Appendix Attachment To Appendix 4e Cleaning Outcome Standards

Transcript

Solutions For Optimum Facility Cleaning Management 1820 Maple Street Vancouver, B.C., V6J 3S7 Tel: (604) 889-8811 Fax: (604) 733-6563 Email: [email protected] BC Health Authorities Housekeeping Cleaning Audit Reference Guide Revision Seven - D - DRAFT Westech Systems, Inc. 1820 Maple Street; Vancouver, B.C., Canada (604) 889-8811 Last Revised: January 24, 2007 Westech Systems, Inc. 1564107 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Westech Systems, Inc. Auditing Training Manual 1564107 Page 2 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT INTRODUCTION TO THE MANUAL:..................................................................................................4 AUDITING GUIDE: NON COMPUTER PROCEDURES AND PROTOCOL...................................5 BC HEALTH AUTHORITIES CLEANING OUTCOME STANDARDS DEFINED .......................................................5 INSPECTION ELEMENTS & CLEANING EXPECTATIONS: ..................................................................................6 IMPORTANT AUDITING CONSIDERATIONS:.....................................................................................................8 Maintenance versus Housekeeping Issues:..................................................................................................8 Time of the Day: ..........................................................................................................................................8 Decision Making When Auditing .................................................................................................................9 Useful Auditing Tools ..................................................................................................................................9 SPECIFIC INSPECTION ELEMENT AUDITING GUIDELINES: ............................................................................11 RISK CATEGORIES .......................................................................................................................................37 AUDITING GUIDE: COMPUTERIZED AUDIT TOOL PROCEDURES ........................................39 SENDING DATA FROM THE COMPUTER TO THE PALM PILOT:......................................................................39 PERFORMING AN AUDIT: .............................................................................................................................41 RETRIEVING THE AUDITS TO THE COMPUTER:.............................................................................................53 REVIEWING REPORTS ON THE COMPUTER:..................................................................................................54 IMPORTANT FEATURES IN THE SA AUDIT COMPUTER SOFTWARE:..............................................................54 Exporting a Report to a Word Document or Excel Spreadsheet ...............................................................55 IMPORTANT DATABASE TABLES....................................................................................................57 SORT FIELD ONE: HIGH LEVEL FUNCTIONAL AREAS ..................................................................................57 SORT FIELD TWO: HOSPITAL SPECIFIC FUNCTIONAL AREAS .......................................................................57 SORT FIELD FOUR: ROOM USE LISTING ......................................................................................................58 CLEANING PROMPTS TABLE ........................................................................................................................60 ROOM TYPES ..............................................................................................................................................61 ROOM TYPE INSPECTION SCHEMES.............................................................................................................61 IMPORTANT AUDITING COMPUTER PROCEDURES & PROTOCOL .....................................64 UPDATING THE SA AUDIT SOFTWARE ON THE LAPTOP & PALM PILOT .......................................................64 BACKING UP & E-MAILING DATABASES ......................................................................................................65 APPENDIX ...............................................................................................................................................67 PHA MANUAL HOUSEKEEPING QUALITY AUDIT FORM................................................................................68 HEALTH AUTHORITY SPECIFIC CLEANING REQUIREMENTS .........................................................................70 Westech Systems, Inc. Auditing Training Manual 1564107 Page 3 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT This training manual has been written with the primary goal of providing information that will make the process of auditing the cleanliness of hospitals as consistent as possible. The document will be updated and revised over time based on input from the different users. The manual is divided into five main sections • Auditing Guide: Non Computer Auditing Procedures and Protocol • Auditing Guide: Computerized Audit Tool Procedures & Palm Pilot Auditing Guide • Important Database Tables • Important Auditing Computer Procedures and Protocol • Appendix Westech Systems, Inc. Auditing Training Manual 1564107 Page 4 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT This section covers the necessary background information required to perform an audit ! The Provincial Health Authorities have developed the following cleaning output specifications that are referred to here as Cleaning Outcome Standards. It is an expectation that Cleaning Outcome Standards be met at all times. The Cleaning Outcome Standards are not an exhaustive list, but reflect many typical outcomes that are expected from housekeeping providers. Housekeeping Services involves meeting numerous standards that are different from and may be confused with Cleaning Standards: • Quality Standards • Frequency Standards • Methods Standards • Materials Standards • Equipment Standards • Response Time Standards Cleaning outcome standards are the outcomes which result from balancing many of the above other standards. The cleaning output specifications listed below are the Participating Health Authority’s desired Service Levels and Standards outcome, with respect to Cleaning Standards. The Cleaning Outcome Standards are designed to meet the following needs: • The primary focus must remain the protection of the patient and resident. Routine cleaning is usually all that is needed to achieve a clean environment. However, surfaces frequently touched by health care providers, and/or patients, such as call bell lights, medical equipment, knobs, handles, light switches and assist rails have a greater potential as vehicles for infectious agents. Therefore, these items require frequent cleaning. • They must help minimize the outbreak and spread of microbial infections. • The standards are understandable and attainable • The standards to remain a viable tool they must be reviewed as often as required. Review is necessary to keep abreast of changes in the Health Care environment Westech Systems, Inc. Auditing Training Manual 1564107 Page 5 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT " # "$ When performing an audit, the following interpretations of the cleaning expectations should help when deciding whether an inspection element is acceptable or unacceptable. When making that judgment call, we must remember that all of the facilities are being used on a continuous basis throughout the day. For this reason, there will always be a certain amount of dust, removable marks, scuffs, finger marks etc. Minimal amounts of these will be considered acceptable. When there is an accumulation of dust, removable marks, scuffs, finger marks etc. on a surface, this is where an item will receive a failing score because of an unacceptable amount of soiling. INTERPRETATIONS FREE OF DUST • Minimal dust is acceptable • An accumulation of dust is unacceptable • If when passing a hand over a vertical surface a visible mark remains in the dust this will be considered as a build up of dust and marked as unacceptable • If when passing a hand or finger over a horizontal surface the amount of dust allows for balling or beading this will be considered as unacceptable REMOVABLE SPOTS • A mark may be tested with a dampened paper towel, if the mark is removable it will be considered as unacceptable SCUFFS & BLACK MARKS • Minimal scuffing is acceptable • Minimal amounts of black marks on flooring will be considered to be acceptable • Scuffing that detracts from the appearance of the area will be considered unacceptable • An accumulation of scuff marks from shoes or equipment will be considered unacceptable • An accumulation of black marks on flooring that detracts from the overall appearance of the floor will be considered as unacceptable FINGER MARKS • A minimal amount of finger marks will be considered acceptable • A build up of finger marks will be considered unacceptable SOILED • Any loose soil that can be removed from the surface will be considered unacceptable SOIL/FLUID BUILD UP • Any build up of soil or fluid that has caused discoloration of a surface will be considered unacceptable • Any soil build up that can be removed by scratching the surface will be considered unacceptable Westech Systems, Inc. Auditing Training Manual 1564107 Page 6 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • Any build up of soap that causes discoloration or hardening around the sink, drain, overflow or the area around where the sink or fixtures attach to the counter will be considered unacceptable COBWEBS • Any accumulation of dust that forms a webbing affect attached to a surface will be considered unacceptable ADHESIVE RESIDUE • A minimal amount of adhesive or tape residue will be considered acceptable • An accumulation of adhesive or tape residue in more than one location will indicate neglect and be considered unacceptable DEBRIS • Debris-paper, tissue, needle caps, sand, gravel etc • Isolated pieces of debris will be considered acceptable An accumulation of debris in more than one location will be considered unacceptable STRINGS OR WIRE • Removable strings or wire that have been attached to walls, ceilings, fixtures that have not been removed will be considered unacceptable • This would include strings or wires that have been used to hang seasonal decorations INCONSISTANT APPEARANCE • When assessing the many different types of floor surfaces, the main thing that you need to consider is if there is a consistent appearance between the traffic and non traffic areas. When there is a noticeable difference between these two areas (caused by scratches, scuffing, traffic wear etc.), then this will be considered unacceptable • When the floor is not properly maintained, soil will accumulate on the surface which will present a dirty surface appearance. This will usually cover the traffic lanes with varying degrees of discoloration DUST BALLS • Any accumulation of dust balls will be considered as unacceptable MINERAL DEPOSITS • Any build up of mineral deposits will be considered unacceptable REMOVABLE RESIDUE • Any noticeable wiping marks caused by inappropriate cleaning technique (dirty mops, cloths, etc) will be considered unacceptable. • Floors which are not maintained on a routine basis will have a gradual build up of dirt accumulate on their surface which will give the floor a dirty surface appearance Note: Any surface that has an obvious residue after being cleaned using Virox, or any other cleaning chemical, will be considered unacceptable Westech Systems, Inc. Auditing Training Manual 1564107 Page 7 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT % & When performing an audit, the auditor must be able to distinguish between Housekeeping issues and Maintenance issues. Conditions such as stained or missing ceiling tiles, flaking paint, holes in a wall surface, years of finish build-up on a baseboard, tarnished washroom fixtures, etc are Maintenance issues that the Housekeeping staff must not be held responsible for. A good rule