Infection Prevention and Control Assessment Tool For Outpatient Settings

Infection Prevention and Control Assessment Tool for Outpatient Settings
This tool is intended to assist in the assessment of infection control programs and practices in outpatient settings. In
order to complete the assessment, direct observation of infection control practices will be necessary. To facilitate the
assessment, health departments are encouraged to share this tool with facilities in advance of their visit.
Please note, Not Applicable should only be checked if the element or domain is not applicable to the types of services
provided by the facility (e.g., the facility never performs point-of-care testing, controlled substances are never kept at
the facility). If a particular service is provided by the facility but is unable to be observed during the visit (e.g., no
injections were prepared or administered during the visit) that section should still be completed by interviewing relevant
personnel about their practices.
Overview V2-3
Section 1: Facility Demographics
Section 2: Infection Control Program and Infrastructure
Section 3: Direct Observation of Facility Practices
Section 4: Infection Control Guidelines and Other Resources
Infection Control Domains for Gap Assessment
I. Infection Control Program and Infrastructure
II. Infection Control Training and Competency
III. Healthcare Personnel Safety
IV. Surveillance and Disease Reporting
V.a/b. Hand Hygiene
VI.a/b. Personal Protective Equipment (PPE)
VII.a/b. Injection Safety (if applicable)
VIII.a/b. Respiratory Hygiene/Cough Etiquette
IX.a/b. Point-of-Care Testing (if applicable)
X.a/b. Environmental Cleaning
XI.a/b. Device Reprocessing
XII. Sterilization of Reusable Devices (if applicable)
XIII. High-level Disinfection of Reusable Devices (if applicable)
VERSION 2.3 SEPTEMBER 2016 1
DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention
Section 1: Facility Demographics
Facility Name (for health
department use only)
NHSN Facility Organization ID
(for health department use
only)
State-assigned Unique ID
Date of Assessment
Type of Assessment On-site Other (specify):
Rationale for Assessment Outbreak
(Select all that apply) Input from accrediting organization or state survey agency
Other (specify):
Is the facility licensed by the
Yes No
state?
Is the facility certified by the
Yes No
Centers for Medicare &
Medicaid Services (CMS)?
Is the facility accredited? Yes No
If yes, list the accreditation organization:

Accreditation Association for Ambulatory Health Care (AAAHC)
American Association for Accreditation of Ambulatory Surgery
Facilities (AAAASF)
American Osteopathic Association (AOA)
The Joint Commission (TJC)
Other (specify):
Is the facility affiliated with a Yes (specify for health department use only):
hospital? No
Which procedures are Chemotherapy Endoscopy Ear/Nose/Throat
performed by the facility? Imaging (MRI/CT) Immunizations OB/Gyn
Ophthalmologic Orthopedic Pain remediation
Select all that apply.
Plastic/reconstructive Podiatry Other (specify):
What is the primary Chemotherapy Endoscopy Ear/Nose/Throat
procedure-type performed by Imaging (MRI/CT) Immunizations OB/Gyn
the facility?
Ophthalmologic Orthopedic Pain remediation
Select only one. Plastic/reconstructive Podiatry Other (specify):
How many physicians work at
the facility?
What is the average number
of patients seen per week?

Section 2: Infection Control Program and Infrastructure
I. Infection Control Program and Infrastructure
Elements to be assessed Assessment Notes/Areas for Improvement

A. Written infection prevention policies and procedures are Yes No
available, current, and based on evidence-based guidelines
(e.g., CDC/HICPAC), regulations, or standards.
Note: Policies and procedures should be appropriate for the services

provided by the facility and should extend beyond OSHA
bloodborne pathogens training
B. Infection prevention policies and procedures are re-assessed at Yes No
least annually or according to state or federal requirements,
and updated if appropriate.
C. At least one individual trained in infection prevention is Yes No
employed by or regularly available (e.g., by contract) to
manage the facilitys infection control program.
Note: Examples of training may include: Successful completion of

initial and/or recertification exams developed by the
Certification Board for Infection Control & Epidemiology;
participation in infection control courses organized by the state
or recognized professional societies (e.g., APIC, SHEA).
D. Facility has system for early detection and management of Yes No
potentially infectious persons at initial points of patient
encounter.
Note: System may include taking a travel and occupational history,

as appropriate, and elements described under respiratory
hygiene/cough etiquette.
II. Infection Control Training and Competency

A. Facility has a competency-based training program that provides Yes No
job-specific training on infection prevention policies and
procedures to healthcare personnel.
Note: This includes those employed by outside agencies and

available by contract or on a volunteer basis to the facility.
See sections below for more specific assessment of training

related to: hand hygiene, personal protective equipment (PPE),
injection safety, environmental cleaning, point-of-care testing,
and device reprocessing

