The hospital infection prevention and control programme is documented whichaims at preventing and reducing the risk of healthcare associated infections in allareas of the hospital.*

The infection prevention and control programme is a continuous process and updated at least once in a year.

The hospital has a multi-disciplinary infection control committee, which coordinates all infection prevention and control activities. *

The hospital has an infection control team, which coordinates implementation of all infection prevention and control activities. *

The hospital has designated infection control officer as part of the infection control team.*

The hospital has designated infection control nurse(s) as part of the infection control team.*

The organization identifies the various high-risk areas and procedures and implements policies and/or procedures to prevent infection in these areas. *

The organisation adheres to standard precautions at all times.*

The organisation adheres to hand-hygiene guidelines. *

The organisation adheres to transmission-based precautions at all times.*

The organisation adheres to safe injection and infusion practices.*

The organisation adheres to cleaning, disinfection and sterilization practices.*

An appropriate antibiotic policy is established and documented *

The organization implements the antibiotic policy and monitors rational use of antimicrobial agents.*

The organisation adheres to laundry and linen management processes.*

The organization adheres to kitchen sanitation and food-handling issues.*

The organization has appropriate engineering controls to prevent infections. *

The organisation adheres to housekeeping procedures.*

Surveillance activities are appropriately directed towards the identified high-risk areas and procedures.

A collection of surveillance data is an on-going process.

Verification of data is done on a regular basis by the infection control team.

The scope of surveillance activities incorporates tracking and analyzing infection risks, rates and trends.

Surveillance activities include monitoring the compliance with hand-hygiene guidelines.

Surveillance activities include mechanisms to capture the occurrence of epidemiological significant diseases, multi-drug-resistant organisms and highly virulent infections.

Surveillance activities include monitoring the effectiveness of house keeping services.

Appropriate feedback regarding Healthcare Associated Infection (HAIs) rates are provided on a regular basis to appropriate personnel.

In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities.

The organisation takes action to prevent catheter associated urinary tract Infections.

The organisation takes action to prevent Ventilator Associated Pneumonia.

The organisation takes action to prevent catheter linked blood stream infections.

The organisation takes action to prevent surgical site infections.

Monitoring includes infection control activities.

Monitoring includes adverse events and near misses.

Adequate and appropriate personal protective equipment, soaps, and disinfectants are available and used correctly.

Adequate and appropriate facilities for hand hygiene in all patient-care areas are accessible to healthcare providers.

Isolation/barrier nursing facilities are available.

Appropriate pre- and post-exposure prophylaxis is provided to all staff members concerned.*

Organisation has a documented procedure for identifying an outbreak.*

Organisation has a documented procedure for handling such outbreaks.*

This procedure is implemented during outbreaks.

After the outbreak is over appropriate corrective actions are taken to prevent recurrence.

The organisation adheres to statutory provisions with regard to biomedical waste.

Proper segregation and collection of biomedical waste from all patient-care areas of the hospital is implemented and monitored.

The organization ensures that biomedical waste is stored and transported to the site of treatment and disposal in properly covered vehicles within stipulated time limits in a secure manner.

The biomedical waste treatment facility is managed as per statutory provisions (if in- house) or outsourced to authorized contractor(s).

Appropriate personal protective measures are used by all categories of staff handling biomedical waste.

Visit by the hospital authorities to the disposal site.

The management makes available resources required for the infection control programme.

The organisation earmarks adequate funds from its annual budget in this regard.

The organisation conducts induction training for all staff.

The organisation conducts appropriate “in-service” training sessions for all staff at least once in a year.

Infection control practices are documented and followed. *

Procedures shall comply with infection control guidelines to prevent cross infection between patients.

OT Patient, personnel and material flow conform to infection control practices.

Staff interview.