of thumb is if a tool is required to fix or remove the item (in order to clean it) than it is most likely a maintenance item (see note below). When auditing, we must look past these deficiencies and assess the surface on the accumulation of soil only. Notes: • It should be emphasized though that in some instances such as in the case where there are bugs under light lenses these items will be counted in the audit no matter what it takes to remove the bugs (i.e., with or without tools) • Any dirt found on a wall, floor, or window area that is inaccessible unless an item is dismantled should be considered a Maintenance issue. The Housekeeping Department must make arrangements with the Maintenance Department so that access can be made possible for the necessary cleaning. The frequency of the scheduled cleaning should be based on the type of area a situation like this may be found in. (i.e. ICU, office or locker room etc) ! ' The ideal time in which to audit an area is after it’s been cleaned. With the Housekeeping Departments running a 24hr work day, it is not always possible for the auditors to accommodate the timing of the cleaning being performed. With this in mind, an auditor must look at the level of soiling on a particular surface and make their judgment based on that and that alone. No matter how frequently a building is being cleaned, there will always be a certain amount of soiling on a surface. We must be able to look past a days worth of dirt while deciding to pass or fail an item. For example, when running your hand over a 6”-12” section of a bed frame and you see a very light film of dust on your fingers, this would be an acceptable level of dust on that surface. However, if your fingers are covered in what looks like fuzzy dirt then the bed would most likely receive a failing grade. Another example would be a mirror in a washroom. In a very busy area, this washroom may be used many times a day. If this mirror is located over the sink, which most are, then it’s going to receive the splashing of soapy water countless times over the course of a day. When assessing this item, first look at the top half of the glass. This should be free of smearing and smudges. If it is, this will demonstrate that the Housekeeper is doing a thorough job of cleaning this surface and any amount of soiling on the bottom half of the glass would not justify this item receiving a failing grade. If a toilet is not flushed and the bathroom has bad odour this item should not fail since it is not the housekeeper’s responsibility to flush the toilet. With garbage containers judgment also has to be used since it does not take long for a garbage can to fill up. If the garbage container has bad odour and dirt on the outside this is usually a good indication that it has not been emptied in a while. If the garbage can is full and overflowing with paper towels that do not look compacted then it might have been emptied quite recently and the auditor should consider other telltale signs in the room prior to making a decision. Westech Systems, Inc. Auditing Training Manual 1564107 Page 8 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT When doing audits on patient rooms, whenever possible, look for ones that have been discharged cleaned. This is when a patient no longer occupies that bed and the Housekeeping staff has thoroughly wiped down all surfaces before making the bed back up for the next patient who is being transferred in. This is when everything should be at its cleanest and it should be much easier to make the decision about whether the item should pass or fail. ! & ( When making a decision on whether to pass or fail a particular inspection element it is important to look at all items in the category. For instance, if there are six or eight items in the same category (i.e., six doors in one room) you must look at all of them. If 85% or more of the item or items are clean to an acceptable level than a passing score can be given or conversely if 15% or more of the item or items are dirty to an unacceptable level than a failing score can be given (referred to as the 85/15 rule). Please keep in mind the 85/15 rule is only a general rule of thumb and common sense and experience must prevail. For instance if an item is extremely dirty and/or it poses a danger (spread of infection) than it overrides the 85/15 rule. A good example where you would ignore the 85/15 rule is when you are auditing doors. For example, if there are a lot of finger marks or dirt near the door handle then a pass or fail decision should not take into consideration the 85/15 rule. This exception is based on the fact that this part of the door is an excellent way to spread infection and therefore requires more attention. Greater emphasis is being place on “human contact points” such as light switches, laundry hamper lids,,cupboard and drawer pulls, underside edges of tables, hand and bed rails, patient equipment, children’s toys, underside lip of wall mounted bumper guards etc. Soap dispensers (especially the underside) are an area of great concern if they are not properly maintained on a daily basis as these can become ideal breeding grounds for Microbes. When encountering heavy concentrations of soiling on one item or a portion of an item (i.e. one door of six or a portion of one wall) the auditor should disregard the 85/15 rule and fail the item because of the degree of soiling found. Another important consideration to make when auditing a room is to not count the same items twice in two different categories or inspection elements. For instance if the top of a cabinet is unacceptable you would (and it warrants a fail) then count this item in the proper category which in this case would be furnishing/fixtures. Do not count the top of the cabinet again in the high dusting category since if you did this it would be considered “double dipping”. The following listing of the different inspection elements defines which category the inventory items in a room belong to. When encountering dirty film, spots or marks on a surface, it’s important that these are tested (by using a wet wipe or wet