III. Healthcare Personnel Safety

A. Facility has an exposure control plan that is tailored to the Yes No
specific requirements of the facility (e.g., addresses potential
hazards posed by specific services provided by the facility).
Note: A model template, which includes a guide for creating an
exposure control plan that meets the requirements of the OSHA
Bloodborne Pathogens Standard is available
at: https://www.osha.gov/Publications/osha3186.pdf
B. HCP for whom contact with blood or other potentially infectious Yes No
material is anticipated are trained on the OSHA bloodborne
pathogens standard upon hire and at least annually.
C. Following an exposure event, post-exposure evaluation and Yes No
follow-up, including prophylaxis as appropriate, are available at
no cost to employee and are supervised by a licensed healthcare
professional.
Note: An exposure incident refers to a specific eye, mouth, other
mucous membrane, non-intact skin, or parenteral contact with
blood or other potentially infectious materials that results from
the performance of an individuals duties.
D. Facility tracks HCP exposure events and evaluates event data Yes No
and develops/implements corrective action plans to reduce
incidence of such events.
E. Facility follows recommendations of the Advisory Committee on Yes No
Immunization Practices (ACIP) for immunization of HCP,
including offering Hepatitis B and influenza vaccination.
Note: Immunization of Health-Care Personnel: Recommendations of
the ACIP available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm
F. All HCP receive baseline tuberculosis (TB) screening prior to Yes No
placement; HCP receive repeat testing, if appropriate, based on
the facility-level risk assessment.
Note: For more information, facilities should refer to the Guidelines
for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Settings, 2005 available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/
rr5417a1.htm ?s_cid=rr5417a1_e
G. If respirators are used, the facility has a respiratory protection Yes No
program that details required worksite-specific procedures and
elements for required respirator use, including provision of Not Applicable
medical clearance, training, and fit testing as appropriate.
H. Facility has well-defined policies concerning contact of Yes No
personnel with patients when personnel have potentially
transmissible conditions.
These policies include:
i. Work-exclusion policies that encourage reporting of
illnesses and do not penalize with loss of wages, Yes No
benefits, or job status.
ii. Education of personnel on prompt reporting of illness
to supervisor. Yes No

IV. Surveillance and Disease Reporting

A. An updated list of diseases reportable to the public health Yes No
authority is readily available to all personnel.
B. Facility can demonstrate knowledge of and compliance with Yes No
mandatory reporting requirements for notifiable diseases,
healthcare associated infections (as appropriate), and for
potential outbreaks.
C. Patients who have undergone procedures at the facility are Yes No
educated regarding signs and symptoms of infection that may be
associated with the procedure and instructed to notify the
facility if such signs or symptoms occur.
V.a. Hand Hygiene

A. All HCP are educated regarding appropriate indications for hand
hygiene:
i. Upon hire, prior to provision of care
Yes No
ii. Annually Yes No
B. HCP are required to demonstrate competency with hand Yes No
hygiene following each training
C. Facility routinely audits (monitors and documents) adherence to Yes No
hand hygiene.
D. Facility provides feedback from audits to personnel regarding Yes No
their hand hygiene performance.
E. Hand hygiene policies promote preferential use of alcohol-based Yes No
hand rub (ABHR) over soap and water in most clinical situations.
Note: Soap and water should be used when hands are visibly
soiled (e.g., blood, body fluids) and is also preferred after caring
for a patient with known or suspected C. difficile or norovirus
during an outbreak.

VI.a. Personal Protective Equipment (PPE)

A. HCP who use PPE receive training on proper selection and use of
PPE: Yes No
i. Upon hire, prior to provision of care
ii. Annually Yes No
iii. When new equipment or protocols are introduced Yes No
B. HCP are required to demonstrate competency with selection Yes No
and use of PPE following each training.
proper PPE selection and use.
their performance with selection and use of PPE.
VII.a. Injection Safety (This element does not include assessment of pharmacy/compounding practices)
If injectable medications are never prepared or administered at the facility check Not Applicable here and skip to Section
VIII.a. Respiratory Hygiene/Cough Etiquette.
A. HCP who prepare and/or administer parenteral medications
receive training on safe injection practices:
i. Upon hire, prior to being allowed to prepare and/or Yes No
administer parenteral medications
ii. Annually Yes No
B. HCP are required to demonstrate competency with safe Yes No
injection practices following each training.

safe injection practices.

their adherence to safe injection practices.
E. Facility has policies and procedures to track HCP access to Yes No

controlled substances to prevent narcotics theft/diversion.
Not Applicable
Note: Policies and procedures should address: how data are (Facility does not
reviewed, how facility would respond to unusual access patterns, prepare or
how facility would assess risk to patients if tampering (alteration administer controlled
or substitution) is suspected or identified, and who the facility substances)
would contact if diversion is suspected or identified.

