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Hospital Standards for Accreditation for Afghanistan
Section 2: Clinical Care
Infection Prevention:
Patient/Client Education
Hospital Standards for Accreditation for Afghanistan: Assessment of Progress in Achieving the Standards
Hospital Department or Area: Infection Prevention: Patient/Client Education Hospital Facility: __________________________________________ Assessor: __________________________________________ Date of assessment: ____________________
Infection Prevention: Patient/Client Education
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
1 There are educational posters for patients/ clients about infection prevention (IP) measures.
Observe if: • There are posters or stickers visible and in
good condition about hand washing and hygiene located in: o Corridors 2 1 0
o Waiting areas 2 1 0 o Toilets 2 1 0 o Wards 2 1 0 • There are signs saying “no littering” to
encourage patients/clients and relatives to avoid littering on the grounds 2 1 0
• There are posters or stickers visible and in good condition about visiting hours and number and age of visitors 2 1 0
Section 2: Clinical Care. Infection Prevention: Patient/Client Education Hospital Standards Manual—Afghanistan 2 of 4
Infection Prevention: Patient/Client Education
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
• There are posters or stickers visible and in good condition about “cough etiquette” 2 1 0
2 There are informational posters about patients’/clients’ rights concerning IP during the provision of care.
Observe if there are posters visible and in good condition informing patients/clients about the critical IP practices (e.g., hand washing, injection safety, use of gloves during invasive procedures) that should be followed by providers during the provision of care, located in: • Outpatient facilities 2 1 0
• Wards 2 1 0 • Casualty area 2 1 0 • Laboratory 2 1 0 • Dental department 2 1 0 3 Observe if there are signs in these areas:
• Laboratory 2 1 0 • Isolation areas 2 1 0
There are signs to alert patients/clients about restricted or risky areas.
• Central supply and Sterilization Department and operating room 2 1 0
• Labor and delivery areas 2 1 0 • Nursery 2 1 0 • Mortuary 2 1 0 • Waste storage areas 2 1 0
Section 2: Clinical Care. Infection Prevention: Patient/Client Education Hospital Standards Manual—Afghanistan 3 of 4
Infection Prevention: Patient/Client Education
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
4 The hospital works with community organizations on IP education.
Verify with the hospital director/manager if:
• There is a written plan to conduct educational activities on IP for the community and for the relatives who accompany patients/clients 2 1 0
• There is a record of activities implemented 2 1 0
Row Scoring compliance with the standards A Total Score (sum total checks for full, partial and no compliance) B Score for each category (Full compliance =2, Partial compliance =1 and
Non-compliance =0) 2 1 0
C Score of Full, Partial and Non-compliance (Multiply Row A times Row B)
D TOTAL: Sum of scores for Full, Partial and Non-compliance—(Add all three columns in Row C)
E Score possible (Total criteria times 2—less any N/A) 42
F Percentage Compliance with these standards (Divide Row D by Row E) %
Total criteria 21 x 2 pts = maximum 42 point s possible (less any N/A)
Section 2: Clinical Care. Infection Prevention: Patient/Client Education Hospital Standards Manual—Afghanistan 4 of 4
Hospital Standards for Accreditation for Afghanistan
Section 2: Clinical Care
Infection Prevention:
Food Service and Catering
Hospital Standards for Accreditation for Afghanistan: Assessment of Progress in Achieving the Standards
Hospital Department or Area: Infection Prevention: Food Service and Catering Hospital Facility: __________________________________________ Assessor: __________________________________________ Date of assessment: ____________________
Infection Prevention: Food Service and Catering
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
1 Verify with the person responsible for food preparation if: • There are written routines/guidelines for
pest control 2 1 0
1. There are written routines/guidelines for pest control and presence of animals in the kitchen. • The presence of animals (e.g., cats, dogs,
etc.) is forbidden in the kitchen 2 1 0 • They are physically placed in this unit
(posted or in a procedure manual) 2 1 0 2 There is a system to
screen and control the health of kitchen personnel.