paper towel) to insure they are removable before failing an item. Use a wet wipe or damp white paper towel comes into play. When film, spots or marks are not removable, the responsibility may shift away from the Housekeeping department and become a maintenance issue. Judgment is needed as to whether a film, spot, or mark can be removed with a chemical and pad e.g. streaky stainless steel, scuff marks on baseboards, etc. ) We have found the following tools extremely useful when auditing: • • • A powerful pen flash light works well for dark areas under beds and corners. A telescoping mechanics mirror is extremely helpful to access hard to reach areas such as high dusting or under beds. Handy wipes or wet paper towels to see if the dirt is removable (especially in areas under sinks and dispensers). Westech Systems, Inc. Auditing Training Manual 1564107 Page 9 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • Optional equipment – camera and a pad of sticky notes so that date and location information can be recorded. Note: • Auditors should not wear protective gloves when auditing • After each audit it is important to wash your hands in order to reduce the risk of spreading infection Inspection Elements That Have Sub Categories When inspecting certain inspection elements (walls, carpets/mats, interior windows, patient equipment, furnishings/fixtures, waste containers, sinks or toilets), the auditor is required to document the specific “sub-element” within each of these categories that is unacceptable. Specifically, the auditor can pick one or all of the specific items from a sub category list. As an example, when an item such as patient equipment has failed, the auditor has to pick the specific element in the patient equipment category that has failed such as “commodes” and/or “call bells”. The following list provides some EXAMPLES of some of the sub categories that appear in the patient equipment category. Please note that the subcategories are different for each inspection element and some inspection elements do not have any subcategories. Example Subcategories Commode IV Poles/Pumps/ Suction Wall Mounted Equipment Lifts/Traction Bars Over Bed/Bedside Tables Wheel/Geri Chairs/walkers Sharp containers Call Bells Once the sub category item/s have been picked, the auditor then picks from the following fail prompt list which will give further information on why the item/s have failed. Example Fail Prompts (different for each inspection element) o Adhesive Residue o Blood o Cobwebs - any accumulation of dust that forms a webbing effect to a surface o Dust - anything that can be easily removed by dry dusting o Feces/Urine o Finger Marks - any substance on the hands that will leave finger marks o Sharps Over 3/4 o Removable Spots - anything that will transfer onto a wet paper towel o Removable Residue - dirty cloths/solution will leave very noticeable wiping marks on the surface o Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting o Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Westech Systems, Inc. Auditing Training Manual 1564107 Page 10 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT " 1. DOORS Definition - All types of doors (including door grilles, overhead doors), sills, surrounding frames, door glass, door closers and hardware, and moldings. Conditions Expected – Clean means: free of dust, removable marks, soil/fluid build up, cobwebs, and adhesive residue. 1. 2. 3. 4. The door, sills and tracks appear to be clean as per the conditions expected. Both sides of the door, all the edges, the frame, moldings and door closer mechanism are clean. There are no removable marks on the doors, sills, and kick plates. The door hardware including the handles, knobs, hinges and push bars are clean. The specific fail prompts for the above item are Note: • That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: Door Door Frame Contact Points o o o o o o o o o o Adhesive residue Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Finger Marks - any accumulation will be considered unacceptable Graffiti – Only put this comment in if housekeeping is able to remove it. If it requires maintenance to remove it then enter a comment and don’t fail the item. Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty mops/cloths) and or inappropriate cleaning solution dilution Removable Spots - anything that can be removed using a damp paper towel Scuff Marks - caused by shoes, protective bumpers on equipment and patient equipment Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Auditing Note: • As a general rule if the door opens into the area being audited, such as a room or hallway, the entire door (this will include both sides of the door, the door frame and the molding) will be part of that area. o An exception to this rule is if a patient room door or a washroom door opens into the hallway it should be audited as part of the patient room or washroom audit since it is Westech Systems, Inc. Auditing Training Manual 1564107 Page 11 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT extremely important that this inspection element is checked. If you are auditing the hallway as well then do not audit the doors that you audited as part of the patient rooms or washrooms. • The top frame or sill of the door way should be checked on both sides of the door that you are auditing. Thus if a door opens into a patient room then you would audit the top frame of the door in the hallway and inside the room. • When auditing doors if there are a lot of finger marks or dirt near or on the door then a pass or fail decision should not take into consideration the 85/15 rule. This exception is based on the fact that this part of the door is an excellent way to spread infection and therefore requires more emphasis. • If auditing in a hallway that falls between two sets of fire doors, and these doors open in opposite directions, only audit the doors which open into the area you are in. • In the odd case where you have a sliding or swinging door audit the door no matter which side of the room you are in. • In a main entrance, audit both sides of a sliding