Infection Prevention an

Overview

The IPC assessment tool is designed for use in hospital settings to:
• Evaluate the system and capacity of IPC for safe healthcare services
• Evaluate the compliance of healthcare workers to IPC standards and practices
• Aid development of work plans for improvement
• Monitor the progress of IPC quality improvement activities over time
The tool has two sections that include:
• Section I (Domains 1-8) - Facility IPC Capacity and System:
• Section II (Domains 1-14) - IPC Practices and Compliances to IPC standards by healthcare workers: This section in

This assessment will be conducted by health facilities quarterly (every three months)

The tool is developed using the World Health Organization (WHO) IPC assessment framework and other regional IPC
IPC requirements and standards. The second section can be used more frequently as per the needs and available res
priority for monitoring compliance to IPC standards and practices.

Instructions for use

1 Conduct a comprehensive assessment of the facility using the agreed list of instructions,in

2 Record additional information under Comments (Col I), for example, the reasons why a pa
3 For each domain (IPC Program, Appropriate Personal Protective Equipment (PPE) Use etc.

Hospital General Information

Name of Hospital and

Jinka General Hospital
type

Location Region, Zone/Sub city, District/Woreda South Ethiopia ,Ari Zone

Name and contact of
Phone No Emaie
CEO
Name of Medical
Phone No Emaie
Director

IPC Team
Phone No Emaie
Leader/coordinator
Date of Assessment
(MM/DD/YY):

Date of Previous
Assessment
(MM/DD/YY):
1. Total Number of Health Professionals ________
1.1.Dedicated IPC experts­­_________
1.2.Total physicians ­_____________
1.3. Environmental Health __________3_________
1.4.Total Nurses all types__________
1.5.Other Health Professionals _______
2. Total Number of Supportive staff _________
2.1.Cleaners/house keeping ______52________
Total number staff
2.2.Laundry staff_______9____________
2.3.Kitchen workers________________
2.4.CSSD staff________________
2.4.Porters and runners________________
2.5.Others __________
3. Total Number of Admin staff________
4. Other staff
5. Total Number of staff _(1+2+3 +4)______568___________
Total bed number
Basic service in-house?
1. Food
2. Cleaning
3. Security
4. Laundry

Name of Assessors
Infection Prevention and Control Program Facility Level Assessment Tool (IPC FLAT)
Updated June 2023
Overview

ervices
rds and practices

ver time

ns 1-8) - Facility IPC Capacity and System: This section addresses high-level IPC systems and capacities
ards by healthcare workers: This section includes routine IPC practices of healthcare workers considering the IPC standards an

ee months)

essment framework and other regional IPC tools. Due to the technical nature of the questions, assessments must be carried ou
equently as per the needs and available resources of the facility and assessment can be done using particular IPC domains (e.g.

cility using the agreed list of instructions,indicators; record whether each indicator meets (Yes), does not meet (No), or the not

(Col I), for example, the reasons why a particular indicator does not meet the target, important observations or questions that
sonal Protective Equipment (PPE) Use etc.), review the score at the bottom. This should calculate automatically according to th

eral Information

Jinka General Hospital

Ethiopia ,Ari Zone

Emaie

Emaie

Emaie
________

_______

______
_____

_568___________

Outsourced Remark
ol (IPC FLAT)

ties
sidering the IPC standards and priorities.

essments must be carried out by IPC experts with relatively good experience and strong familiarity with
particular IPC domains (e.g. Hand Hygiene compliance) or combination of domains depending on the

es not meet (No), or the not applicable (N/A).

bservations or questions that need further investigation.

utomatically according to the number of indicators that have been assessed.
Section –I: Facility IPC Program Capacity a
SN Domain
Criteria Yes No N/A

1.1. IPC programme supported by an IPC case team comprised

Yes
of IPC-trained professionals.

1.2. The IPC programme has an IPC ToT-trained full-time focal

Yes
person, case Team leader, or Director.

1.3.Check that the IPC team has an evidence-based annual

Yes
plan.
1.4.The facility has a functional IPC committee (with defined
Yes
TOR and regular meetings)
IPC
Program 1.5. Leadership shows clear commitment and actively supports
1 the IPC program by allocating a budget specifically for the IPC Yes
program.

1.6.The IPC programme is linked to or integrated with other

vertical or horizontal programmes (e.g., AMR, Quality & Safety, Yes
WASH, immunisation,MCH,TB, Occupational Health, etc.).

1.7.The IPC program has access to microbiological laboratory

Yes
support (either onsite or offsite) for routine day-to-day use.

Domain score 7
Domain percentage score 100%
2.1. Facility has updeated national IPC reference guidelines /
or adopted Yes
2.2 facility has SOP on Standard precautions for the following:

2.2.1. Hand hygiene yes

2.2.2. Instrument reprocessing yes
2.2.3. Injection safety Yes
2.2.4. Waste management yes
2.2.5. Envionmental cleaning Yes
2.2.6. Personal Protective Equipment yes
2.3 Facility has SOP on Transmission-based precautions
IPC
2.3.1 Prevention of vascular catheter-associated bloodstream
guidelines infections no
or
standard 2.3.2 Prevention of catheter-associated urinary tract infections no
operating
procedure 2.3.3 Prevention of Surgical Site infection (SSI) no
s (SOPs) 2.3.4 Prevention of healthcare associated pneumonia (HAP) no
standard
operating
procedure
s (SOPs)
2.3.5 Prevention of healthcare associated diaharrea no
2.3.6 Prevention and containement of multidrug-resistant
(MDR) pathogen no
2.3.7 Outbreak preparedness and response no
2.3.8 Healthcare worker protection and safety no
2.3.9. Other(s) (List additional SOPs) including dead body
handling, laundry, food & water safety no
2.4. All the facility level IPC SOPs/ guidelines are easily
accessed by healthcare workers Yes

Domain score 9 8
Domain percentage score 52%
3
3.1 The Facility has an ongoing development system to
No
train/educate HCWs on IPC

3.2. All Health professionals including students and new staff

No
receive training/orientation on the updated IPC guideline.

