Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
ASC ENVIRONMENTAL ROUNDS SURVEY TOOL Date (s) of observation: __________________________________________________________ Observer: ________________________________ Any answer that is in a RED box requires an action plan Compliant: YES STANDARDS Compliant: NO NA DESCRIPTION/COMMENTS I. Infection Control Policies and Procedures 1. Staff has access to ASC Infection Control policies 2. Staff can articulate the procedure for reportable diseases 3. Staff can articulate the procedure for reporting infections related to procedures performed at their facility or at any other facility 4. Staff can articulate symptoms of illness that should keep them from coming to work, as reflected in the ASCs “Personnel Illness Restriction” Policy 5. Staff can articulate what should be done if two or more employees or patients in their unit or department have developed influenza-like illness or gastrointestinal illness 6. Staff can articulate the procedure to follow after blood, body fluid exposure YES YES NO NO YES NO YES NO YES NO YES NO II. Handwashing Facilities 1. Artificial fingernails are not allowed on healthcare direct patient care providers 2. Soap dispensers accessible, operating correctly and dispensing appropriate antimicrobial agent? 3. Paper towels available and adequately dispensed 4. Antimicrobial waterless hand agents available, especially where hand washing sinks are unavailable 5. Staff can explain and/or staff is observed complying with the hand hygiene policy 6. Staff dons and removes gloves at appropriate opportunities YES NO YES NO YES NO YES NO YES NO YES NO 1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL 1 Compliant: YES YES STANDARDS 7. Lotions are used appropriately in clinical areas Compliant: NO NO NA DESCRIPTION/COMMENTS III. Storage of Supplies 1. Clean and sterile supplies and equipment are stored appropriately 2. Items stored at least 12”-18” from a sink or there is a protective barrier (splash guard) to prevent splash contamination; storage under sinks of patient care supplies is prohibited and storage of other items is discouraged. 3. Supplies stored on shelves and off floors 4. Supplies are within expiration date 5. There is clear separation of clean and dirty activities 6. Items labeled as "single use only" (SUDs) are not reused YES NO YES NO YES YES YES NO NO NO YES NO Exception for approved third-party reprocessor VI. Medication Management 1. Medications must be separated by type and dosage YES NO 2. Requirements for storage and use of OR state-supplied vaccines are YES NO met 3. Open irrigation solutions are labeled with date and time YES NO 4. IV fluids spiked at time of use YES NO 5. Medications are within date YES NO 6. Medications are stored appropriately YES NO 7. Medications requiring special care after initial use are YES NO stored/labeled appropriately 8. Medications are prepared safely YES NO V. Safe Injection Practices ONE NEEDLE: ONE SYRINGE: ONE PATIENT: ONE TIME 1. Single-dose vials are never used as multi-dose vials YES NO 2. Fluid infusion and administration sets (IV bags, tubing, and YES NO connectors) are used for one patient only and discarded after use 3. Patient's skin is prepped with an approved prep before IV placement YES NO 4. Single dose medications or infusates are used for only one patient and not collected or combined (bags of IV fluids are ALWAYS single YES NO use) 5. Medication vials used for more than one (1) patient are always YES NO entered with a new needle and new syringe 6. The rubber septum on a medication/infusate vial is disinfected with YES NO 1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL 2 STANDARDS Compliant: YES Compliant: NO YES NO YES NO YES YES NO NO YES NO YES NO YES YES NO NO alcohol or antiseptic prior to piercing 7. Needles and syringes are used for only one patient 8. Medications or infusates that are packaged as prefilled syringes are used for only one patient 9. Hand hygiene is performed before preparing medications 10. Medications or infusates are drawn up at start of each procedure 11. Needles and syringes are discarded intact in an appropriate sharps container after use 12. Flushes are not drawn from a bulk container NA DESCRIPTION/COMMENTS VI. Linens 1. Linens are stored appropriately and kept covered until use 2. Clean and soiled linens are kept separated VII. Surface Disinfection 1. Toys are disinfected per policy 2. Non-critical items are cleaned per policy 3. Point of care devices are cleaned according to policy YES YES YES NO NO NO VIII. Instrument Decontamination/Cleaning Items are thoroughly pre-cleaned and decontaminated with enzymatic detergent according to manufacturer instructions, evidence-based guidelines and ASC policy prior to high level disinfection or sterilization. YES NO IX. High Level Disinfection (HLD) 1. Medical instrument