VIII.a. Respiratory Hygiene/Cough Etiquette

A. Facility has policies and procedures to contain respiratory Yes No
secretions in persons who have signs and symptoms of a
respiratory infection, beginning at point of entry to the facility
and continuing through the duration of the visit.
Policies include:
i. Offering facemasks to coughing patients and other Yes No
symptomatic persons upon entry to the facility, at a
minimum, during periods of increased respiratory
infection activity in the community.
ii. Providing space in waiting rooms and encouraging
persons with symptoms of respiratory infections to sit as Yes No
far away from others as possible.
Note: If available, facilities may wish to place patients with

symptoms of a respiratory infection in a separate area while
waiting for care.
B. Facility educates HCP on the importance of infection prevention Yes No
measures to contain respiratory secretions to prevent the
spread of respiratory pathogens.
IX.a. Point-of-Care Testing (e.g., blood glucose meters, INR monitor)
If point-of-care testing is never performed at the facility check Not Applicable here and skip to Section X.a. Environmental
Cleaning
A. HCP who perform point-of-care testing receive training on
recommended practices:
i. Upon hire, prior to being allowed to perform point-of- Yes No
care testing
ii. Annually Yes No

B. HCP are required to demonstrate competency with Yes No
recommended practices for point-of-care testing following each
training.
recommended practices during point-of-care testing.
their adherence to recommended practices.

X.a. Environmental Cleaning

A. Facility has written policies and procedures for routine cleaning Yes No
and disinfection of environmental surfaces, including
identification of responsible personnel.
B. Personnel who clean and disinfect patient care areas (e.g.,
environmental services, technicians, nurses) receive training on
cleaning procedures
i. Upon hire, prior to being allowed to perform
environmental cleaning
Yes No
ii. Annually Yes No

Note: If environmental cleaning is performed by contract personnel,
facility should verify this is provided by contracting company.
C. HCP are required to demonstrate competency with Yes No
environmental cleaning procedures following each training.
D. Facility routinely audits (monitors and documents) adherence to Yes No
cleaning and disinfection procedures, including using products in
accordance with manufacturers instructions (e.g., dilution,
storage, shelf-life, contact time).
E. Facility provides feedback from audits to personnel regarding Yes No
their adherence to cleaning and disinfection procedures.
F. Facility has a policy/procedure for decontamination of spills of Yes No
blood or other body fluids.

X.a. Environmental Cleaning, continued
Operating Room
For the purposes of this checklist, an operating room is defined as a patient care area that met the Facilities Guidelines Institutes (FGI)
or American Institute of Architects (AIA) criteria for an operating room when it was constructed or renovated. This is the same
definition that is used in the National Healthcare Safety Networks Procedure-associated Module for the SSI Event
(http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf)
If the facility does not have an operating room check Not Applicable here and skip to section XI.a. Device Reprocessing
G. Operating rooms are terminally cleaned after last procedure of Yes No
the day.
H. Facility routinely audits (monitors and documents) adherence to

recommended infection control practices for surgical infection
prevention including:
i. Adherence to preoperative surgical scrub and hand Yes No

hygiene
ii. Appropriate use of surgical attire and drapes Yes No

iii. Adherence to aseptic technique and sterile field Yes No
iv. Proper ventilation requirements in surgical suites Yes No
v. Minimization of traffic in the operating room Yes No
vi. Adherence to cleaning and disinfection of environmental Yes No
surfaces
I. Facility provides feedback from audits to personnel regarding Yes No

their adherence to surgical infection prevention practices.

XI.a. Device Reprocessing
The following basic information allows for a general assessment of policies and procedures related to reprocessing of reusable medical
devices. Outpatient facilities that are performing on-site sterilization or high-level disinfection of reusable medical devices should
refer to the more detailed checklists in separate sections of this document devoted to those issues.
Categories of Medical Devices:
Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior
to use (see Sterilization Section).
Semi-critical items (e.g., endoscopes for upper endoscopy and colonoscopy, vaginal probes) are objects that contact mucous
membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse (see High-level Disinfection
Section).
Non-critical items (e.g., blood pressure cuffs) are objects that may come in contact with intact skin but not mucous
membranes and should undergo cleaning and low- or intermediate-level disinfection depending on the nature and degree of
contamination.
Single-use devices (SUDs) are labeled by the manufacturer for a single use and do not have reprocessing instructions. They may not
be reprocessed for reuse except by entities which have complied with FDA regulatory requirements and have received FDA clearance
to reprocess specific SUDs.
Note: Cleaning must always be performed prior to sterilization and disinfection