3.3. Cleaning staff and non-clinical staff directly involved in

IPC Yes
patient care receive IPC training at least per year
education
3.4. Administrative and managerial staff receive general IPC
and No
training/orientation
training
3.5. IPC training is integrated into clinical practice and in-
service trainings of other specialties (e.g., training on Yes
prevention of Tuberculosis)
3.6. Specific IPC training is in place for inpatients or family
members and incorporated in the weekly hospital HE Yes
program to minimize the potential for HAI.

3.7. Healthcare facility maintains records of IPC trained HCWs Yes

Domain score 4 3
Domain percentage score 57%
4.1. Facility has adopted the national HAI surveillance
Yes
guidance Check that applies to the facility practices
4.2. Facility has assigned a dedicated trained (on basic
epidemiology/surveillance) professional for HAI surveillance No
activities

4.3. Informatics/IT is available to conduct surveillance (e.g.,

No
equipment, mobile technologies or electronic health records)
4.4. Facility has standard surveillance case definitions
according to national or international definitions for a disease Yes
of interest
4.5. Use standardized data collection methods (e.g., active
prospective surveillance) according to national or international Yes
surveillance protocols

Health 4.6. Responsible personnel regularly review data quality (e.g.,

care- assessment of case report forms, review of microbiology Yes
results, denominator determination, etc.)
associated
4 infection 4.7. Surveillance data are used to make tailored facility-based
(HAI) Yes
plans for the implementation or improvement of IPC practices
surveillanc
e 4.8. HAI surveillance is currently ongoing: (if yes, check from
Yes
the options below)

4.8.1. Surgical site infection (SSI) Yes

4.8.2. Catheter-associated urinary tract infections (CAUTI) Yes

4.8.3. Blood stream -associated bloodstream infections (BSI) Yes

4.8.4. Clinically-defined infections (for example, definitions

based only on clinical signs or symptoms in the absence of yes
microbiological testing)

4.8.5 Facility regularly (for example,

quarterly/half-yearly/annually) provides up-to-date
Yes
surveillance information to managers, department heads and
front line HCWs
Domain score 11 2
Domain percentage score 84%
5 5. 1 Facility use multimodal strategies including any or all of
the following elements

5.1.1 System change to ensure the necessary infrastructure

Yes
and continuous availability of supplies are in place

5.1. 2.Education & training Yes

Multimoda 5.1. 3. Monitoring & feedback Yes

l
Strategies 5.1.4. Communication & reminders Yes

5.1.5 Safety climate & culture change (If no, specify

no
components with multimodal strategies)
Strategies

5.2. Multi-disciplinary team (organized from different

unit/department) is used to implement IPC multimodal yes
strategies
5.3. Facility has conducted QI projects on IPC, implemented,
and successful change ideas were identified that were no
implemented
Domain score 5 2
Domain percentage score 71%
6
6.1. Well-defined monitoring plan with clear goals, targets and
yes
activities are available

6.2. Locally adapted facility IPC data collection tools are

Yes
available (if yes, specify in the comments)

6.3.At least the following processes and indicators are to be

monitored:
Monitoring 6.3.1. Hand hygiene (HH) compliance (using the WHO HH Yes
observation tool or equivalent)
/audit of
IPC
practices
and 6.3.2. Transmission-based precautions and isolation to prevent
Yes
the spread of infection
feedback

6.3 Provide feedback auditing reports (e.g., HH compliance

data) on the state of the IPC activities/performance to staff in
Yes
the areas being audited and report performance to IPC
committee and facility managers

6.4. Monitoring data are reported regularly (at least quarterly

Yes
to facility managers
Domain score 6
Domain percentage score ###
7 Workload,
staffing and 7.1. Facility assesses appropriate staffing levels at least
bed occupancy annually according to patient workload using national Yes
standards or WHO tool such as the WHO workload indicators
of staffing (staff to patient ratio)
7.2. System in place to act on the results of staffing needs
Yes
assessments when staffing levels are deemed to be too low
7.3. There is adequate spacing of >1 meter between patient
Yes
beds
7.4. System in place to assess and respond when adequate bed
Yes
capacity is exceeded
Domain score
Domain percentage score
8.1. Functional Hand hygiene stations are available at the
no
entrance and at all points of care
8.2. Designated isolation areas are available for patients with
suspected and confirmed infectious diseases including COVID-
Yes
19, tuberculosis, Ebola Virus Disease, MDRO & others as
applicable

8.3. Reliable safe drinking water are present and accessible for
staff, patients and families at all times and in all Yes
locations/wards