Verify with the person responsible for food preparation if: • The responsible person screens/controls
kitchen personnel for: o Personal hygiene including uniform 2 1 0
o Acute diarrhea 2 1 0 o Draining abscess and impetigo 2 1 0
Section 2: Clinical Care. Infection Prevention: Food Service and Catering Hospital Standards Manual—Afghanistan 2 of 7
Infection Prevention: Food Service and Catering
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
• Kitchen personnel have work restrictions if they have these conditions 2 1 0
• There is a record keeping book with the information on screening and control measures applied 2 1 0
3 The kitchen has an adequate physical plant and equipment.
Verify if there is: • Food preparation area:
o Sink with running hot and cold water 2 1 0 o Working drainage system 2 1 0 o Windows with screens 2 1 0
• Storage area: o Cupboards 2 1 0
o Shelves 2 1 0 o Refrigerator 2 1 0 o Freezer 2 1 0 o Windows with screens 2 1 0
4 The area for food preparation is clean.
Verify the absence of dust, soil, blood, trash, spider webs, leftover food, flies, and pests in the following areas: • Work area:
o Floors 2 1 0 o Walls 2 1 0 o Counters 2 1 0 o Sink 2 1 0 o Utensils and cooking pots 2 1 0
Section 2: Clinical Care. Infection Prevention: Food Service and Catering Hospital Standards Manual—Afghanistan 3 of 7
Infection Prevention: Food Service and Catering
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
o Chopping boards 2 1 0
• Storage area: o Floors 2 1 0
o Doors 2 1 0 o Walls 2 1 0 o Shelves or cupboards 2 1 0
• Equipment: o Stove 2 1 0
o Refrigerator 2 1 0 o Freezer 2 1 0 • Vehicles and/or trolleys used to transport
food 2 1 0 5 The food is stored
properly Verify if: • All goods are stored in clean wrappers or
containers with covers 2 1 0 • All wrappers or containers are marked
with date and contents 2 1 0 • The food is stored at least 6 inches above
floor level and away from walls 2 1 0 • All goods stored are within the expiration
dates 2 1 0 • The temperature of the refrigerator is
check and recorded daily 2 1 0
Section 2: Clinical Care. Infection Prevention: Food Service and Catering Hospital Standards Manual—Afghanistan 4 of 7
Infection Prevention: Food Service and Catering
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
6 Food preparation is performed properly.
Observe during food preparation if the personnel: • Wear a hair net or cap 2 1 0
• Wash hands with running water and soap for 10–15 seconds and dry with an individual clean towel, paper towel, or allow hands to air-dry: o Before food preparation 2 1 0
o After using toilet 2 1 0 o After contact with unclean equipment
or work surfaces 2 1 0 o After handling raw food 2 1 0 • Clean with soap or detergent and running
water (utensils and cutting boards between uses) 2 1 0
• Clean and disinfect the working surfaces and all utensils after each period of use 2 1 0
• Limit the traffic of unauthorized individuals into the food preparation area (e.g., vendors, personnel from other departments, etc.) 2 1 0
7 The kitchen has an adequate process for holding and serving
Verify if: • Food is defrosted only once and then
consumed or discarded 2 1 0
Section 2: Clinical Care. Infection Prevention: Food Service and Catering Hospital Standards Manual—Afghanistan 5 of 7
Infection Prevention: Food Service and Catering
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
prepared food. • Cooked perishable foods are served within 2 hours of preparation, and after this are disposed of 2 1 0
• During transportation, food is protected from vectors using nets, clean cloths, or covers 2 1 0