A. Facility has policies and procedures to ensure that reusable Yes No
medical devices are cleaned and reprocessed appropriately prior
to use on another patient.
Note: This includes clear delineation of responsibility among HCP for

cleaning and disinfection of equipment including, non-critical
equipment, mobile devices, and other electronics (e.g., point-of-
care devices) that might not be reprocessed in a centralized
reprocessing area.
B. The individual(s) in charge of infection prevention at the facility Yes No
is consulted whenever new devices or products will be
purchased or introduced to ensure implementation of
appropriate reprocessing policies and procedures.
C. HCP responsible for reprocessing reusable medical devices
receive hands-on training on proper selection and use of PPE
and recommended steps for reprocessing assigned devices:
i. Upon hire, prior to being allowed to reprocess devices Yes No

ii. Annually Yes No
iii. When new devices are introduced or Yes No
policies/procedures change.
Note: If device reprocessing is performed by contract personnel,

facility should verify this is provided by contracting company.
D. HCP are required to demonstrate competency with reprocessing Yes No
procedures (i.e., correct technique is observed by trainer)
following each training.

XI.a. Device Reprocessing, continued

E. Facility routinely audits (monitors and documents) adherence to Yes No
reprocessing procedures.
F. Facility provides feedback from audits to personnel regarding Yes No

their adherence to reprocessing procedures.
G. Facility has protocols to ensure that HCP can readily identify Yes No
devices that have been properly reprocessed and are ready for
patient use (e.g., tagging system, storage in designated area).
H. Facility has policies and procedures outlining facility response Yes No

(i.e., risk assessment and recall of device) in the event of a
reprocessing error or failure.
I. Routine maintenance for reprocessing equipment (e.g., Yes No

automated endoscope reprocessors, steam autoclave) is Not Applicable
performed by qualified personnel in accordance with (Reprocessing
manufacturer instructions; confirm maintenance records are equipment is not
available. used at the facility)

Section 3: Direct Observation of Facility Practices
Certain infection control lapses (e.g., reuse of syringes on more than one patient or to access a medication container
that is used for subsequent patients; reuse of lancets) have resulted in bloodborne pathogen transmission and should be
halted immediately. Identification of such lapses warrants appropriate notification and testing of potentially affected
patients.
If an element is unable to be observed during an assessment (e.g., no patients received point-of-care testing during the
visit), assess the element by interviewing appropriate personnel about facility practices. Notation should also be made
in the notes section that the element was not able to be directly observed.
V.b. Hand hygiene

A. Supplies necessary for adherence to hand hygiene (e.g., soap, Yes No
water, paper towels, alcohol-based hand rub) are readily
accessible to HCP in patient care areas.
Hand hygiene is performed correctly:
B. Before contact with the patient Yes No

C. Before performing an aseptic task (e.g., insertion of IV or Yes No
preparing an injection, administering eye drops)
Not Applicable
D. After contact with the patient Yes No
E. After contact with objects in the immediate vicinity of the Yes No
patient
F. After contact with blood, body fluids or contaminated surfaces Yes No
G. After removing gloves Yes No
H. When moving from a contaminated-body site to a clean-body Yes No
site during patient care
Not Applicable
VI.b. Personal Protective Equipment (PPE)

A. Sufficient and appropriate PPE is available and readily accessible Yes No
to HCP.
PPE is used correctly:
B. PPE, other than respirator, is removed and discarded prior to Yes No

leaving the patients room or care area. If a respirator is used, it
is removed and discarded (or reprocessed if reusable) after
leaving the patient room or care area and closing the door.
C. Hand hygiene is performed immediately after removal of PPE. Yes No