8.4. At least 4 toilets or improved latrines are available for

Yes
outpatient settings or ≥ 1 per 20 users for inpatient settings

8.5. Facility has sufficient energy/power supply available at day

and night for all uses (e.g., pumping and boiling water,
Yes
sterilization and decontamination, incineration or alternative
treatment technologies, electronic medical devices)

8.6. Facility has functioning and sufficient environmental

ventilation (natural or mechanical) available in patient care Yes
areas
8.7. Facility has a:

8.7.1.Fenced and functional burial pit waste dump available

no
for disposal of non-infectious (non-hazardous/general waste)

8.7.2. Municipal pick-up available for disposal of non-

no
infectious (non-hazardous/general waste)
8.7.3. Facility has an incinerator or alternative treatment
technology for the treatment of infectious and sharp waste Yes
that is functional and of a sufficient capacity
8.7.4. Facility has a waste water treatment system (for
example, septic tank followed by drainage pit) present on or Yes
off site and functioning reliably

Built 8.7. 5. Facility has dedicated decontamination area and/or

environme sterile supply department (either present on or off site and
operated by a licensed decontamination management service) Yes
nt,
for the decontamination and sterilization of medical devices
materials and other items/equipment
8 and
equipment
for IPC 8.8. Disposable items available when necessary (e.g., injection
Yes
safety devices, examination gloves)
8 and
equipment
for IPC

8.9. A designated person is responsible for managing and

requesting critical IPC supplies (provide consumption rate(per
Yes
2 weeks) for critical supplies and performs an inventory of IPC
supplies at least monthly)
8.10. PPE stored in a safe location off the floor Yes
8.11. Facility has adequate quantities (enough for at least one
month) of the following supplies in stock at the time of the Yes
assessment

8.12. PPE

8.12.1. Non-sterile gloves yes

8.12.2. Gowns yes
8.12.3. Aprons Yes
8.12.4. Eye protection (face shields or goggles) Yes
8.12.5. Medical masks Yes
8.12.6. N95, FFP2, or equivalent respirators Yes
8.13. Hand hygiene supplies no
8.13.1. Alcohol-based hand rub no
8.13.2. Soap Yes
8.13.3. Disposable or reusable towels no
8.13.4. Veronica buckets with functional taps, lids and basin
for collecting used handwashing water
no
* If functional sinks are not available in registration or waiting
areas
8.14. Cleaning supplies yes
8.14.1. Neutral detergent, liquid or powdered soap Yes
8.14.2. Cleaning cloths Yes
8.14.2. Mops currently available Yes
8.14.3. Portable buckets (for mopping and surface cleaning
Yes
solutions) currently available
8.14.4. Hospital-grade disinfectants (e.g., sodium hypochlorite)
Yes

Domain Score 26 6
Domain score percentage 81%
68/8
Section-I subtotal Total 9
76/
Section-I subtotal percentage score
%
gram Capacity and System
Comment
Assessment Instructions/Guide

Check the lists of IPC team Members and look that

they are certified for IPC training and letter of
assignment and JD.
Look for the letter of assignments as IPC Focal
person/Case Team Leader/Coordinator and for
the ToT certificate.

Ask for the IPC updated annual plan.

Ask to see a copy of the TOR and meeting meeting

minutes and regularity

Check budget allocation specifically for the IPC

program and senior management team minutes.

Check joint planning/ performance report

comprises those programs and the IPC team is a
committee member for those programs.

Ask availability of microbiology lab services, See

MoU, and communicate evidence with the
regional Laboratory or referal facility with Private
Microbiology laboratories.
Total score for Yes, No and N/A

See/look for the guideline availability

Ask and check the guide/ SOP

Ask and check the guide/ SOP
Ask and check the guide/ SOP
Ask and check the guide/ SOP
Ask and check the guide/ SOP
Ask and check the guide/ SOP

Ask and check the guide/ SOP

Ask and check the guide/ SOP

Ask and check the guide/ SOP

Ask and check the guide/ SOP
Ask and check the guide/ SOP
Ask and check the guide/ SOP

Ask and check the guide/ SOP

Ask and check the guide/ SOP
Ask and check the guide/ SOP

Check SOPs/guidelines are within the reach of

HCWs or easily accessible in different units

Total score for Yes, No and N/A

Ask for dates of the most recent training (Both on

site and off site IPC training) including induction
training and check training unit's annual plan

Check for list of IPC trained professionals from

training record

Check for list of IPC trained cleaning and other

non-clinical staff from training records
Check for list of IPC trained administrative and
managerial staff from training records

Check training modules that incorporated into IPC

training .

Ask a training guide/programme for patients and

family members and check the schedule of health
education on IPC.

Confirm availability of training record

Total score for ‘Y’, ‘N’ and ‘N/A’

Check the guidance

Ask for letter of assignment and training

certificate

Check availability of the required equipment and

their functionality
Check in surveillance guidline on use or posted on
wall

Check surveillance SOPs or protocols

Check surveillance reports

Ask cases and records when the surveillance data

used for interventions

Check this domain only for those Hospitals

implementing HAI surveillance

Check for the existing of SSI surveillance ongoing

Check for the existing of CAUTI surveillance

ongoing

Check for the existing of BSI surveillance ongoing

Look for clinical definitions on HAI surveillance

guideline or posted on wall

Check surveillance reports and feedback notes

Total score for ‘Y’, ‘N’ and ‘N/A’

