least once monthly.
Surveillance data are regularly collected & reported to MOH through national approved electronic surveillance
C - 4.9 D SI 0 1 2 NA
platform .
Results of surveillance are regularly analyzed, interpreted, and communicated to HCWs and concerned
C - 4.10 D SI 0 1 2 NA
departments.
Results of surveillance are regularly reviewed by the IPC committee, and the action plan is developed and
C - 4.11 D SI 0 1 2 NA
followed up accordingly (at least once quarterly).
C - 4.12 Results of surveillance are used to reduce HAIs through well designed quality improvement projects. D SI 0 1 2 NA
Element # C-5 Patient's Care Bundles For Prevention Of HAIs & MDROs Activities Score comment
C - 5.1 There is a written policy and procedure concerning patient's care bundle for prevention of CAUTI. D 0 1 2 NA
C-5.1a Hospital has a competency-based training program for insertion and maintenance of urinary catheters. D SI 0 1 2 NA
IPC practitioners regularly conduct auditing rounds to monitor and document HCWs’ adherence to
C-5.1b D SI 0 1 2 NA
recommended practices for insertion and maintenance of urinary catheters in critical care units (weekly).
IPC department provides compliance audit feedback to the critical care unit's HCWs regarding their
C-5.1c performance in the insertion and maintenance of urinary catheters regularly and corrective actions are applied D SI 0 1 2 NA
accordingly.
Urinary catheter insertion is performed under complete aseptic technique including antimicrobial handwashing
C-5.1d with sterile items (urinary catheter, urinary bags, gloves, solution and single-use gel). Cleansing the perineal area D SI O 0 1 2 NA
with skin antiseptic solution and with sterile draping of the patient.
Hospital apply urinary catheter maintenance activities including securement of the catheter to the patient's
C-5.1e thigh, ensuring low level fixation of urine bag below the level of the bladder at all times, maintain a continuous D SI O 0 1 2 NA
closed drainage system, antiseptic cleaning in the drain port for urine drainage and, routine meatal hygiene.
Nursing staff review daily the ongoing need of indwelling urinary catheter and the possibility of discontinuation
C-5.1f D SI 0 1 2 NA
with the treating physician.
C - 5.2 There is a written policy and procedure concerning patient's care bundles for prevention of CLABSI. D 0 1 2 NA
C-5.2a Hospital has a competency-based training program for insertion and maintenance of central line catheter. D SI 0 1 2 NA
IPC practitioners regularly conducting auditing round to monitor and document adherence to recommended
C-5.2b D SI 0 1 2 NA
practices for insertion and maintenance of central catheter lines in critical care units (weekly).
IPC department provides compliance audit feedback to the critical care unit's HCWs regarding their
C-5.2c performance in insertion and maintenance of central catheter lines regularly and corrective actions are applied D SI 0 1 2 NA
accordingly.
Central line catheter insertion is performed under ultrasound guidance with complete aseptic technique
C-5.2d including antimicrobial handwashing, & use of maximum barrier precautions (sterile gloves, mask, sterile gown, D SI O 0 1 2 NA
and sterile full body drape).
preparation of the skin site with an alcoholic chlorhexidine solution, and use of transparent chlorhexidine
C-5.2e D SI O 0 1 2 NA
impregnated dressing.
Nursing staff scrub the access port or hub with friction immediately prior to each use with an appropriate
C-5.2f D SI O 0 1 2 NA
approved antiseptic for at least 15 seconds.
 Nursing staff review daily the ongoing need of central venous catheter and the possibility of discontinuation with
C-5.2g D SI 0 1 2 NA
the treating physician
C - 5.3 There is a written policy and procedure concerning patient's care bundles for prevention of VAEs. D 0 1 2 NA
C-5.3a Hospital has a competency-based training program for prevention of VAEs. D SI 0 1 2 NA
IPC practitioners regularly conducting auditing round to monitor and document adherence to recommended
C-5.3b D SI 0 1 2 NA
practices for management of ventilated patients in critical care units (weekly).
IPC department provides compliance audit feedback to the critical care unit's HCWs regarding their
C-5.3c D SI 0 1 2 NA
performance for management of ventilated patients regularly and corrective actions are applied accordingly.