VI.b. Personal Protective Equipment (PPE), continued

D. Gloves
i. HCP wear gloves for potential contact with blood, body Yes No
fluids, mucous membranes, non-intact skin, or
contaminated equipment.
ii. HCP do not wear the same pair of gloves for the care of Yes No
more than one patient.
iii. HCP do not wash gloves for the purpose of reuse. Yes No
E. Gowns
i. HCP wear gowns to protect skin and clothing during Yes No
procedures or activities where contact with blood or Not Applicable
body fluids is anticipated.
ii. HCP do not wear the same gown for the care of more Yes No
than one patient.
Not Applicable
F. Facial protection
i. HCP wear mouth, nose, and eye protection during Yes No
procedures that are likely to generate splashes or Not Applicable
sprays of blood or other body fluids.
VII.b. Injection safety (This element does not include assessment of pharmacy/compounding practices)
If injectable medications are never prepared or administered at the facility check Not Applicable here and skip to Section
VIII.b. Respiratory Hygiene/Cough Etiquette
A. Injections are prepared using aseptic technique in a clean area
free from contamination or contact with blood, body fluids or Yes No
contaminated equipment.
B. Needles and syringes are used for only one patient (this includes
manufactured prefilled syringes and cartridge devices such as Yes No
insulin pens).
C. The rubber septum on a medication vial is disinfected with
alcohol prior to piercing. Yes No
D. Medication containers are entered with a new needle and a new
syringe, even when obtaining additional doses for the same Yes No
patient.
E. Single dose (single-use) medication vials, ampules, and bags or
bottles of intravenous solution are used for only one patient. Yes No
F. Medication administration tubing and connectors are used for Yes No
only one patient.
Not Applicable
(Facility does not use
tubing or connectors)
G. Multi-dose vials are dated by HCP when they are first opened Yes No
and discarded within 28 days unless the manufacturer specifies
a different (shorter or longer) date for that opened vial. Not Applicable
(Facility does not use
Note: This is different from the expiration date printed on the vial. multi-dose vials or
discards them after
single patient use)

VII.b. Injection safety (This element does not include assessment of pharmacy/compounding practices), continued

H. Multi-dose vials to be used for more than one patient are kept in Yes No
a centralized medication area and do not enter the immediate
patient treatment area (e.g., operating room, patient Not Applicable
room/cubicle). (Facility does not use
multi-dose vials or
Note: If multi-dose vials enter the immediate patient treatment area discards them after
they should be dedicated for single-patient use and discarded single patient use)
immediately after use.
I. All sharps are disposed of in a puncture-resistant sharps Yes No
container.
J. Filled sharps containers are disposed of in accordance with state Yes No

regulated medical waste rules.
K. All controlled substances (e.g., Schedule II, III, IV, V drugs) are Yes No
kept locked within a secure area.
Not Applicable
(Controlled
substances are not
kept at the facility)
L. HCP wear a facemask (e.g., surgical mask) when placing a Yes No
catheter or injecting material into the epidural or subdural space
(e.g., during myelogram, epidural or spinal anesthesia). Not Applicable
(Facility does not
perform spinal
injection procedures)
VIII.b. Respiratory Hygiene/Cough Etiquette

A. Facility:
i. Posts signs at entrances with instructions to patients Yes No

with symptoms of respiratory infection to:
a. Inform HCP of symptoms of a respiratory
infection when they first register for care, and
b. Practice Respiratory Hygiene/Cough Etiquette
(cover their mouths/noses when coughing or
sneezing, use and dispose of tissues, and
perform hand hygiene after hands have been
covered with respiratory secretions).
ii. Provides tissues and no-touch receptacles for
disposal of tissues. Yes No
iii. Provides resources for performing hand hygiene in
or near waiting areas. Yes No

IX.b. Point-of-Care Testing (e.g., blood glucose meters, INR monitor)
If point-of-care testing is never performed at the facility check Not Applicable here and skip to Section X.b. Environmental
Cleaning

A. New single-use, auto-disabling lancing device is used for each Yes No
patient.
Not Applicable
Note: Lancet holder devices are not suitable for multi-patient use.
B. If used for more than one patient, the point-of-care blood Yes No
testing meter is cleaned and disinfected after every use
according to manufacturers instructions. Not Applicable
Note: If the manufacturer does not provide instructions for cleaning

and disinfection, then the testing meter should not be used for
>1 patient.
X.b. Environmental Cleaning

A. Supplies necessary for appropriate cleaning and disinfection Yes No
procedures (e.g., EPA-registered disinfectants) are available.
Note: If environmental services are performed by contract

personnel, facility should verify that appropriate EPA-registered
products are provided by contracting company
B. High-touch surfaces in rooms where surgical or other invasive Yes No
procedures (e.g., endoscopy, spinal injections) are performed
are cleaned and then disinfected with an EPA-registered Not Applicable
disinfectant after each procedure.
C. Cleaners and disinfectants are used in accordance with Yes No
manufacturers instructions (e.g., dilution, storage, shelf-life,
contact time).
D. HCP engaged in environmental cleaning wear appropriate PPE to Yes No
prevent exposure to infectious agents or chemicals (PPE can
include gloves, gowns, masks, and eye protection).
Note: The exact type of correct PPE depends on infectious or

chemical agent and anticipated type of exposure.