Check that applies to the facility practices

Check for IPC supply stock monitoring records

Randomly ask 5 professionals whether they are

trained on specific IPC measures to solve IPC
gaps
Check filled monitoring IPC practice report and
feedback provided
Check for availability of reminder poster at point
of use
Check for risk management protocol/guidance,
risk assessments
Ask interventions reports or meeting notes

Check for conducted QI project topic on IPC,

implementation and learning session report

Total score for ‘Y’, ‘N’ and ‘N/A’

Ask monitoring plan that includes goals and

activity list including tools to collect data in a
systematic way
Check for IPC data collection tools (e.g. IPC
system/capacity assessment, facility IPC practices,
and others)

Check on monitoring/feedback reports (by the

time of audit completion)

Check on monitoring/feedback reports (e.g.,

multidrug-resistant organisms (MDRO),
Enviromental cleaning, Disinfection & sterlization
of medical equipements and wast mangement)

Ask/check meeting notes or feedback reports (by

the time of audit completion)

Ask/Check notes or reports

Total score for ‘Y’, ‘N’ and ‘N/A’

Ask assessment report or meeting note on

assessment of staffing

Ask SOP or protocol for staffing needs assessment

and staffing plan

Observe randomly for spacing of beds

Check facility bed occupancy rate report, a plan

document for higher bed demands
Check availablity and functionality of hand
hygiene stations

Check isolation areas

Check drinking water is available all the time, ask

if water quality test is regularly performed (at
least every quarter)

Observe toilets or improved latrines

Ask if sufficient power is available 24/7. If not,

please specify how frequently there is a power
outage, check power availability

Check for availability of functional ventilation of

any type in patient care areas

Check for functionality and fenced waste disposal

area

Check for contract agreement with municipality or

waste transporting facility

Check/ observe its availability

Check/ observe its availability

Check/ observe its availability

Check availability during the assessment

Check for assignments of designated person for
managing IPC supplies and observe for recent
inventory activities and requisition
records/documents
Observe how stocks are stored

For the following PPEs, check whether there is

sufficient stock and use for the specific
procedure/work area
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock

Check for the availability of sufficient stock

Check for the availability of sufficient stock

Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock
Check for the availability of sufficient stock

Check for the availability of sufficient stock

Section II - IPC Practices and Compliances by
SN Domain Criteria Yes

1.1. SOPs for PPE use are easily available and accessible to staff. Yes

1.2. HCWs are trained on proper PPE use, including donning and
Yes
doffing

Appropriate 1.3. Availability of sufficient PPE supplies at different service Yes

delivery points
Personal
Protective
1 Equipment
(PPE) Use
1.4. Appropriate PPE is used during patient care delivery Yes

1.5.PPE is donned and doffed in appropriate steps and sequence. Yes

1.6. PPE is stored in a safe and accessible location (keeping it in a

clean, designated area away from chemicals, temperature Yes
extremes, etc.).
Domain score 6
Domain percentage score 100

2.1. All hand hygiene stations have alcohol-based

hand rubs or soap and water.

2.2. Hand hygiene posters or job aids are available at Yes

all HH stations.
Hand
Hygiene (HH)
Practice 2.3. The facility conducts HH audits quarterly using
2 Yes
Compliance the WHO HH observation tool.

2.4. Hand hygiene audit report findings are regularly

analyzed, and feedback is shared with staff and Yes
respective stakeholders.
2.5. Hand hygiene celebration days are conducted
quarterly.
Domain score 3
Domain percentage score 60/%
3.1.The facility has a designated isolation room for the care of
patients with the same active infection who are isolated or
Yes
cohorted in a designated ward or room (who need transmission
based precautions).

3.2. Hand hygiene facilities are available in isolation areas.

3.3. The PPE required for transmission-based precautions is

Yes
available in inpatient departments.

3.4. Staff don appropriate PPE (gloves and other PPE as indicated)
Yes
as per the risk level.

3.5. Transport and movement of patients outside the isolation

area are limited to medically necessary purposes (e.g., operation Yes
procedures)

Transmission-
based 3.6.Frequently touched surfaces (e.g., bed rails, overbed tables,
Precautions bedside commodes, lavatory surfaces in patient bathrooms,
3 doorknobs) and equipment in the immediate vicinity of the Yes
Adherence patient are cleaned and disinfected twice daily and when visibly
soiled.

3.7.Toilets are cleaned twice daily, and when visibly soiled. Yes

3.8. There is no equipment or practice in the patient room that

Yes
could exacerbate any environmental contamination.
3.9.Contaminated, reusable, non-critical patient-care equipment
is placed in a plastic bag for transport to a soiled utility area for Yes
reprocessing.

3.10. The facility has policies and a system for triaging coughing
patients to prevent airborne or droplet transmission at OPDs.

Yes
3.11. The facility ensures the wearing of facemasks by coughing
clients and other symptomatic persons upon entry to the facility
Yes
(including providing facemasks for coughing patients with no
mask).

3.12. The facility has posted signs on respiratory hygiene

(coverring mouth /nose with tissues while coughing or sneezing,
Yes
perform hand hygiene after touching respiratory secretions) for
individuals with symptoms of respiratory infection

Domain score 11
Domain percentage score 91%

4.1.The facility has a designated Central Sterilization Services

Yes
Department (CSSD).

4.2. Reprocessing of contaminated medical instruments follows

the updated national standard (point-of-use cleaning). ---> Yes
(thorough cleaning) ---> (high-level disinfection or sterilization)

Instrument 4.3. Critical medical devices (e.g., forceps, scissors) are sterilized
Reprocessing as indicated per standard Yes
4

4.4. The Facility has clear separation of clean and contaminated

Yes
medical equipment.