door. • Large & small partition doors are audited as part of walls. Access doors are audited as part of its location i.e. ceiling or wall. • A vent in a door should be counted in the door category. • A mirror on a door should be counted in the mirror category. • Blinds are counted in the window coverings category. Westech Systems, Inc. Auditing Training Manual 1564107 Page 12 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 2. WALLS Definition - All types of walls including hand and chair rails, room dividers including columns, low partition walls, cubicle walls, chair rails, wall bumper rails, washroom stall partitions (including mounting brackets and door hardware), switch plates, panels & outlets. Any vertical piping going up the wall (not counting plumbing fixtures under the sink or toilet) should also be counted in this category. Horizontal piping below five feet would also be counted in the wall category. Conditions Expected - Clean means: free of dust, removable marks, soil/ fluid build up, cleaning fluid residue, streaking, cobwebs and adhesive residue. 1. The surface of the walls appear to be clean as per the conditions expected 2. There are no removable marks 3. Walls requiring polishing are kept in polished state and appear clean, including wall plaques The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: o o o o o o o o o o o o Stall Partitions - any type of structure that surrounds a toilet, inclusive of stall door, or is placed between urinals Walls Room Dividers Wall bumpers Adhesive residue Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Feces/Urine Finger Marks - any accumulation will be considered unacceptable Graffiti – Only put this comment in if housekeeping is able to remove it. If it requires maintenance to remove it then enter a comment and don’t fail the item. Removable Spots - anything that can be removed using a damp paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Scuff Marks - caused by protective bumpers on equipment and patient equipment Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Auditing Note: • When encountering cobwebs that are attached to the walls and the ceiling, these must only be failed in one category either the walls or the ceiling. An exception to this rule is if there are an excessive amount of cobwebs on both the walls and ceilings. • If the top portion of a wall surface has dust on it, this will be counted as dust on the wall and will not be including in the high dusting category. The same will apply for low dust. • The top of a bathroom stall partition is included in this category and not high dusting. Westech Systems, Inc. Auditing Training Manual Page 13 of 71 1564107 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • The handrails on stairwells and elevators are included in this category. • Pictures, bulletin boards, white boards, clocks, fire bells, fixed signage, etc. that are on the wall surface are not part of the wall, these items will fall under the furnishing or high dusting category. • Shower walls, walls around a tub and the wall area directly behind a toilet will be covered in the sink/tub/shower or toilet category. • Horizontal piping above five feet should be counted in the high dusting category. • Assist bars in the toilet or shower area will be counted as part of the toilet or shower inspection items. • The underside lip of wall mounted bumper guards should be checked for blood. On a few occasions bloody finger prints have been found in this area This is a contact point that is most often over looked. By elevators or patient rooms it is not uncommon for people to lean against the wall and put their finger tips right on these areas. Westech Systems, Inc. Auditing Training Manual 1564107 Page 14 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 3. CEILINGS Definition - All types of ceilings, Conditions Expected - Clean means: free of dust, removable marks, soil/fluid build up, cobwebs, adhesive, strings or wire that is not in use. 1. The ceiling appears to be clean as per the conditions expected 2. T-Bar/support frames are clean The specific fail prompts for the above item are o o o o o o Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Removable Spots - anything that can be removed using a damp paper towel Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Auditing Note: • When evaluating a ceiling, have a good look around where the ceiling vents are located (remember, the vents have their own category so don’t include them in with the ceilings). This is usually where the greatest accumulation of dust will be found with this item. • Most ceiling tiles used for suspended ceilings are porous and will stain very easily when any liquid comes in contact with them. Once they become stained, they are almost impossible to clean and will usually need replacing. Remember, this is now a Maintenance issue. • There is a suspended ceiling tile that has a very thin vinyl coating. This product can be easily wiped removing any substance that has been splashed onto it. • The t-bars holding the ceiling tiles in place are easy to wipe and should be counted as a housekeeping item in the ceiling category. Westech Systems, Inc. Auditing Training Manual 1564107 Page 15 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 4. VENTS/REGISTERS/EXHAUST HOODS Definition - All types of air vents, heat registers, hood exhausts whether on a wall or a ceiling Conditions Expected - Clean means: free of dust, removable marks, cobwebs, debris and soil/fluid build up 1. The vents, hoods and heat registers appear to be clean as per the conditions expected The specific fail prompts for the above item are o o o o o o o o Adhesive residue Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Removable Spots - anything that can be removed using a damp paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Auditing Note: • When inspecting vents, registers or exhaust hoods concentrate on the outer surfaces and the area inside the vent if it can be removed by a vacuum. Areas of the vent that are not accessible by a vacuum or cloth that require cleaning will be considered a maintenance item since a tool will be required to access these areas. If the cleaning of the vent is considered a maintenance item a note should still be entered. • A vent in the door should be counted in the door category. • This category includes speakers on the ceiling. Westech Systems, Inc. Auditing Training Manual 1564107 Page 16 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 5. HARD FLOORING Definition - All types of hard flooring including stairs, risers, stair treads, stair nose, transition strips, metal thresholds, elevator tracks. Conditions Expected - Clean means: free of dust, dust balls, debris, soil/fluid build up, removable marks and has the appropriate gloss 1. 