Quality Assurance Calendar Infection Control Responsible Party Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Transcription

1 Statement of authority Scope of service Plan Infectious disease risk assessment Preventive activities for patients For every with risk factors patient Investigation of potential hospital For every acquired infections patient with signs and symptoms of treatment for patients For every with confirmed hospital acquired patient with infections confirmed hospital Environmental monitoring with formal tours monthly Post discharge follow-up for surgical For all surgical site infections patients Timely implementation of isolation For every patient warranting isolation Isolation practice compliance For every isolation patient CDC guideline compliance Response to an influx of infectious As per policy patients and Reporting of reportable diseases For every surgical patient

2 Consent for HIV test Healthcare worker consent to perform HIV antibody test Authorization for disclosure of results of the HIV antibody blood test Management of accidental blood/body fluid exposure/contamination Management of accidental blood/body fluid exposure/contamination-hbv/hiv post exposure evaluation form Accidental blood/body fluid exposure/contamination-medical evaluation form Accidental blood/body fluid exposure/contamination-employee follow-up instruction form Accidental blood/body fluid exposure/contamination-report of exposure to bloodborne pathogen Bloodborne pathogen protocols PPE availability PPE compliance Reportable disease identification Reportable disease reporting For each HIV test For each HIV test For each HIV test For each reportable case For each reportable disease

3 MRSA precautions VRE precautions QA Topic Management of multiple drug resistant organisms (MDROs) Management of Severe Acute Respiratory Syndrome (SARS) Pre-employment physical examination Two step tuberculosis skin test Health questionnaire for positive skin test reactions Chest x-ray for all positive skin tests Routine mantoux testing Availability and appropriate use of respiratory protection equipment N95 Fit-testing Rubella screening With each MRSA case With each VRE case With each applicable culture For each SARS case For each new employee before patient contact For all new employees For all positive tests based on employee risk category

4 Rubella vaccine consent form Varicella Zoster screening Reporting of personnel illness Personnel illness trending report to Committee Employee exposure to communicable disease Infectious control log for hospital acquired and community-acquired infections Sharps Injury Protection Plan Sharps injury log Offer of Hepatitis B vaccine Consent for Hepatitis B vaccine Statement of declination for Hepatitis B vaccination Medical waste management plan Medical waste tracking form Medical waste hauler contract Medical waste secured storage Departmental infection control plan Flooring integrity For every Rubella vaccine administration With each personnel illness Monthly for high risk employees For every vaccination For every declination

5 Asepsis Attire in the operating room Gowning and gloving technique On every surgical case Sterile technique Waterless, scrubless, brush-free surgical hand prep antiseptic Sterilization Cleaning of ventilators Cleaning of anesthesia machines Biological monitoring FDA issues of notice For every FDA notice Rotation of sterile supplies Disposable versus nondisposable protocols Event-related sterility maintenance (shelf-life) Outdates and dated items Recall notices for outdated or potentially contaminated supplies Management of implantable devices Flash sterilization Processing flexible endoscopes

6 Management of Creutzfeldt-Jakob Disease Skin preparation for invasive s Air filter preventive maintenance Rodent/pest control Negative-pressure isolation room integrity Positive/negative air flows Per filter change schedule per HBsAg Screening of pregnant women Immunoprophylaxis of newborns Hand hygiene Handwashing Waterless hand cleaners General hygiene and attire policy and review Approval of cleaning supplies review and approval of cleaning supplies Employee training on new/revised policies and s Opening/dating of sterile vials With every new cleaning supply On creation of or revision of policy or

7 Cleaning and technique for laminar flow hood Sharps box management General trash management and disposal Eye wash station integrity review of employee job descriptions employee performance appraisal General cleaning protocols Horizontal surface cleaning Deep cleaning schedules for every department Special cleaning protocols Storage 4 inches off the floor Food temperatures Food storage Dish washing/ sanitizing Food prep Daily or when every receptacles are 3/4 full Daily and on each use Per schedules When situation demands it Per safe practice Per safe practice Per safe practice Per safe practice

8 Food Handling QA Topic