Hospital applies bundle of care for management of ventilated patients includes elevation of the head of the bed
C-5.3d to between 30 and 45 degrees, daily sedative interruption with assessment of readiness to extubate, peptic ulcer D SI O 0 1 2 NA
prophylaxis, deep venous thrombosis prophylaxis, and daily oral care with chlorhexidine solution.
There is a written policy and procedure concerning patient's care bundles for the prevention of surgical site
C - 5.4 D 0 1 2 NA
infections (SSIs)
Hospital has a competency-based training program for surgical care improvement including surgical site
C-5.4a D SI 0 1 2 NA
infections prevention care bundle (preoperative, Intraoperative & post operative phases).
IPC practitioners regularly conduct auditing round to monitor and document adherence to recommended
C-5.4b D SI 0 1 2 NA
practices for surgical site infection prevention care bundles (weekly).
IPC department provides compliance audit feedback to the surgical HCWs regarding their performance in
C-5.4c D SI 0 1 2 NA
surgical site infections prevention care bundle regularly and corrective actions are applied accordingly.
Hospital applies bundle of care for prevention of surgical site infections including proper antimicrobial
prophylaxis, no preoperative hair removal or use of electric hair clippers if hair removal is necessary, controlled 6
C-5.4d D SI O 0 1 2 NA
AM postoperative serum glucose, maintaining perioperative normothermia, patient full body shower at least the
night before surgery with antimicrobial soap, and intraoperative skin preparation with approved antiseptic.
C - 5.5 There is a written policy and procedure concerning patient's care bundles for the prevention of MDROs. D 0 1 2 NA
C-5.5a Hospital has a competency-based training program for prevention of MDROs. D SI 0 1 2 NA
IPC practitioners regularly conducting auditing round to monitor and document adherence to recommended
C-5.5b D SI 0 1 2 NA
practices for management of Patients with MDROs (weekly).
IPC department provides compliance audit feedback to the HCWs regarding their performance in
C-5.5c D SI 0 1 2 NA
implementation of MDRO bundle on regular basis and corrective actions are applied accordingly.
Hospital applies bundle of care for prevention of Multidrug Resistant Organisms (MDROs) including judicious Use
C-5.5d of Antimicrobial Agents, Patient placement in hospitals, standrard Infection Control Precautions to Prevent D SI O 0 1 2 NA
Transmission of MDROs, environemntal meaures etc
C - 5.6 There is a written policy and procedure concerning patient's care bundles for prevention of dialysis event (DE). D 0 1 2 NA
C-5.6a Hospital has a competency-based training program for heamodialysis patients' care bundle. D SI 0 1 2 NA
IPC practitioners regularly conducting auditing round to monitor and document adherence to the recommended
C-5.6b D SI 0 1 2 NA
practices for managment of heamodialysis patient to prevent DE (weekly).
IPC department provides compliance audit feedback to the heamodialysis's HCWs regarding their performance
C-5.6c in recommended practices for managment of heamodyalisis patient to prevent DE regularly and corrective D SI 0 1 2 NA
actions are applied accordingly.
Hemodialysis HCWs apply bundle of care for prevention of DE including catheter connection, disconnection, and
C-5.6d D SI O 0 1 2 NA
the required access (fistula/graft) care, as per the type of catheter inserted.
Domain - D Departmental Infection Prevention & Control Measures
Element # D-1 Hemodialysis Unit (HD) Activities Score comment
D - 1.1 There is a written policy and procedure for infection control in hemodialysis unit. D 0 1 2 NA
D - 1.2 The distance separating adjacent dialysis chairs or beds is not less than 1.2 m. O 0 1 2 NA
Special room is available for central venous line insertion, and it is equipped with appropriate hand washing
D - 1.3 O SI 0 1 2 NA
facility and required PPE.
Hand washing supplies (sinks, soap, water, paper towels, antimicrobial soap),are available in adequate number
D - 1.4 O 0 1 2 NA
(one for every 4 chair/beds) and easily accessible.
D - 1.5 Alcohol hand rub dispensers are available (one for every patient's chair/bed) O 0 1 2 NA