4.5. The facility has a dedicated area for cleaning and sterilizing
Yes
medical devices.
4.6. Reprocessed medical equipment (sterilized or HLD) is safely
stored in a designated and safe area (free from moisture, dust, Yes
insects, rodents, etc.).

4.7. Sterilization machine preventive and corrective maintenance

Yes
and calibration are conducted regularly.
Domain score 7
Domain percentage score 100%

5.1. Environmental cleaning follow-up monitoring systems are

Yes
available and completed at the time of this assessment.

5.2. Cleaning and disinfection of wards/rooms occurs twice daily

Yes
and when visibly soiled.

5.3.Frequently touched surfaces in consultation/examination

Yes
areas are cleaned and disinfected at least twice daily.

5.4. Walls, windows, ceilings, and doors should be spot cleaned

Yes
with a towel, detergent, and water (specify rooms observed).

5.5. Toilets and latrines should be cleaned with a dedicated mop,

Yes
cloth, or brush and a disinfectant solution.

Environmenta 5.6. Instructions on making solutions for disinfection are posted Yes
where the solution is prepared.
l Cleaning
5
5.7. Required cleaning supplies (a bucket, mop, cleaning cloths,
Yes
and disinfectant solution, e.g., bleach) are all available.

5.8. Rooms are terminally cleaned and disinfected after patient

discharge, including floors, sinks, toilets, ceilings, walls, and any Yes
material in the room (sinks and toilets after use).
5.9. The drainage system within and around hospital building(s),
e.g., gutters, pipes, etc., should be free from any obstructions, Yes
e.g., vegetation.

5.10. Cleaning campaigns should be conducted every month. Yes

5.11. The dedicated utility room for the storage of cleaning

Yes
equipment
5.12. Stairs, steps, and lifts, internal and external, including all
Yes
component parts, are visibly clean and well-maintained.
Domain score 12
Domain percentage score 100%
6.1. Proper HH, using alcohol-based hand rub (ABHR) or soap and
water, is performed prior to preparing, during the administration Yes
of medications, and after the procedure.
6.2.Injections are prepared using aseptic technique in a clean area
free from contamination or contact with blood, body fluids, or Yes
contaminated equipment.
6.3. Needles and syringes are used for only one patient (this
includes manufactured prefilled syringes and cartridge devices Yes
such as insulin pens).
6.4.HCWs dispose of needles appropriately (i.e., needles are
discarded after single use and are not recapped, bent, or broken Yes
prior to disposal in a sharps container).
6.5. The rubber septum on a medication vial is disinfected with
Yes
alcohol prior to piercing
Adherence 6.6. Medication vials are entered with a new needle and a new
with Injection syringe, even when obtaining additional doses for the same Yes
Safety patient
6 Practices
6.7. Single-dose or single-use medication vials, ampoules, and
bags or bottles of intravenous solution are used for only one Yes
patient
6.8. Medication administration tubing and connectors are used
Yes
for only one patient.

6.9. Multi-dose vials are dated when they are first opened and
discarded within 28 days, unless the manufacturer specifies a Yes
different (shorter or longer) date for that opened vial.

6.10.Multi-dose vials are dedicated to individual patients

Yes
whenever possible.
6.11. Multi-dose vials used for more than one patient are kept in
a centralized medication area and do not enter the immediate
Yes
patient treatment area (e.g., operating room, patient
room/cubicle).
Domain score 11
Domain percentage score 100%
7.1. The facility has a policy to access hospital premises and
Yes
manage traffic flow.

7.1.1. Visiting hours for clients, including time for rounds, cleaning
, patient meals, and the number of attendants per patient, are Yes
determined.

7.1.2. Triage and appointment systems should be established in

Yes
the hospital.

Facility
Design and 7.1.3. Patient waiting areas are well ventilated and not crowded. Yes
Patient Flow
7 Management
Facility
Design and
Patient Flow
7 Management
7.1.4. The facility has assigned a dedicated person to handle
Yes
traffic flow at all service delivery points.

7.1.5. The facility practices regarding zoning restrictions at

Yes
different high-risk departments

7.2. The hospital compound is safe for patients, visitors, and staff Yes

7.3. The hospital regulates the flow of visitors, patients, and staff
using signs (such as authorized personnel only, reminders, and Yes
physical barriers, e.g., closed doors) in designated areas.

Domain score 8
Domain percentage score 100

8.1.The facility has a functional laundry service.

8.2. The facility has physically separated storage areas for

cleaned/washed linens and for soiled linens with sufficient Yes
ventilation and light.

8.3. Appropriate PPE is utilized by laundry personnel at all times Yes

8.4. The laundry has uninterupted water availability for 24 hours a

day, 7 days a week.

Processing 8.5. The laundry has a well-maintained sewage system. Yes

reusable
textiles and 8.6.The laundry has a continuous electric supply (24 hours per
Yes
8 laundry day, 7 days per week) with a backup source.
services
8.7. The laundry has adequate natural or artificial ventilation. Yes
8.8. Handwashing sinks are available in the laundry
8.9. consistent and sufficient supply of detergents and chemicals
Yes
for washing/disinfecting linen.
8.10.Separate physical storage areas and different trolleys and
waterproof containers are used for transporting clean, washed, Yes
and dirty/contaminated linens.
8.11. Appropriate waste disposal containers are available in the
Yes
laundry for high- and low-risk waste.