8 The waste is managed properly in the kitchen.
Verify if: • There are washable, leakproof garbage
containers with tight-fitting lids 2 1 0 • The garbage is immediately placed into
the containers 2 1 0 • The garbage containers are stored
outdoors after use 2 1 0 • The garbage containers are collected daily 2 1 0 • The garbage containers are washed daily
or sooner if needed 2 1 0
Section 2: Clinical Care. Infection Prevention: Food Service and Catering Hospital Standards Manual—Afghanistan 6 of 7
Row Scoring compliance with the standards A Total Score (sum total checks for full, partial and no compliance) B Score for each category (Full compliance =2, Partial compliance =1 and
Non-compliance =0) 2 1 0
C Score of Full, Partial and Non-compliance (Multiply Row A times Row B)
D TOTAL: Sum of scores for Full, Partial and Non-compliance—(Add all three columns in Row C)
E Score possible (Total criteria times 2—less any N/A) 102
F Percentage Compliance with these standards (Divide Row D by Row E) %
Total criteria 21 x 2 pts = maximum 102 point s possible (less any N/A)
Section 2: Clinical Care. Infection Prevention: Food Service and Catering Hospital Standards Manual—Afghanistan 7 of 7
Hospital Standards for Accreditation for Afghanistan
Section 2: Clinical Care
Infection Prevention:
Laundry
Hospital Standards for Accreditation for Afghanistan: Assessment of Progress in Achieving the Standards
Hospital Department or Area: Infection Prevention: Laundry Hospital Facility: __________________________________________ Assessor: __________________________________________ Date of assessment: ____________________
Infection Prevention: Laundry
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
1 Verify if: • There are separate areas for:
o Receiving and sorting 2 1 0 o Washing linen 2 1 0
The laundry has adequate physical plant, traffic flow, and equipment.
o Ironing, folding, repairing, and storing of clean linen 2 1 0
• There are washbasins with running water for rinsing soiled linen 2 1 0
• There are washing machines for washing clothes 2 1 0
• There are drying machines or clotheslines to dry the linen 2 1 0
• There are tables and shelves to handle, fold, and store clean linen 2 1 0
Section 2: Clinical Care. Infection Prevention: Laundry Hospital Standards Manual—Afghanistan 2 of 5
Infection Prevention: Laundry
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
2 The process of handling used and/or soiled linen is performed properly.
Observe in the laundry: • Workers wear personal protective
equipment while handling soiled linen: o Utility gloves 2 1 0
o Plastic aprons 2 1 0 o Goggles 2 1 0 o Masks 2 1 0 o Gumboots or enclosed shoes 2 1 0 • Soiled linen is separated from non-soiled
linen 2 1 0 • Soiled linen is checked for foreign objects
such as instruments, needles, human tissue, and personal property 2 1 0
• Workers perform hand hygiene after handling used and/or soiled linen: 2 1 0
o Wash hands with running water and soap for 10–15 seconds and dry with an individual clean towel, paper towel, or allow hands to air-dry, or
o Rub hands with 3–5 ml of an alcohol-based solution until the hands are dry (if hands are not visibly soiled)
2 1 0
• Utility gloves and plastic aprons are
cleaned thoroughly and dried after use 2 1 0
Section 2: Clinical Care. Infection Prevention: Laundry Hospital Standards Manual—Afghanistan 3 of 5
Infection Prevention: Laundry
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
3 Verify if: • Soiled linen is washed separately from
non-soiled linen 2 1 0
The process of washing of used and/or soiled linen is performed properly. • Detergent is used to wash linen 2 1 0
• All linen is washed for a minimum of 25 minutes in a washing machine or according to the machine cycle 2 1 0
• Linen is re-washed if still visibly soiled/dirty 2 1 0
• Washed linen is not placed on the floor 2 1 0 4 The process of drying
clean linen is performed properly.
Observe if: • Linen is dried in a drying machine or
hung outside on a clothesline 2 1 0 • Dried, clean linen is not placed on the
floor 2 1 0 5 The collection and
transportation of linen is performed properly.