and devices are visually inspected for residual soil and re-cleaned as needed before high-level disinfection 2. HLD equipment is maintained according to manufacturer instructions or evidence-based guidelines 3. Chemicals used for HLD are prepared according to manufacturer instructions or evidence-based guidelines 4. Chemicals used for HLD are tested for appropriate concentration (MEC) according to manufacturer instructions or evidence-based guidelines, and are replaced before they expire 5. Chemicals used for HLD are documented to have been prepared and replaced according to manufacturer's instructions or evidence-based guidelines YES NO YES NO YES NO YES NO YES NO 1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL 3 STANDARDS Compliant: YES Compliant: NO YES NO YES YES YES NO NO NO YES NO YES NO YES YES NO NO YES NO 6. Equipment is high-level disinfected according to manufacturer's instructions or evidence-based guidelines and according to the ASC Infection Control Cleaning, Disinfection and Sterilization policy 7. Items that undergo HLD are dried before re-use 8. HLD logs are in order 9. Test strips are properly dated NA DESCRIPTION/COMMENTS X. Sterilization 1. Autoclaves: chemical and biological indicators are used appropriately 2. Biological indicators run at least weekly or with each load with an implantable 3. Sterilization logs accurate and up to date 4. Process is in place for embargo of instruments until BI is read 5. Sterile packages are inspected for integrity and compromised packages are reprocessed XI. General Decontamination/HLD/Sterilization 1. Proper PPE is worn when processing dirty equipment 2. Competencies are maintained for cleaning, disinfection and sterilization processes 3. HLD, decontamination, and /or sterilization is performed in appropriate environment 4. Areas used for cleaning or disinfection flow from dirty to clean 5. There is a procedure in place for identification and recall of inadequately sterilized or high level disinfected instruments 6. After sterilization or high level disinfection, devices and instruments are stored in a designated clean area so sterility/cleanliness is not compromised YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO XII. Isolation 1. Staff are able to articulate isolation policies (such as for TB, chickenpox, “Respiratory Etiquette”) 2. Staff are able to state how patients should be managed that have a known resistant organism (e.g. MRSA, VRE, C. difficile, draining wound or rash) 3. Personal protective equipment (PPE) is available 1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL 4 Compliant: YES STANDARDS Compliant: NO NA DESCRIPTION/COMMENTS XIII. General Issues 1. Areas free of dust, dirt, soil, trash, odors, clutter and hazards (fixtures, walls, ceilings, floors) 2. Areas and furnishings are in good repair 3. Objects and environmental surfaces that are touched frequently in patient care areas (stretchers, IV pumps and poles, medication prep areas, procedure tables, toilet surfaces, waiting area surfaces) are disinfected with an EPA-registered, ASC designated and approved disinfectant. 4. Environmental cleaning contracts follow ASC Infection Control Policy 5. For ASCs with an IV treatment room or procedure room-IV pumps, chairs and procedure tables are cleaned between each pt. 6. Areas identified as nursing responsibility are cleaned appropriately 7. Staff food and drinks are placed in appropriate areas 8. Regulated waste containers are in appropriate locations and covered YES NO YES NO YES NO YES NO YES NO YES YES YES NO NO NO XIV. Refrigerators, Freezers, Ice Machines, Ice Chests 1. Refrigerators and freezers are large enough to properly store medications. 2. Refrigerators and freezers well maintained and clean 3. Medication refrigerator temperatures maintained between 36-46 degrees F (between 2-8 degrees Celsius) Temperatures checked minimum of daily. Twice a day if storing state-supplied vaccines. 4. Medication freezer maintained below 5 degrees F (below -15 degrees Celsius) 5. An appropriate means to check medication in event of a power outage is in place 6. Food and medications are stored separately 7. Food and/or medications are within date 8. Specimens and culture media are stored separately from food and medications 9. Specimens and lab reagents are stored appropriately 10. Ice chests and ice machines are maintained according to ASC policy YES NO YES NO YES NO YES NO YES NO YES YES NO NO YES NO YES YES NO NO 1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL 5 REFERENCE Developed by the Oregon Patient Safety Commission; adapted from tools by Duke University, BJC Healthcare, Kaiser Permanente, University Hospital North Carolina, and Oregon Health and Sciences University. DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations. 1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL 6