Appropriate PPE are available and used according to standard and/or transmission based precautions (gloves:
D - 1.6 O SI 0 1 2 NA
clean/sterile - gowns: clean/sterile - face shield or goggles - mask or N95 respirators).
D - 1.7 Patient and staff members wear masks for all central venous catheter (CVC) access connections. O SI 0 1 2 NA
D - 1.8 Mobile common medication carts or trays are strictly prohibited. O SI 0 1 2 NA
 Separate clean area is available and maintained for preparation of medications and not handling or storing
D - 1.9 O SI 0 1 2 NA
contaminated or used supplies, equipment, blood samples, or biohazard containers.
Unused supplies or medications within the patient's station are not used on other patients and never returned to
D - 1.10 O SI 0 1 2 NA
the common clean area.
Patient care equipment such as blood pressure cuffs, stethoscopes, and thermometers are allocated to a single
D - 1.11 patient during the whole session and are disposed (if single use) or cleaned and disinfected (if reusable) at the O SI 0 1 2 NA
end of each patient's treatment session.
Written rules are strictly followed for the process of internal cleaning and disinfection of dialysis machines in-
D - 1.12 D O SI 0 1 2 NA
between patients (as per manufacturer's recommendations).
Cleaning and disinfection of hemodialysis patients’ environment is performed after each treatment session with
D - 1.13 MOH approved disinfectants using a detailed checklist to ensure disinfection of all environmental surfaces at D O SI 0 1 2 NA
patient’s zone especially high touched areas.
Cleaning and disinfection of the water treatment and distribution system is performed at least once weekly.
D - 1.14 Complete dialysis system is considered during the disinfection procedure (water treatment system, distribution D SI 0 1 2 NA
system, and dialysis machines).
Quantitative microbiological testing for water and dialysate is conducted at least monthly, and if standard is
D - 1.15 D SI 0 1 2 NA
exceeded, testing is done weekly until meeting standard.
Quantitative endotoxin testing for water and dialysate is performed at least once per month, and if not up to the
D - 1.16 D SI 0 1 2 NA
standard, testing is repeated weekly until the problem is resolved.
D - 1.17 The results of microbiological and endotoxin testing of water documents are available. D SI 0 1 2 NA
Patient is tested for HBV markers (HBsAg, anti-HBc, anti-HBs) upon admission & with vaccination provided to
D - 1.18 MR D 0 1 2 NA
susceptible one. Patient with negative results are periodically re-tested with prompt review of results.
Patient is tested for HCV markers upon admission (ALT and anti-HCV – ELISA) & patients with negative results are
D - 1.19 MR D 0 1 2 NA
periodically re-tested with prompt review of results.
Previously HCV +ve patient who was treated with direct antiviral agents (DAAs) and achieved sustained virologic
D - 1.20 MR D 0 1 2 NA
response (SVR), is tested for HCV-RNA (PCR) semi-annually to detect relapse.
Only patients with risk factors for HIV infection (High-risk behaviors, e.g., repeated blood transfusions, drug abuse
D - 1.21 MR D 0 1 2 NA
…etc) are tested for markers of HIV infection.
HVB +ve patients are strictly segregated in a separate room(s), treated by dedicated staff during dialysis sessions
D - 1.22 D O SI 0 1 2 NA
using designated machines, equipment, instruments, supplies, and medications which are used only for them.
Training and education of patients (or family members for patients unable to be responsible for their own care)
D - 1.23 regarding infection prevention & control practices should be given upon admission to dialysis and at least D MR 0 1 2 NA
annually thereafter.
Element # D-2 Compound Sterile Preparation (CSP) In The Pharmacy Activities Score comment
D - 2.1 There is a written IPC policy and procedure for compound sterile preparation (CSP) area. D 0 1 2 NA
Compound sterile preparation (CSP) is restricted to competent pharmaceutical HCW except during emergency
D - 2.2 O SI 0 1 2 NA
situations, it could be covered with HCW familiar with aseptic techniques and proper use of appropriate PPE.