2. 3. 4. 5. The floor appears to be clean as per the conditions expected The floor has a consistant appearance from wall to wall There is no soil build-up including corners and edges The stair risers, stair nose appear to be clean. There is no accumulation of dust or debris in the tracks of elevators and in the grooves of thresholds The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: Floor Corners & edges o o o o o o Blood Debris – accumulation of paper, tissue, needle caps, sand, gravel etc. Dust – anything that can be easily removed by dry dusting Dust Balls – often called dust bunnies, under beds, stairways, hallways etc. Feces/Urine Inconsistent Appearance – discoloration from lack of proper cleaning. o Removable Residue - Any noticeable mopping marks or sticky residue caused by inappropriate cleaning technique (dirty mops) and or inappropriate cleaning solution dilution Floors which are not maintained on a routine basis will have a gradual build up of dirt accumulate on their surface which will give the floor a dirty surface appearance. Removable Spots – anything that can be removed using a damp paper towel Scuff Marks – caused by shoes , equipment and furniture wheels Soiled – accumulation of wet or dried soil that can’t be removed by dry dusting o o o Auditing Note: • Auditing a floor is one of the toughest inspection elements to accurately and consistently make a decision on. When assessing whether to pass or fail a floor that isn’t excessively soiled or extremely clean the first thing to keep in mind is to apply the 85/15 rule. With the 85/15 rule in mind the auditor should be looking for the following issues when determining whether or not to pass or fail a floor: o Surface soiling that is easily removable with a wet wipe or damp paper towel. Use a wet wipe or damp paper towel, and rub the floor surface in a non traffic area about 6-8 inches away from a wall. It is best to do this in two or three areas if you are having trouble making your Westech Systems, Inc. Auditing Training Manual 1564107 Page 17 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT o o o o decision. The traffic lane should also be tested and there should not be a huge visual difference between these two areas. Inconsistent Appearance caused by surface soiling (not able to determine using a wet wipe). When a floor is not project cleaned on a regular basis, the surface will gradually become soiled and present a dirty appearance. This condition usually does not cover 100% of the floor and may be heaviest in the traffic lanes. A dead give away as to how dirty the floor really is happens when aggressive spot cleaning has taken place, usually in the removal of black scuff marks using a pad. This action causes very noticeable cleaned lines in the surface soiling. Inconsistent Appearance caused by traffic wear is the responsibility of the housekeeping department. A floor should have a consistent appearance from wall to wall whether it has a floor finish applied or not. When traffic wear is not repaired on a regular basis, the gradual accumulation of scratches, scuff and black heel marks etc. cause a definite visual difference between the traffic and non traffic areas. Inconsistent Appearance caused by staining of the floor which will not be the responsibility of the Housekeeping Department. A stain on a floor surface is always irregular in shape and will not cover 100% of the surface. There will be noticeable patches of damage which can be lighter but are usually darker than the original color of the floor. Unlike the surface soiling and traffic wear, these stains are impossible to remove. Inconsistent Appearance due to traffic damage which will not be the responsibility of the Housekeeping Department. Some resilient floor surfaces have had severe traffic damage to the point that the actual pattern of the floor in the traffic lane has been worn out. When looking at this type of damage it is very obvious that the floor is ruined and the only way to fix it is by replacing it. • The floor area right behind floor mounted toilets is counted in the “toilet” category as well as 6 inches immediately surrounding it. • Metal transition strips found in certain areas of flooring should be included in this category • If there is a dirty line on the floor around the perimeter of the room and the floor is clean everywhere else, fail the baseboard and not the floor. The reason for this is when using the 85/15 rule the dirty line around the perimeter of the room is not enough to fail the floor so to be fair the item gets counted in a lower weighted category which in this case is the baseboard. • If the floor is dirty and there is a dirty line on the floor around the perimeter of the room and the baseboard is clean then only fail the floor. Westech Systems, Inc. Auditing Training Manual 1564107 Page 18 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 6. CARPETED FLOORING/MATS Definition – All types of carpet, including matting (no matter what material the mat is made of) Conditions Expected – Clean means: free of dust, debris and soil/fluid build up 1. The carpet appears to be clean as per the conditions expected 2. There is no gum or tar, all spots are removed 3. Edges, corners and around furniture legs – are free of dust, lint and soil/fluid build up 4. If the floor under the mat is “hard floor” than it should be counted in the “hard floor” category and not this category. If the floor under