XI.b. Device Reprocessing

A. Policies, procedures, and manufacturer reprocessing instructions Yes No
for reusable medical devices used in the facility are available in
the reprocessing area(s).
B. Reusable medical devices are cleaned, reprocessed (disinfection Yes No
or sterilization) and maintained according to the manufacturer
instructions.
Note: If the manufacturer does not provide such instructions, the

device may not be suitable for multi-patient use.
C. Single-use devices are discarded after use and not used for more Yes No
than one patient unless they have been appropriately
reprocessed as described in the note below.
Note: If the facility elects to reuse single-use devices, these devices

must be reprocessed prior to reuse by a third-party reprocessor
that it is registered with the FDA as a third-party reprocessor and
cleared by the FDA to reprocess the specific device in question.
The facility should have documentation from the third party
reprocessor confirming this is the case.
D. Reprocessing area:
i. Adequate space is allotted for reprocessing activities. Yes No
ii. A workflow pattern is followed such that devices clearly Yes No
flow from high contamination areas to clean/sterile
areas (i.e., there is clear separation between soiled and
clean workspaces).
E. Adequate time for reprocessing is allowed to ensure adherence Yes No
to all steps recommended by the device manufacturer, including
drying and proper storage.
Note: Facilities should have an adequate supply of instruments for

the volume of procedures performed and should schedule
procedures to allow sufficient time for all reprocessing steps.
F. HCP engaged in device reprocessing wear appropriate PPE to Yes No
prevent exposure to infectious agents or chemicals (PPE can
include gloves, gowns, masks, and eye protection).
Note: The exact type of correct PPE depends on infectious or

chemical agent and anticipated type of exposure.
G. Medical devices are stored in a manner to protect from damage Yes No
and contamination.

XII. Sterilization of Reusable Devices
If all device sterilization is performed off-site, complete elements M-O and check Not Applicable for the remaining elements in this
section.
If sterilization of reusable devices is never performed (either at the facility or off-site) check Not Applicable here and skip to
Section XIII.
A. Devices are thoroughly cleaned according to manufacturer
instructions and visually inspected for residual soil prior to Yes No
sterilization. Not Applicable
Note: Cleaning may be manual (i.e., using friction) and/or
mechanical (e.g., with ultrasonic cleaners, washer-disinfector,
washer-sterilizers).
Ensure appropriately sized cleaning brushes are selected for

cleaning device channels and lumens.
B. Cleaning is performed as soon as practical after use (e.g., at the
point of use) to prevent soiled materials from becoming dried Yes No
onto devices. Not Applicable
C. Enzymatic cleaner or detergent is used for cleaning and
discarded according to manufacturers instructions (typically Yes No
after each use) Not Applicable
D. Cleaning brushes are disposable or, if reusable, cleaned and
high-level disinfected or sterilized (per manufacturers Yes No
instructions) after use. Not Applicable
E. After cleaning, instruments are appropriately
wrapped/packaged for sterilization (e.g., package system Yes No
selected is compatible with the sterilization process being Not Applicable
performed, items are placed correctly into the basket, shelf or
cart of the sterilizer so as not to impede the penetration of the
sterilant, hinged instruments are open, instruments are
disassembled if indicated by the manufacturer).
F. A chemical indicator (process indicator) is placed correctly in the Yes No
instrument packs in every load.
Not Applicable
G. A biological indicator, intended specifically for the type and cycle
parameters of the sterilizer, is used at least weekly for each Yes No
sterilizer and with every load containing implantable items. Not Applicable
H. For dynamic air removal-type sterilizers (e.g., prevacuum steam
sterilizer), an air removal test (Bowie-Dick test) is performed in Yes No
an empty dynamic-air removal sterilizer each day the sterilizer is Not Applicable
used to verify efficacy of air removal.
I. Sterile packs are labeled with a load number that indicates the
sterilizer used, the cycle or load number, the date of Yes No
sterilization, and, if applicable, the expiration date. Not Applicable
J. Sterilization logs are current and include results from each load. Yes No
Not Applicable
K. Immediate-use steam sterilization, if performed, is only done in Yes No
circumstances in which routine sterilization procedures cannot
be performed. Not Applicable

XII. Sterilization of Reusable Devices, continued

L. Instruments that undergo immediate-use steam sterilization are Yes No
used immediately and not stored.
Not Applicable
M. After sterilization, medical devices are stored so that sterility is Yes No
not compromised.
Not Applicable
N. Sterile packages are inspected for integrity and compromised Yes No
packages are reprocessed prior to use.
Not Applicable
O. The facility has a process to perform initial cleaning of devices (to Yes No
prevent soiled materials from becoming dried onto devices) prior
to transport to the off-site reprocessing facility. Not Applicable