8.12. Laundry machines in the facility are regularly maintained

8.13. The laundry keeps records of receiving and distributing yes
linens.
Domain score 9
Domain percentage score 69%

9.1. Food handlers are educated and trained in food safety and
good food handling procedures

9.2. The kitchen has a hot water source for washing kitchen
utensils, with at least three compartments for washing.
9.3.After each use, kitchen utensils are cleaned and/or disinfected
(if necessary)
9.4. The facility provide necessary and suitable PPE for kitchen
staff

9.5. Prepared food transported to the patient room using a clean

and covered cart
9.6.The facility has separate storage areas for perishable and non-
perishable raw foods.
9.7. Food handlers undergo medical examinations for foodborne
transmittable infections at least every three months.
9.8. The kitchen has dedicated and adequate sinks with running
water and soap at all times for hand washing

9.9. The Kitchen is well maintained and has a posted cleaning

Food and schedule.
Water Safety
9
9.10. The Kitchen checks and documents the temperatures of the
refrigerator and cold rooms regularly.

9.11. The facility has washable, leak-proof garbage containers

with tight-fitting lids, and garbage is collected daily.
9.12. The facility has a regular Physicochemical and
bacteriological water quality monitoring system.
9.13.The kitchen has a policy to limit the traffic of unauthorised
individuals into the food preparation area.
9.14. The kitchen cleanliness and personal hygiene of the food
handlers are monitored regularly by a knowledgeable and
responsible professional.

9.15.A responsible person or team is assigned to ensure the

quality of food entering the kitchen. (meat, vegetables, and milk).

9.16. There is a system for the management of food handlers

illnesses.
Domain score
Domain percentage score

10.1. Waste collection containers for non-infectious (general),

Yes
infectious, and sharps waste are available at each clinical area.

10.2. Waste is correctly segregated into general, infectious waste,

Yes
and sharps at the point of generation
10.3. Waste segregation posters (including sharp containers) are
Yes
displayed above all waste bins
10.4. Each waste bin and sharp container is filled less than its ¾th
Yes
volume.
Waste 10.5. No sharps or needles were observed on the floor at the time
Management of this assessment. Yes
and Sharps
11 Disposal 10.6. Bins and bags are transported upright in carts or trolleys to a
central waste storage site, burial pit, waste dump, or municipal Yes
pick-up area.
10.7. The facility has a designated waste storage area. yes
10.8.The facility has a designated and fenced incinerator for both
solid waste and sharps.
10.9. The facility has a designated waste disposal area. Yes
10.10.The facility has an appropriate liquid waste management
Yes
system.
10.11. Janitors and transporters are available 24 hours a day, 7
Yes
days a week.
Domain score 10
Domain percentage score 90%
11.1. The facility has policies and a reporting structure for
Yes
occupational exposure and management.
11.2. All HCWs and waste handlers are vaccinated against
Hepatitis B.
Healthcare 11.3. HCWs are aware of management procedures following
Yes
Workers exposure to blood or body fluids.
11 Safety 11.4. The facility has a plan in place for monitoring HCWs exposed
to patients with respiratory illnesses, including TB, COVID-19, and Yes
other infectious diseases.
11.5. Healthcare workers receive post-exposure counselling and
Yes
PEP
Domain score 4
Domain percentage score 80%
12.1.The facility has SOPs for handling dead bodies, including
those with highly contagious diseases.

IPC in
Mortuary
12
12.2.The facility has a functional dead body freezer (refrigerator).
12.3. The staff working in the mortuary are trained for dead body
IPC in management and care.
Mortuary
12 12.4. Appropriate PPE is used by care providers, relatives, or
Yes
other individuals involved in the handling of dead bodies.

12.5. A proper dead body plastic bag (cadaver pouch) should be

used when necessary.
Domain score 1
Domain percentage score 20%
13.1.The facility has a functional Outbreak response committee or
Yes
task force.
13.2. Outbreak preparedness and response plans are in place. Yes
13.3. The facility has a SOP for managing contact tracing. yes
13.4. Determined maximum capacity in the event of a surge
(availability of physical space, human resources, intensive care Yes
capabilities, ventilator support, etc.) for an outbreak.
13.5.Developed a plan to stop non-essential services (e.g.,
Yes
elective or non-urgent procedures) in the event of a surge.
Outbreak
13.6. Identified additional space that can be used to expand the
Preparedness number of patients that can be treated (assuming adequate Yes
13 and Response human resources, supplies, etc. are available).

13.7. Developed a plan to move non-critical patients elsewhere

(e.g., for home-based care) to increase capacity in the event of a Yes
surge.
13.8. The facility has clear communication and reporting
Yes
mechanisms in the event of a surge.
13.9. The facility has a procedure for estimating consumption
rates for critical supplies, including PPE, in the context of a surge Yes
scenario.
Domain score 9
Domain percentage score 100%
14.1. The facility has a fence that surrounds all the hospital
grounds and will not allow the entrance of pets and other animals
without a functional gate, or at least two gates.
Yes

Environmenta 14.2. The hospital's external ground (at least 5–20 m from the Yes
l cleanliness fence) is free from any hospital or community-generated waste.
14 and safety
14.3. The hospital has a good Internal compound appearance
(Designated social green areas or parks with seating facilities) and Yes
tidiness.
14 and safety

14.4. The Hospital has established a system/mechanism for pest

and rodent control (outsourced or trained and assigned
personnel).
Domain score 3
Domain percentage score 75
Section Grand Total 93/108
Section Grand Total percentage 86%
Compliances by Healthcare Workers
No N/A Assessment Instructions/Guide Comment
Check the availability and accessibility of SOP at least
in the following sites for routine use: OR, Maternity,
ICU, NICU, and Labour ward.
Ask 3-5 staff randomly whether training /orientation
on the proper use of PPE including donning & doffing
provided to them.

