EQUIPMENT CLEANING AUDIT IMPLEMENTATION PLAN

Implementation of the Equipment Cleaning Audit is a collaborative process betweenthe unit/areaandthe Infection Control Professional(ICP). Accreditation Canada Infection Prevention Controlstandards require the organization to monitor compliance.

The Equipment Cleaning audit implementation processshould include the following:

  1. Designation of Individual(s)
  2. The unit/site/program is to designate the individual(s) to perform the equipment cleaning audits.
  1. Education
  2. The ICP will educate the individual(s)responsible for performing the audit as well as appropriate unit/area managers/supervisors. This education willincludea review of the Equipment Cleaning Audit and how to perform the audit.
  3. The initial audit will be performed cooperatively with the ICP and designated unit auditor in order to mentor the individual.
  4. The ICP will evaluate subsequent audits performed independently by the designated unit auditorat least once after initial auditor training and when results are out of the expected range, e.g.,excessive number of items were flagged as deficient compared to the previous audit or no items were flagged indicating no room for improvement.
  1. Frequency of Audits
  2. At minimum, audits are to be performed annually by all units/areas.
  3. Whereresources permit, quarterly audits by each unit/areais preferable in order to identify deficiencies and corrective actions in a timely manner.
  4. Follow-up audits are recommended for units/areas with significant or critical deficiencies. Examples of deficiencies include commode chairs are not visibly clean, suction equipment is not visibly clean, other equipment/supplies that are not visibly clean, contaminated items found in designated clean spaces and clean supplies stored in soiled utility rooms.
  1. Communication of Audit Results
  2. The ICP will provide an electronic report after each completed Equipment Cleaning Audit to:
  3. The Unit Manager
  4. Quality Improvement or Patient Safety, if appropriate
  5. Senior Management if significant deficiencies identified
  6. Annually, the site ICP(s) will submit a cumulative electronic Equipment Cleaning Audit Report tothe Regional IP&C Committee. This annual site report will identify:
  7. Number of individuals educated regarding the Equipment Cleaning Audit
  8. Unit/areas audited over the year
  9. Compliance rate range for each site/area
  10. A summary of deficiencies found and interventions implemented
  11. A list of individualswhohave received communication from IP&C regarding the Equipment Cleaning Audit results and implemented interventions.
  1. Interventions
  2. The Manager to review interventions and develop a plan to address deficiencies in a timely and appropriate manner with the ICP.

Date Issued: December 17, 2009Revised January 2015