XIII. High-Level Disinfection of Reusable Devices
If all high-level disinfection is performed off-site, complete elements L-N below and check Not Applicable for the remaining elements
in this section.
If high-level disinfection of reusable devices is never performed (either at the facility or off-site) check here: Not Applicable
A. Flexible endoscopes are inspected for damage and leak tested as Yes No
part of each reprocessing cycle. Any device that fails the leak
test is removed from clinical use and repaired. Not Applicable
B. Devices are thoroughly cleaned according to manufacturer Yes No
instructions and visually inspected for residual soil prior to high-
level disinfection. Not Applicable
Note: Cleaning may be manual (i.e., using friction) and/or

mechanical (e.g., with ultrasonic cleaners, washer-disinfector,
washer-sterilizers).
Ensure appropriately sized cleaning brushes are selected for

cleaning device channels and lumens.
C. Cleaning is performed as soon as practical after use (e.g., at the Yes No
point of use) to prevent soiled materials from becoming dried
onto instruments. Not Applicable
D. Enzymatic cleaner or detergent is used and discarded according Yes No
to manufacturer instructions (typically after each use).
Not Applicable
E. Cleaning brushes are disposable or, if reusable, cleaned and Yes No
high-level disinfected or sterilized (per manufacturer
instructions) after use. Not Applicable
F. For chemicals used in high-level disinfection, manufacturer
instructions are followed for:
i. Preparation
Yes No
Not Applicable
ii. Testing for appropriate concentration Yes No
Not Applicable
iii. Replacement (i.e., upon expiration or loss of efficacy) Yes No
Not Applicable

XIII. High-Level Disinfection of Reusable Devices, continued

G. If automated reprocessing equipment (e.g., automated Yes No
endoscope reprocessor) is used, proper connectors are used to
assure that channels and lumens are appropriately disinfected. Not Applicable
H. Devices are disinfected for the appropriate length of time as Yes No
specified by manufacturer instructions.
Not Applicable
I. Devices are disinfected at the appropriate temperature as Yes No
specified by manufacturer instructions.
Not Applicable
J. After high-level disinfection, devices are appropriately rinsed as Yes No
specified by the manufacturer.
Not Applicable
K. Devices are dried thoroughly prior to reuse. Yes No
Note: For lumened instruments (e.g., endoscopes) this includes Not Applicable
flushing all channels with alcohol and forcing air through
channels.
L. After high-level disinfection, devices are stored in a manner to Yes No
protect from damage or contamination.
Not Applicable
Note: Endoscopes should be hung in a vertical position.
M. Facility maintains a log for each endoscopy procedure which Yes No
includes: patients name and medical record number (if
available), procedure, date, endoscopist, system used to Not Applicable
reprocess the endoscope (if more than one system could be
used in the reprocessing area), and serial number or other
identifier of the endoscope used.
N. The facility has a process to perform initial cleaning of devices Yes No
(to prevent soiled materials from becoming dried onto devices)
prior to transport to the off-site reprocessing facility. Not Applicable

Section 4: Infection Control Guidelines and Other Resources
General Infection Prevention
CDC/HICPAC Guidelines and recommendations: http://www.cdc.gov/HAI/prevent/prevent_pubs.html
Healthcare Personnel Safety
Guideline for Infection Control in Healthcare Personnel: http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf
Immunization of HealthCare Personnel: http://www.cdc.gov/vaccines/spec-grps/hcw.htm
Occupational Safety & Health Administration (OSHA) Bloodborne Pathogens and Needlestick Prevention
Standard: http://www.osha.gov/SLTC/bloodbornepathogens/index.html
OSHA Respiratory Protection Standard:

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=12716&p_table=STANDARDS
OSHA Respirator Fit Testing: https://www.osha.gov/video/respiratory_protection/fittesting_transcript.html
Hand Hygiene
Guideline for Hand Hygiene in Healthcare Settings: http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
Hand Hygiene in Healthcare Settings: http://www.cdc.gov/handhygiene/
Examples of tools that can be used to conduct a formal audit of hand hygiene practices:
http://www.jointcommission.org/assets/1/18/hh_monograph.pdf
http://compepi.cs.uiowa.edu/index.php/Research/IScrub
Personal Protective Equipment
2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
Guidance for the Selection and Use of Personal Protective Equipment in Healthcare
Settings: http://www.cdc.gov/HAI/prevent/ppe.html
Injection Safety
CDC Injection Safety Web Materials: http://www.cdc.gov/injectionsafety/
CDC training video and related Safe Injection Practices Campaign materials:
http://www.oneandonlycampaign.org/