Check the availability of the following PPEs: Medical

masks
N95, FFP2, or equivalent respirator; aprons; eye
protection (face shields, eye goggles); gowns; sterile
gloves; non-sterile gloves; Heavy-duty gloves, rubber
or plastic boots, and head caps.

Observe at least three HCWs in four service areas

(e.g., emergency, ICU, OR, maternity, etc.) using the
standard PPE observation checklist.
Observe at least four HCWs in four service areas (e.g.,
Emergency, ICU, OR, Maternity, etc.) using standard
PPE and an observation checklist

Observe how the PPE supplies are stored in closed

and safe location and easily accessible for use at
service delivery points.
Total score for ‘Y’, ‘N’ and ‘N/A’
100
Observe the availability of HH supplies and
no check the functionality of HH stations
(check at least 5 HH stations at the service
delivery point).

Check for the availability of posters and

observe the five moments of HH for hand
washing steps that are posted.
Check the HH assessment report and audit
score (HH audits were conducted at least at
five different service delivery points).
Check for documents showing feedback
was provided or pictures of meetings with
stakeholders on feedback sharing.

No Check for pictures and an activity report.

2 Total score for ‘Y’, ‘N’ and ‘N/A’
60/%

Observe or look for a labeled isolated room, and if

cohorted patients are placed at least 1 meter apart.

Check if ABHR and/or water and soap are available in

No
the isolation room.

Check if the required PPEs are available for the

defined TBP.
• N95 or other respirators (airborne)
• Face masks, face shields, or goggles (droplets)
• Gowns (contact precaution)
• Disposable gloves
• Boots and
• Hazma Suits

Observe the practice of applying PPE (interview staff if

there is no patient under TBP). Check if there are
designated donning and doffing areas and observe
donning and doffing practices before and after patient
transport.

Look for signs limiting patient movement. Check if the

facility has a SOP for transmission-based precautions
and if it entails how patients in isolation are
transported.

Check cleaning checklists and visual observations for

cleanliness.

Review the checklist and observe for a visibly soiled

toilet.

Observe

Ask and observe how bedsheets and patient pajamas

works too.

Check if:
• Coughing patients are triaged separately; •
Coughing patients should be separated by at least one
meter.
• Coughing patients are given priority in que
Observe patients in waiting area and TB clinic for
wearing of mask

Observe the posted signage and posters.

1 Total score for ‘Y’, ‘N’ and ‘N/A’

91%

Check for availability of CSSD with a responsible

person assigned with a letter; signage is posted to
restrict entry to the CSSD room; CSSD has a separate
entrance and exit gate for unidirectional flow of
traffic; and CSSD has a zonal partition to delimit the
placement of contaminated and sterilized items.

Observe the reprocessing process, SOP availability,

water availability at the point of use cleaning site, and
at least three different wards:-
• Point of care
cleaning
• Thorough cleaning
• Sterilization

Check how instruments are sterilized. Check if

chemical sterilizing agents are available
(glutaraldehyde (2-4%), peracetic acid 0.3%, hydrogen
peroxide 8.3%, or mixed H2O2).

Observe utility rooms in care units and sterilizing

areas in CSR, Zonning

Check the availability of CSR and the presence of a

unidirectional flow of traffic in CSR.

Observe storage

Check out the document:

• Daily preventive maintenance
• Corrective maintenance as needed
• Calibration based on manufacturer instructions
Total score for ‘Y’, ‘N’ and ‘N/A’
100%
Locate the cleaning forms or checklists and check if
they are completed, the frequency of completion, and
how frequently they are completed.

Ask for the schedule and check SOPs.

Ask for the schedule and check SOPs and verification

by visual inspection/ fluorescent marker.

Check cleaning checklists and visual observations for

cleanliness.

Check cleaning checklists and visual observations for

cleanliness; check if cleaning equipment is stored
separately.

Observe the poster or instructions posted.

Check for the availability of cleaning supplies and

equipment; check for the availability of a cleaning
supply stock monitoring tool or mechanism.

Check cleaning checklists and visual observations for

cleanliness.

Observe

Check for the availability schedule, pictures, and

report.
Check cleaning checklists and visual observations for
cleanliness.

Observe

Total score for ‘Y’, ‘N’ and ‘N/A’

100%

Observe at least three HCWs` per ward performing

HH.

Observe at least three HCWs per ward practicing

injection procedures.
Observe at least three HCWs per ward.

Observe at least 3 HCWs doing injection procedures

per ward and check the availability of a safety box in
the hand-accessible area.

Observe during the injection procedure.