Verify in the laundry if: • Used linen is collected in the wards in
leak-proof containers with lids or covers 2 1 0 • Used linen is transported from the wards
to the laundry in leak-proof containers with lids or covers 2 1 0
• Carts, trolleys, or other leak-proof containers are cleaned before taking clean linen back to the wards 2 1 0
Section 2: Clinical Care. Infection Prevention: Laundry Hospital Standards Manual—Afghanistan 4 of 5
Infection Prevention: Laundry
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
• Clean linen is transported separately from used/soiled linen in a clean cart, trolley, or other container. 2 1 0
• Clean linen is covered or wrapped during transportation 2 1 0
Row Scoring compliance with the standards A Total Score (sum total checks for full, partial and no compliance) B Score for each category (Full compliance =2, Partial compliance =1 and
Non-compliance =0) 2 1 0
C Score of Full, Partial and Non-compliance (Multiply Row A times Row B)
D TOTAL: Sum of scores for Full, Partial and Non-compliance—(Add all three columns in Row C)
E Score possible (Total criteria times 2—less any N/A) 58
F Percentage Compliance with these standards (Divide Row D by Row E) %
Total criteria 29 x 2 pts = maximum 58 point s possible (less any N/A)
Section 2: Clinical Care. Infection Prevention: Laundry Hospital Standards Manual—Afghanistan 5 of 5
Hospital Standards for Accreditation for Afghanistan
Section 2: Clinical Care
Infection Prevention:
Waste Management
Hospital Standards for Accreditation for Afghanistan: Assessment of Progress in Achieving the Standards
Hospital Department or Area: Infection Prevention: Waste Management Hospital Facility: __________________________________________ Assessor: __________________________________________ Date of assessment: ____________________
Infection Prevention: Waste Management
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
1 There is a written plan for waste management.
Verify with the person responsible for waste management if: • There is a written plan for waste
management including: o Segregation at point of use 2 1 0
o Transportation 2 1 0 o Interim storage 2 1 0 o Final disposal 2 1 0
2 The hospital promotes good practices for waste management and disposal.
Observe if: • There are sufficient dustbins outside of
the hospital (in the grounds) for general waste to avoid littering 2 1 0
• The grounds (outside of the hospital) are clean. 2 1 0
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 2 of 9
Infection Prevention: Waste Management
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
3 The staff uses the PPE when handling waste.
Observe during the visit, if: • Housekeeping personnel wear personal
protective equipment (PPE) when handling medical waste: o Utility gloves 2 1 0
o Gumboots 2 1 0 o Plastic apron 2 1 0 o Masks covering nose and mouth 2 1 0 • Disposable PPE (examination gloves,
surgical masks) are decontaminated in 0.5% chlorine solution (if applicable) and disposed in a leakproof container after use 2 1 0
• Re-usable PPE (e.g., utility gloves, gumboots, plastic apron, face shield) are reprocessed after use: o Decontaminated in 0.5% chlorine
solution 2 1 0
o Washed with soap and water 2 1 0 o Dried and stored 2 1 0
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 3 of 9
Infection Prevention: Waste Management
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
4 The staff washes hands after handling waste and removing gloves.
Observe if housekeeping staff performs hand hygiene after handling waste and removing gloves: • Wash hands with running water and soap
for 10–15 seconds and dry with an individual clean towel, paper towel, or allow hands to air-dry,
or • Rub hands with 3–5 ml of an alcohol-
based solution until the hands are dry (if hands are not visible soiled)
2 1 0
5 Waste segregation is performed according to the standards.
Observe if there is a segregation system at point of use: • Sharps
o Sharps are discard and collected in puncture-resistant containers (e.g., heavy cardboard box, hard plastic, or can containers) 2 1 0
o Sharps containers are closed and collected when three quarters full 2 1 0
o Each sharp container is used only once 2 1 0 • Other medical waste (e.g., used cotton
rolls, gauze, dressing, etc.): o Are disposed of in leak-proof
containers with a plastic bag 2 1 0
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 4 of 9
Infection Prevention: Waste Management
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
o Are closed and collected when three-quarters full 2 1 0
• General waste: o Is collected from all areas in adequate
closed containers and transported to the interim storage area or for disposal 2 1 0
6 There is a system for interim storage of waste.
Observe if: • The traffic in the interim storage area is
controlled (accessible only to the in-charge personnel) 2 1 0
• Containers are leak-proof and closed with tight lids 2 1 0
• All waste is inside of the containers 2 1 0 • The interim storage area is free of waste
on the grounds 2 1 0
Verify with the manager if: • There is a written plan for a short-term
storage of waste (maximum of two days) and cleaning of storage area and containers 2 1 0
• Waste is transported in vehicles or containers used only to transport waste 2 1 0
• Vehicles transporting waste have a cover or tarp to prevent waste from littering during transport 2 1 0
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 5 of 9
Infection Prevention: Waste Management
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
7 The contaminated waste is disposed properly.
Verify if: • Contaminated waste is disposed of on-site
by: o incinerating, or
o burying, or o burning in a closed pit
2 1 0
8 The non-contaminated
waste is disposed properly.