the mat is carpet then both the mat and carpet are counted in this category. The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: Mats Carpets o o o o o o o o Blood Cobwebs – any accumulation of dust that forms a webbing effect to a surface Debris – accumulation of paper, tissue, needle caps, sand, gravel etc. Dust – anything that can be easily removed by dry dusting Dust Balls – often called dust bunnies, under beds, stairways, hallways etc. Feces/Urine Removable Spots – anything that will transfer onto a wet paper towel Soiled – accumulation of wet or dried soil that can’t be removed by dry dusting Auditing Note: • When trying to determine if the color discoloration on the surface of a carpet is a spot or a stain, use a wet wipe or damp paper towel. Blot or gently rub the area. If it transfers onto the wet wipe or damp paper towel, then this would be classified as a removable spot. Westech Systems, Inc. Auditing Training Manual 1564107 Page 19 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 7. INTERIOR WINDOWS/GLASS/MIRRORS Definition – All types of windows, glass, mirrors, including frames, sashes, hardware, sills, interior screens and moldings. Conditions Expected – Clean means: free of dust, removable marks, cobwebs and soil/fluid build up 1. The interior surfaces appear clean as per the conditions expected 2. The interior frames, sills, screens and hardware appears clean and are free of dust, spots, smudges, adhesives and soil/fluid build up 3. Audit both sides of the glass in high profile main entrance areas The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: Windows Mirrors Frames/sills o Adhesive residue o Blood o Cobwebs – any accumulation of dust that forms a webbing effect to a surface o Debris – wide window sills can accumulate paper, tissue, coffee cups, dead bugs etc. o Dust – anything that can be easily removed by dry dusting o Finger Marks - any accumulation will be considered unacceptable o Removable Spots – anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution o Soiled – accumulation of wet or dried soil that can’t be removed by dry dusting Auditing Note: • Make sure you determine if the dirt on the glass is on the side of the room you are auditing. If the dirt is on the other side of the room (outside in the elements or outside of the room) then don’t count it in the current audit of the room you are in. • The glass on a door is counted in the door category if the glass is only a small insert or the whole door. • Mirrors inside a dresser and over bed table are included in the furnishing and patient equipment categories respectively and not the mirror category. • Glass walls are counted as glass and not walls. • Smoked or opaque windows are counted in this category. Westech Systems, Inc. Auditing Training Manual 1564107 Page 20 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 8. WINDOW COVERINGS Definition – All types of window coverings (curtains, vertical and horizontal blinds, wood louvers etc.) Conditions Expected – Clean means: free of dust (on appearance and by touch), cobwebs, removable marks and soil/fluid build up 1. The window coverings appear to be clean as per the conditions expected 2. The window coverings are appropriate and properly hung 3. The window coverings, ie drapes\curtains, do not have a musty or dusty smell The specific fail prompts for the above item are o o o o o o o o Adhesive residue Cobwebs – any accumulation of dust that forms a webbing effect to a surface Dust – anything that can be easily removed by dry dusting Finger Marks - any accumulation will be considered unacceptable Removable Spots – anything that will transfer onto a wet paper towel Soiled – accumulation of wet or dried soil that can’t be removed by dry dusting Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Not Properly hung Auditing Note: • • • Look at the top edge of the pleats, this is an area where the dust will build-up more quickly and a gentle tap or shake of the curtain will allow you to see how much dust is released. The top of the window curtains is not high-dusting and falls under this category. If the window covering does not have a clean feel, test it with a wet wipe. Westech Systems, Inc. Auditing Training Manual 1564107 Page 21 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 9. CUBICLE CURTAINS Definition – All types of cubicle curtains. Conditions Expected – Clean means: free of dust, cobwebs, removable marks and soil/fluid build up 1. The curtains appear to be clean as per the conditions expected 2. The curtains are properly hung and in good repair 3. Curtains are uniform in length and color The specific fail prompts for the above item are o o o o o o Blood Dust – anything that can be easily removed by dry dusting Feces/Urine Removable Spots – anything that will transfer onto a wet paper towel Soiled – accumulation of wet or dried soil that can’t be removed by dry dusting Not Properly hung Auditing Note: • There will be a greater possibility of finding body fluids splashed on cubical curtains because of their proximity to the patient bed. • Do not fail the curtains if you find pen marks. • The top of the cubicle curtain track is counted in “high dusting”. • Use a wet wipe or damp paper towel to determine whether a spot or mark is removable. Westech Systems, Inc. Auditing Training Manual 1564107 Page 22 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 10. BEDS/EXAM TABLES/STRETCHERS Definition – All types of patient beds, operating room tables, examination tables, exam chairs (chemo, renal, etc), dental chairs, cots, cribs, bassinettes, isolettes and stretchers Conditions Expected – Clean means: free of dust, cobwebs, removable marks, adhesive or tape residue and soil/fluid build up 1. The bed, tables, cots, cribs and stretchers appear to be clean as per the conditions expected, for example but not limited to • frame, hand rails, head and foot boards, control panel, wheels, remote controls • storage space under, pedestal bases, wheels are locked and in proper position The specific fail prompts for the above item are o o o o o o o o o o o Adhesive