D - 2.3 Compound sterile preparation (CSP) room/area is a functionally separate facility which is under positive pressure. D O 0 1 2 NA

D - 2.4 The doors of the compound sterile preparation (CSP) room/area are equipped with an auto-closure mechanism. O 0 1 2 NA
Mixing IV medications is performed only in laminar air flow hood or safety cabinet, with air supplied through High-
D - 2.5 D O 0 1 2 NA
Efficiency Particulate Air (HEPA) filter.
Compound sterile preparation (CSP) room/area is cleaned and disinfected with an approved
D - 2.6 D O SI 0 1 2 NA
detergent/disinfectant and by assigned well trained housekeeper in cleaning/disinfection methods.
Working surface (under the laminar air flow hood) is regularly disinfected by an approved disinfectant using non-
D - 2.7 O SI 0 1 2 NA
lining wipes.
D - 2.8 Maintenance records for hoods and safety cabinets are available. D 0 1 2 NA
D - 2.9 All supplies and containers used in CSPs preparations are sterile. O SI 0 1 2 NA
Element # D-3 Operating Room (OR) Activities Score comment
There is a written policy and procedure for IPC in OR including a clear policy to handle patients under air-borne
D - 3.1 infection isolation precaution inside OR (e.g., TB) & patients with infectious transmissible diseases are scheduled D 0 1 2 NA
towards the end of the operating list.
There is a clear demarcation between unrestricted, semi restricted, and restricted zones of OR with restrictions
D - 3.2 O SI 0 1 2 NA
and special precautions for movement between these zones.
Floors, walls, & ceiling are formed of one piece without connections, cracks, or decorative parts, with minimal
D - 3.3 O 0 1 2 NA
openings that are completely sealed, and withstand repeated cleaning and disinfection.
D - 3.4 At least one large scrubbing sink is available at entry to each operating theater. O 0 1 2 NA
Storage areas in the OR are organized and well maintained and distribution of sterile items following the first in -
D - 3.5 D O 0 1 2 NA
the first out (FIFO) principle.
D - 3.6 Only necessary items are kept in the restricted area of the OR. O 0 1 2 NA
D - 3.7 Doors are kept closed and only necessary HCWs are allowed in the theater. O SI 0 1 2 NA
OR environment is maintained clean and there are clear procedures for cleaning and disinfection by allocated
D - 3.8 D O SI 0 1 2 NA
housekeeping staff after each surgical procedure and at least daily.
Ventilation system operates all the time and never shuts down even in long holidays, and air is introduced from
D - 3.9 D O SI 0 1 2 NA
the ceiling and exhausted near the floor.
All re-circulated or fresh air is filtered through High-Efficiency Particulate Air (HEPA) filters that are maintained and
D - 3.10 D 0 1 2 NA
replaced as per the manufacturer recommendations.
D - 3.11 Operating room is maintained at positive pressure (at least +2.5 Pascal) with respect to corridors. D O 0 1 2 NA
D - 3.12 Operating Room is maintained at ≥ 20 air changes per hour (ACH) with 20% fresh air. D O 0 1 2 NA
D - 3.13 Operating room temperature ranges from 21 °C to 24 °C and relative humidity from 20% to 60%. D O 0 1 2 NA
Element # D-4 Laboratory Department Activities Score comment
D - 4.1 There is a written policy and procedure for IPC in the laboratory. D 0 1 2 NA
D - 4.2 Access is restricted with a sign incorporating the universal biohazard symbol posted at the entrance. O 0 1 2 NA
D - 4.3 Eating, drinking, handling contact lenses, and storing food are not permitted. O SI 0 1 2 NA
All manipulations of infectious materials that may generate aerosols are properly contained or conducted in a
D - 4.4 O SI 0 1 2 NA
biological safety cabinet (BSC - class II-B).
Biological safety cabinets (BSC - class II-B) dedicated for aerosols generating procedures are well maintained,
D - 4.5 D 0 1 2 NA
tested, and certified at least annually.
D - 4.6 Whenever possible, plastic tubes are used instead of glass ones to avoid sharp injuries. O SI 0 1 2 NA
Each work area contains a dedicated well equipped sink for washing hands together with easily accessible
D - 4.7 D O SI 0 1 2 NA
eyewash facility to be used in emergency in case of exposure to blood and body fluids.
D - 4.8 Specimen collection and receiving area are equipped with hand washing facilities and proper PPEs. O 0 1 2 NA
Mycobacteriology laboratory that manipulates cultures of suspected or confirmed Mycobacterium Tuberculosis
D - 4.9 D O SI 0 1 2 NA
cases should be in at least Biosafety Level III Laboratory (BSL-3 laboratory).
Microbiological cultures should be autoclaved within the laboratory in an autoclave that is placed in appropriate
location and fullfils quality control parameters (except cultures for organisms not mentioned in the approved list
D - 4.10 D O SI 0 1 2 NA
of highly infectious microorganisms, that could be double packed and send to the contractor for final disposal as
infectious medical waste.
D - 4.11 Working surfaces and equipment are regularly cleaned and disinfected. D O SI 0 1 2 NA
D - 4.12 Laboratory HCWs perform hand hygiene and wear appropriate PPE when indicated. O SI 0 1 2 NA