Respiratory Hygiene/Cough Etiquette
Recommendations for preventing the spread of influenza:

http://www.cdc.gov/flu/professionals/infectioncontrol/
Environmental Cleaning
Guidelines for Environmental Infection Control in Healthcare Facilities:

http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf
Options for Evaluating Environmental Infection Control:

http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html
Equipment Reprocessing
Guideline for Disinfection and Sterilization in Healthcare Facilities:

http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
FDA regulations on reprocessing of single-use devices:

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm071434
Point-of-Care Testing
Infection Prevention during Blood Glucose Monitoring and Insulin Administration:

http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html
Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration:
http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html
Resources to assist with evaluation and response to breaches in infection control
Patel PR, Srinivasan A, Perz JF. Developing a broader approach to management of infection control breaches
in health care settings. Am J Infect Control. 2008 Dec; 36(10); 685-90
http://www.ajicjournal.org/article/S0196-6553(08)00683-4/abstract
Steps for Evaluating an Infection Control Breach:

http://www.cdc.gov/hai/outbreaks/steps_for_eval_IC_breach.html
Patient Notification Toolkit: http://www.cdc.gov/injectionsafety/pntoolkit/index.html
Antibiotic Stewardship
Get Smart Programs & Observances: http://www.cdc.gov/getsmart/


Infection Prevention and Control Assessment Tool For Outpatient Settings

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Infection Prevention and Control Assessment Tool for Outpatient Settings

Section 1: Facility Demographics

Section 2: Infection Control Program and Infrastructure

Section 3: Direct Observation of Facility Practices

Section 4: Infection Control Guidelines and Other Resources

Infection Control Domains for Gap Assessment

I. Infection Control Program and Infrastructure

II. Infection Control Training and Competency

III. Healthcare Personnel Safety

IV. Surveillance and Disease Reporting

V.a/b. Hand Hygiene

VI.a/b. Personal Protective Equipment (PPE)

VII.a/b. Injection Safety (if applicable)

VIII.a/b. Respiratory Hygiene/Cough Etiquette

IX.a/b. Point-of-Care Testing (if applicable)

X.a/b. Environmental Cleaning

XI.a/b. Device Reprocessing

XII. Sterilization of Reusable Devices (if applicable)

XIII. High-level Disinfection of Reusable Devices (if applicable)

VERSION 2.3 SEPTEMBER 2016 1

DEPARTMENT OF HEALTH & HUMAN SERVICES

If yes, list the accreditation organization:

VERSION 2.3 SEPTEMBER 2016 2

DEPARTMENT OF HEALTH & HUMAN SERVICES

I. Infection Control Program and Infrastructure

Elements to be assessed Assessment Notes/Areas for Improvement

Note: Policies and procedures should be appropriate for the services

Note: Examples of training may include: Successful completion of

Note: System may include taking a travel and occupational history,

II. Infection Control Training and Competency

Elements to be assessed Assessment Notes/Areas for Improvement

Note: This includes those employed by outside agencies and

See sections below for more specific assessment of training

VERSION 2.3 SEPTEMBER 2016 3

DEPARTMENT OF HEALTH & HUMAN SERVICES

Elements to be assessed Assessment Notes/Areas for Improvement

DEPARTMENT OF HEALTH & HUMAN SERVICES

Elements to be assessed Assessment Notes/Areas for Improvement

V.a. Hand Hygiene

Elements to be assessed Assessment Notes/Areas for Improvement

VERSION 2.3 SEPTEMBER 2016 5

DEPARTMENT OF HEALTH & HUMAN SERVICES

Elements to be assessed Assessment Notes/Areas for Improvement

C. Facility routinely audits (monitors and documents) adherence to Yes No

D. Facility provides feedback from audits to personnel regarding Yes No

E. Facility has policies and procedures to track HCP access to Yes No

VERSION 2.3 SEPTEMBER 2016 6

DEPARTMENT OF HEALTH & HUMAN SERVICES

Elements to be assessed Assessment Notes/Areas for Improvement

Note: If available, facilities may wish to place patients with

IX.a. Point-of-Care Testing (e.g., blood glucose meters, INR monitor)

iii. When new equipment or protocols are introduced Yes No

VERSION 2.3 SEPTEMBER 2016 7

DEPARTMENT OF HEALTH & HUMAN SERVICES

Elements to be assessed Assessment Notes/Areas for Improvement

ii. Annually Yes No

VERSION 2.3 SEPTEMBER 2016 8

DEPARTMENT OF HEALTH & HUMAN SERVICES