Verify if: • Non-contaminated waste is disposed of
on-site by: o incinerating, or
o burying, or o burning in a closed pit
2 1 0
OR • Non-contaminated waste is sent off-site
(e.g., to a municipal waste or sanitary landfill) 2 1 0
9 The waste disposal process is performed properly.
Verify: If the waste is incinerated: • The traffic in this area is controlled and
accessible only to the in-charge personnel 2 1 0
• During incineration, there are flames 2 1 0 • Ash from incinerated material is disposed
of as non-contaminated waste 2 1 0
• There is no waste lying around the grounds 2 1 0
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 6 of 9
Infection Prevention: Waste Management
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
OR If the waste is buried in a pit:
• The area is not accessible to other staff, community, and domestic animals 2 1 0
• The burial site is lined with a material of low permeability (e.g., clay) 2 1 0
• The burial site is at least 50 meters away from any water source, and it is located in an area free of floods 2 1 0
• The pit is about 1 meter square and 2 meters deep 2 1 0
• The disposed waste is covered with 10–15 cm of dirt each day 2 1 0
• The final layer of dirt is 50–60 cm 2 1 0 • The burial pit lasts a maximum of 30–60
days 2 1 0
• There is no waste lying around the grounds 2 1 0
OR If the waste is burned:
• The area is not accessible to other staff, community, and domestic animals 2 1 0
• The waste is burned in a small designated area 2 1 0
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 7 of 9
Infection Prevention: Waste Management
Standard Number
Standard
Criteria for Verification of Meeting
Standard
Compliance in Meeting Standard
(Score)
Basis for Evaluation Grade/ Comments/Action Plan
Full 2
Partial 1
None 0
(Circle appropriate score)
• The waste is transported to the area just before burning 2 1 0
• During burning, there are flames 2 1 0 • The person in charge remains with the fire
until it is out 2 1 0
• A layer of dirt is used to cover the burned waste 2 1 0
• The grounds around this area are free of waste 2 1 0
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 8 of 9
Row Scoring compliance with the standards A Total Score (sum total checks for full, partial and no compliance) B Score for each category (Full compliance =2, Partial compliance =1 and
Non-compliance =0) 2 1 0
C Score of Full, Partial and Non-compliance (Multiply Row A times Row B)
D TOTAL: Sum of scores for Full, Partial and Non-compliance—(Add all three columns in Row C)
E Score possible (Total criteria times 2—less any N/A) 100
F Percentage Compliance with these standards (Divide Row D by Row E) %
Total criteria 50 x 2 pts = maximum 100 point s possible (less any N/A)
Section 2: Clinical Care. Infection Prevention: Waste Management Hospital Standards Manual—Afghanistan 9 of 9
Infection Prevention Standards Compliance Performance Scoring Summary
Summary of Performance Scoring
Column A B C D
Infection Prevention Areas Assessed Total
Criteria for Assessment
Total Points Possible
(2 pts * # of criteria)
Actual Points Scored
Percentage Compliance
(2 pts * Column A)
From assessment
(Column C/ Column B)
Central Sterilization and Supply Department (CSSD) 122 244 %Surgical Unit 176 352 %Isolation Systems 33 66 %Labor and Delivery Unit 137 274 %Emergency, Surgical and Medical Wards 197 394 %MCH & Family Planning Clinic 99 198 %Dental Unit 79 158 %Laboratory 113 226 %Blood Bank 135 270 %Post-Mortem Care 32 64 %Administrative Functions 63 126 %Patient Education 21 42 %Food Service and Catering 51 102 %Laundry 29 58 %Waste Disposal 50 100 %
TOTAL for Infection Prevention 1337 2674 %
Section 2: Clinical Care. Infection Prevention: Summary Form Hospital Standards Manual—Afghanistan 1 of 1