Element # D - 5 Dental Services Activities Score comment

D - 5.1 There is a written IPC policy and procedure for the dental setting. D 0 1 2 NA
No reprocessing of instruments is carried inside the dental clinic (all the contaminated items are sent to the
D - 5.2 O SI 0 1 2 NA
central sterilization services department (CSSD)).
D - 5.3 All reusable dental instruments (critical and semicritical dental items) are sent to CSSD after each patient. O SI 0 1 2 NA
Contaminated dental instruments including dental handpieces are transferred to the central sterilization services
D - 5.4 O SI 0 1 2 NA
department in a closed, sealed, and puncture resistant containers.
If transportation to CSSD is not expected within two hours, instruments inside transferring containers are sprayed
D - 5.5 O SI 0 1 2 NA
with transportation gel/spray before sending them.
Single-use devices (e.g., disposable examination set, anesthesia carpule/cartridge, etc. …) are discarded
D - 5.6 O SI 0 1 2 NA
immediately after each patient.
If needles with self-sheathing mechanism and recapping devices are not available, dental care HCW use one-
D - 5.7 O SI 0 1 2 NA
handed recapping (scoop technique) for recapping needles.
 Clinical contact surfaces (contaminated and frequently touched surfaces in the patient-care area): light
D - 5.8 handles, bracket trays, switches on dental units, computer equipment are either barrier protected or cleaned D O SI 0 1 2 NA
and disinfected after each patient.
Housekeeping surfaces (e.g., floors, walls, and sinks) cleaned with water and detergent or approved MOH
D - 5.9 D O SI 0 1 2 NA
disinfectant/detergent on a routine basis or when they are visibly dusty or soiled.
The products and protocols recommended by dental unit manufacturer to maintain water quality are followed. (if
D - 5.10 the manufacture instructions are not available, water lines are disinfected daily /weekly with an approved MOH D SI 0 1 2 NA
solution and as per the manufacturer’s instructions
In order to ensure that the water used in routine patient treatment meet standards for drinking water (that is, less
D - 5.11 than 500 CFU/mL of bacteria), water sampling is taken from all water outlets at all the clinics with a minimum D SI 0 1 2 NA
frequency of semiannually and sent to the microbiology lab.
During surgical procedures, only sterile solutions are used as a coolant / irrigant using an appropriate delivery
D - 5.12 O SI 0 2 NA
device.
D - 5.13 Dental care HCWs apply standard precautions while performing dental x-rays. O SI 0 1 2 NA
D - 5.14 Dental lab HCWs adhere to standard precautions while performing dental lab procedures. O SI 0 1 2 NA
Before handling dental prostheses and prosthodontics materials in the dental lab (e.g., impressions, bite
D - 5.15 O SI 0 1 2 NA
registrations, and occlusal rims), they are cleaned and disinfected according to manufacturer’s instructions.