Observe Interview HCP

Observe Interview HCP

Observe during medication administration

Observe. This is different from the expiration date

printed on the vial. (Interview HCP)

Check if multi-dose vials are used for a patient

(Interview HCP)
Observe. If multi-dose vials enter the immediate
patient treatment area, they should be dedicated for
single-patient use and discarded immediately after
use.
Total score for ‘Y’, ‘N’ and ‘N/A’
100%
Observe

Check and verify

• Facility visitor hour’s protocol
• Visitor hours are posted at the hospital gate.
• Visiting hours, round time, meal delivery time, and
the number of allowed attendants are posted clearly
in each ward.

Observe the triage services and appointment system

at Liason, IPDs, and OPDs and check if the block-hour
appointment system is followed.

Observe waiting areas, adequate seating based on

patient load, and natural or artificial ventilation.
Observe traffic flow management at the facility. Check
if appropriate signage and physical barriers are used
in restricted areas.

Check the OR, ICU, labour ward, CSD, Kitcken, etc.

Observe and check that the waiting areas, garden,

cafeteria, and walkways are free and safe for patient
transport.

Check service areas randomly for signage, reminders,

and physical barriers.

Total score for ‘Y’, ‘N’ and ‘N/A’

100
Check that the laundary has separate areas for
no segregation, collection of soiling linens, washing,
drying, ironing, and storing clean linen.

Check cleaned/washed linens observed separately

from soiled linen.

Observe laundry staff wearing appropriate PPE.

Observe the availability of water by opening the pipe

no
and checking that the laundry has a hot water source.

Check the number of openable windows and doors

and the availability of artificial ventilation. Check that
sewage is not spilled on the floor.
Observe the availability of electricity 24/7 with
backup source.
Check the number of openable windows and doors
and the availability of artificial ventilation.
no Observe the presence of a functional sink with soap.
Check for SOPs on disinfectant and detergent, and ask
the laundry head for a consistent supply.

Observe the containers/trolleys used for transporting

clean, washed, and dirty/contaminated linens.

Observe the availability and cleanliness of color-coded

waste containers.
Observe the functionality of the machine and the
no
maintenance schedule
Observe records
4 Total score for ‘Y’, ‘N’ and ‘N/A’
69%
Ask food handlers whether they are trained in food
Na handling and safety procedures; check their names at
the training office and their certificate.

Observe whether the kitchen has three

Na
compartments and a hot water source.

na Observe the cleaning practice

Observe at least 3 food handlers wearing appropriate

Na
PPE (e.g., aprons, face masks, hair covers)

Observe whether food is transported using clean and

Na
covered carts
Observe whether raw food storage is separate for
Na
perishable and non-perishable foods.
Ask for and observe the medical certificates of food
Na
handlers.

Na Observe the availability of sinks (at least one).

Check for washable floors, walls, and ceilings free of

Na
dirt and debris. Check the posted cleaning schedule.

Observe refrigerator temperature monitoring

mechanisms (documentation, temperature gauge up
Na
to the requirement), and check the functionality of
the refrigerator.

Na Check waste containers

Check that water quality is tested every three months

Na
(Check documentation).
Observe the policy and check for relevant signage and
Na
posters.
Check whether there is an assigned professional to
Na monitor the cleanliness and hygiene of the kitchen
and food handlers.

Observe the signed document and ask the kitchen

Na
store head

Check the documentation from the kitchen

Na coordinator (Treated properly; sick leave was given
and rescreened before return to the work place).
Total score for ‘Y’, ‘N’ and ‘N/A’

Observe that all waste bins are clearly marked to

indicate the type of waste (e.g., colour-coding or
labelling to indicate the type of waste) and available
at each clinical area.
Observe the segregation practise at the point of
generation.

Observe availability of posters

Observe the dust bins and safety boxes at least at

three points of use.

Observe the floor

Ask about and observe waste transportation practises

to the disposal site.

Observe the storage site (e.g., temporary storage).

no Observe the incinerator plant
Observe the disposal practise
Observe the availability of liquid waste treatment
plants.

Check the schedule /attendance sheet.

1 Total score for ‘Y’, ‘N’ and ‘N/A’

90%
Ask for the policy and reporting structure, and check if
they are available for all wards.
Check vaccination records or reports. If not all, specify
no
the percentage of vaccinated staff in the notes.
Ask for a reporting register or form and reporting
lines.

Ask about the plan and reports for monitoring HCWs.

Specify the specific plan in the notes

1 Total score for ‘Y’, ‘N’ and ‘N/A’

80%
no Observe updated SOPs.
no Observe the availability of functional refrigerators.
no Observe the document/ask the care providers

Check the availability of PPE and observe whether all

wear appropriate PPE during the handling of dead
bodies.

no Check the availability of plastic bags

5 Total score for ‘Y’, ‘N’ and ‘N/A’

20%
Check the meeting note, TOR, and Letter of
Assegment of Taskforce.
Check the plan.
Check the availability of the plan.

Committee meeting notes and action points

Check availability SOP

Check the plan

Check the plan in the planning document.

Check the plan

Check the inventory report.

Total score for ‘Y’, ‘N’ and ‘N/A’

100%
Fences are strong enough to restrict the entrance of
Pets and other animals. There are at least two
separate gates for the entry and exit of both
pedestrians and vehicles. A separate gate for staff.
Gates are spacious enough to accommodate
emergency scenarios.

Observe the hospital external ground.

Check the availability of green areas with seats and

walkways. Check their cleanliness and tidiness.
no Check the activity report and certification.

1 Total score for ‘Y’, ‘N’ and ‘N/A’

75
93/108
86%