Domain - E Supportive Services Departments & Related Measures

Element # E - 1 Medical Departmental Stores Activities Score comment

E - 1.1 There is a written policy and procedure for the medical departmental stores. D 0 1 2
Medical storage areas are of adequate capacity, regularly cleaned, secured and away from contamination, air
E - 1.2 O 0 1 2
vents and direct sunlight.
Medical storage areas have controlled ventilation with adjusted temperature and humidity (temperature ranges
E - 1.3 D O 0 1 2
from 22 °C to 24 °C & relative humidity up to 70%)
E - 1.4 Storage shelves dimensions are at least, 40 cm from the ceiling, 20 cm from the floor, and 5 cm from the wall. O 0 1 2
E - 1.5 Storage shelves are made of easily cleanable material, e.g., fenestrated stainless steel, aluminium or hard plastic. O 0 1 2
Sterile and clean items are completely separated from personal items, foods and drinks. No expired items,
E - 1.6 O SI 0 1 2
broken packs or packs with stains are present.
E - 1.7 No Items are kept in their original shipping boxes, especially in the clinical areas. O SI 0 1 2

Element # E - 2 Dietary Services Department Activities Score comment

E - 2.1 There is a written policy and procedure addressing dietary services and kitchen staff hygiene. D 0 1 2
E - 2.2 Adequate numbers of hand washing facilities and/or hand rub antiseptic devices are available. O SI 0 1 2 NA
Kitchen staff practice hand hygiene properly and use suitable PPE while handling food, gloves should be
E - 2.3 O SI 0 1 2 NA
changed while moving between Critical Control Points.
Kitchen staff with respiratory infections, gastroenteritis, diarrhea or hand infections or wounds are restricted from
E - 2.4 D MR SI 0 1 2 NA
handling food.
Medical evaluation is performed routinely upon hiring, every 6 months and after returning from long vacation.
E - 2.5 MR SI 0 1 2 NA
Results are reviewed by the employee’s health clinic and the IPC team.
All kitchen staff receive vaccines against hepatitis-A, typhoid and meningococcal meningitis and influenza
E - 2.6 MR 0 1 2 NA
vaccine.

Kitchen is designed as physically separated areas with specified equipment & supplies (e.g., mixers, juicers,
E - 2.7 boards, plates, knives … etc.) for different types of food. Boards, plates and knives used to cut meat, poultry, fish O SI 0 1 2 NA
or vegetables are identifiably separated (color- coded) and immediately washed after use.

Temperature requirements and protection from contamination are considered during receiving, storage,
E - 2.8 preparation, display and transportation of food. Freezers & fridges temperatures are continuously monitored and D O SI 0 1 2 NA
documented on log sheets and relevant actions are taken.
Water used for cooking is supplied by commercially approved companies or hospital water that is tested at least
E - 2.9 D SI 0 1 2 NA
monthly to ensure that its quality meets regulatory national standards for potable water.
Food containers are properly labelled with expiry dates that should be checked every time before use, and all
E - 2.10 O SI 0 1 2 NA
food products should be arranged in respect to first in first out (FIFO) principle.
 E - 2.11 Fruits and vegetables are washed and disinfected. O SI 0 1 2 NA
Food containers and cooking utensils are washed immediately after being emptied, and thoroughly dried before
E - 2.12 O SI 0 1 2 NA
storing or used.
E - 2.13 There is an Insect and rodent control plan that is strictly implemented. D O SI 0 1 2 NA
E - 2.14 The kitchen environment is clean (i.e., frequently cleaned, dry and dust free). D O SI 0 1 2 NA
E - 2.15 Storage shelves dimensions are at least, 40 cm from the ceiling, 20 cm from the floor, and 5 cm from the wall. O 0 1 2 NA
E - 2.16 Food carts in use are dedicated for hot & cold meals. D O SI 0 1 2 NA

Element # E - 3 Laundry Department Activities Score comment

There is a written policy and procedure for linen management, (e.g., collection, transportation, sorting, washing,
E - 3.1 D 0 1 2
storing, and dispensing).
E - 3.2 Work flow is unidirectional from a soiled area to clean area with complete physical separation between them. O SI 0 2 NA
E - 3.3 Hand hygiene facilities and supplies are available & easily accessible. O 0 1 2 NA
Dirty linen are separated from clean linen during collection & transport and linen carts used for clean and dirty
E - 3.4 O 0 2
linen are clearly identified.
All workers who handle the soiled textiles follow standard precautions (i.e., handled as little as possible,
E - 3.5 O SI 0 1 2
practicing hand hygiene using appropriate PPE, leak-proof laundry bags and containers for collection).
During high temperature washing cycle, water temperature is at a minimum of 71°C for 25 minutes (heat
E - 3.6 D O SI 0 1 2 NA
disinfection), and must be recorded.
During low temperature washing cycle (22°C - 50°C), sodium hypochlorite is added as a disinfectant during
E - 3.7 D O SI 0 1 2 NA
bleach wash cycle with residual bleach 50 - 150 ppm and is monitored.
E - 3.8 Routine inspection for blood or/and body fluid stains conducted after washing. O SI 0 1 2 NA

Element # E - 4 Mortuary Department Activities Score comment

There is a written policy and procedure that address safe handling of dead bodies, including postmortem
E - 4.1 D 0 1 2
handling of patients under isolation precautions and bodies with open wounds.
E - 4.2 Hand hygiene facilities and supplies are available & easily accessible. O 0 1 2 NA
There is a schedule of housekeeping activities (cleaning and disinfection) for all environmental surfaces including
E - 4.3 D O SI 0 1 2 NA
the inside of refrigerator and deep freezing equipment.
Transport cadaver bags that fulfill MOH approved specifications are available in 2 sizes & to be used for dead
E - 4.4 O 0 1 2 NA
bodies.
E - 4.5 All mortuary HCWs are well trained on hand hygiene, and proper use of PPE. D O SI 0 1 2 NA
Transportation card that denotes the type (s) of isolation precautions is attached to the dead body of patient
E - 4.6 D SI 0 1 2 NA
under any type of isolation.
Mortuary HCWs are fully oriented about handling deceased patients with infectious diseases or died while under
E - 4.7 O SI 0 1 2 NA
isolation precautions according to the relevant approved hospital policy.

Element # E - 5 Construction & Renovation Measures in Healthcare Facilities Activities Score comment

There is a written policy and procedure for IPC considerations during demolition, renovation, and construction
E - 5.1 D 0 1 2
projects.
IPC team is involved prior to, during, and post any construction, demolition, and renovation project (planning,
E - 5.2 D SI 0 1 2
ICRA, IPC permit, continuous follow - up, and authority to stop the project).
Microbiological cultures are conducted after construction for positive pressure isolation rooms and operating
E - 5.3 D SI 0 1 2 NA
theater or when required (e.g, outbreak) based on the IPC recommendations.
IPC measures are followed during the construction, demolition, and renovation projects by using infection control
E - 5.4 D O SI 0 1 2
risk assessment (ICRA).

Element # E - 6 Housekeeping & Hospital Environment Activities Score comment

There is a written policy and procedure for environmental cleaning & disinfection including safe management of
E - 6.1 D 0 1 2
blood/body fluids spills.
E - 6.2 There is a written policy and procedures for pest control (regular schedule & pesticides list). D SI 0 1 2
Each unit has an environmental cleaning/ disinfection schedule that records responsible worker, used agents,
E - 6.3 D O SI 0 1 2
methods of cleaning, and the environmental surfaces intended to be cleaned.
 Cleaning agents and disinfectants are consistent with hospital's policy and used in the correct method according
E - 6.4 O SI 0 1 2
to manufacturer's recommendations including dilution and contact time.
E - 6.5 There are separate clean and dirty utility rooms in each patient care area. O SI 0 1 2
Housekeepers are trained on hand hygiene, use of PPE, methods of cleaning, and proper and safe mixing of
E - 6.6 D O SI 0 1 2
chemicals. Only experienced housekeeping staff are allowed in critical care units.
E - 6.7 Hospital environment, lockers, and cabinets are regularly cleaned, dry and dust free. O 0 1 2
E - 6.8 Bedside curtains are clean, free of stains and changed regularly & when visibly contaminated. D O SI 0 1 2
E - 6.9 Terminal cleaning process is done by using ultraviolet machine or fog machine when indicated. D O SI 0 1 2
Terminal cleaning process after discontinuation of isolation is supervised by the in-charge nurse, and in case of
E - 6.10 D O SI 0 1 2
an outbreak by IPC practitioner.
Biological spill kits are available in all areas that have risk of blood and body fluid splashes and HCWs are
E - 6.11 O SI 0 1 2
capable of using them properly.
Routine environmental microbiological cultures (for air, water, or environmental surfaces) are not recommended
E - 6.12 D SI 0 1 2
routinely. Only environmental sampling is conducted when indicated and approved by the IPC team.
E - 6.13 Endocavitary ultrasound probes are cleaned and high level disinfected then covered with clean cover till use. D O SI 0 2 NA
There is a specific area for routine scheduled cleaning and disinfection of incubators or when required and by
E - 6.14 D O 0 1 2 NA
using approved MOH disinfectant and based on manufacturer's recommendation.
Hydrotherapy equipment (for example, hubbard tanks, tubs, whirlpools, whirlpool spas, or birthing tanks) used in
E - 6.15 SI 0 1 2 NA
Burn and Physiotherapy Units are drained, cleaned and disinfect after each patient’s use.
E - 6.16 Flowers and plants are permitted in the rooms of immunocompetent patients only. D O 0 1 2 NA
Medical equipment are cleaned/disinfected properly as per hospital's policies and manufacturer
E - 6.17 D O SI 0 1 2
recommendations (frequency, recommended products, dilutions, contact time, methods,… etc.).

Element # E - 7 Disinfectants & Antiseptics Supplies Activities Score comment

E - 7.1 Infection control team is involved in the evaluation and purchase of antiseptics and disinfectant supplies. D SI 0 1 2
Antiseptics, disinfectants, and detergent/disinfectant are used in accordance with current scientific national
E - 7.2 D O SI 0 1 2
guidelines and recommended practices.

Element # E - 8 Infectious Medical Waste Activities Score comment

There is a written policy and procedure for infectious waste management that covers (sorting, collection,
E - 8.1 D 0 1 2
transport, storage, PPE) according to the updated national guidelines.
All non sharp generated medical waste is disposed in black bags as general waste except that heavily soiled
E - 8.2 with liquid blood or other body fluid (dribbling) should be considered infectious medical waste and discarded in O SI 0 1 2
yellow bag or based on the national medical waste updated guideline & regulations.
Disposal of waste from isolation rooms is done properly based on patients’ diagnosis as general waste or medical
E - 8.3 O 0 1 2
waste according to updated national medical waste regulations
In general wards, all clinical procedures are performed using procedural trolley equipped with biohazard waste
E - 8.4 O SI 0 1 2
bag and sharp container.
E - 8.5 Sharp containers are wall mounted or placed on a stand and available inside the patient zone. O 0 1 2
E - 8.6 No bent, broken, or recapped needles are observed inside the sharp containers. O SI 0 1 2
E - 8.7 No infectious medical waste or sharps are observed outside specified containers. O 0 1 2
Medical waste bags are collected after being securely closed when filled to 3/4 of its maximum capacity and
E - 8.8 O SI 0 1 2
labelled with the date and place of production.
Sharp boxes are collected after being securely closed when filled to 3/4 of its maximum capacity and labelled
E - 8.9 O SI 0 1 2
with the date and place of production.
Collection & transportation of medical waste are done by medical waste workers wearing proper PPE at fixed
E - 8.10 D O SI 0 1 2
time and on demand.
Infectious medical waste is transported in closed and impervious specified carts with biohazard sign. Carts are
E - 8.11 O SI 0 1 2
cleaned after each use or at least daily.
The medical waste store is consistent with the approved national specifications (adequate in space, away from
E - 8.12 D O SI 0 1 2
traffic, secured, well ventilated with controlled temperature).
E - 8.13 Infectious medical waste is transported outside the hospital every 24 hours for final disposal. D O SI 0 1 2
Medical waste workers are vaccinated against blood borne pathogens and trained on hand hygiene, use of PPE,
E - 8.14 D MR SI 0 1 2
appropriate steps required post exposure to sharps or blood or bodily fluid, and safe handling of waste.