residue Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Debris - accumulation of paper, tissue, needle caps etc. Dust - anything that can be easily removed by dry dusting Dust Balls Feces/Urine Finger Marks - any accumulation will be considered unacceptable Removable Spots - anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Strings or Wire - mop strand or wire that can get lodged in the wheels Auditing Note: • When looking under these items, a flashlight will help accent any unacceptable conditions that may be present. • Check the wheels for mop strands/wire and the underside of the bed and bed frame for any removable spots or residue • Items attached to beds and not physically part of the beds should be counted in the patient equipment category. • If a Geri chair is being used as an exam chair then audit it in the bed category and not the patient equipment category. • When a chair has drop down arms such as one found in a blood collection or chemo areas etc, check the underside of these for removable spots and accumulation of finger marks. Westech Systems, Inc. Auditing Training Manual 1564107 Page 23 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 11. PATIENT EQUIPMENT Definition - All types of patient equipment including wall mounted equipment Conditions Expected - Clean means: free of dust, cobwebs, debris, adhesive/tape and soil/fluid build up 1. The patient equipment appears to be clean as per the conditions expected, for example but not limited to • Wall mounted equipment-including blood pressure cuffs, suction containers, patient equipment (diagnostic) monitors, cables • Commodes- inside and outside, seat, bowl and frame, wheels • Night/Over bed tables-top, sides, legs, mirrors, shelves, drawers, wheels, (other tables will captured under furnishings) • Wheelchairs-seat/Geri chairs, back, arms, wheels, attachments, (other chairs will be captured under furnishings) • Monkey Bar/Traction Bars, assist bars. • Patient scales • IV Poles/Pumps-stand, exterior casing of pumps, wheels • Sharps Containers-clean exterior, not filled to above the fill line • Specialty equipment such as Toys, and patient lifts. • Equipment attached to the beds but not physically part of the bed. • Removable bumper pads are counted as patient equipment • Call bell buttons and cords The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: Commode IV Poles/Pumps/ Suction Wall Mounted Equipment Lifts/Traction Bars Over Bed/Bedside Tables Wheel/Geri Chairs/walkers/Patient Scales Sharp containers Call Bells Toys Underside Contact Points o Adhesive Residue o Blood o Cobwebs - any accumulation of dust that forms a webbing effect to a surface o Dust - anything that can be easily removed by dry dusting o Feces/Urine Westech Systems, Inc. Auditing Training Manual 1564107 Page 24 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT o o o o o Finger Marks - any substance on the hands that will leave finger marks Sharps Over 3/4 Removable Spots - anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Auditing Note: • Geri chairs (high back wheel chair) that are found in residential care facilities are part of patient equipment and must not be confused with other high backed styled chairs that would be part of furnishing and fixtures. • Be careful to not touch the sharps container for safety reasons. • When auditing over bed tables remember to check inside and underneath for spilled coffee, food, juice etc. • If auditing over bed tables in offices these should be counted in the furnishing category, otherwise they are to be counted in the patient equipment category. The main point is to not count them in two categories or to “double dip”. • If auditing furniture outside a patient area that is normally considered patient equipment audit it as furnishing. • Ceiling Lifts (the ceiling lift track and motor (cassette) is counted as high dusting and the handle and control unit that come down is treated as patient equipment. Westech Systems, Inc. Auditing Training Manual 1564107 Page 25 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • 12. FURNISHING/FIXTURES Definition - All types of furnishings and fixtures Conditions Expected - Clean means: free of dust, cobwebs, debris and soil/fluid build up. 1. The furniture and fixtures appears to be clean as per the conditions expected, for example but not limited to Chairs Stools Computer Monitors Artificial Plants Cabinets Lockers Diaper Decks Desks/Work stations Counters/Vanity Couches/Love Seats Filing Cabinets Patient Closets (including mirrors) Medication Carts Linen Hampers Appliances/Ceiling, wall, floor and desk fans Coffee/End Tables Meeting Room Tables Dining Room Tables Cupboards Televisions/Stands/Brackets Black/white boards/pictures/wall hanging, bulletin boards Shelving Units Fixed signage on walls The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: Carts/Hampers/Med Carts/Diaper Decks Desk/Tables/Counters/Vanities Computer Monitors/Televisions/Appliances Pictures/Bulletin Boards/Signage Seating Shelving/Cabinet/Locker/Cupboards/Closets Contact Points o Adhesive residue o Blood o Cobwebs - any accumulation of dust that forms a webbing effect to a surface o Dust - anything that can be easily removed by dry dusting o Dust Balls - often called dust bunnies, under beds, stairways, hallways etc. o Feces/Urine o Finger Marks - any accumulation will be considered unacceptable o Removable Spots - anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution o Scuff Marks - caused by protective bumpers on equipment and patient equipment o Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting o Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Auditing Note: • • • Remember include the tops of cabinets, lockers, cupboards, shelving units, book cases etc. in this category and not the high dusting category Room dividers that are part of workstations and are included in the wall category. Don’t audit personal items or decorations, use judgment. Westech Systems, Inc. Auditing Training Manual 1564107 Page 26 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • • Mirrors inside a dresser are in furnishing category and mirrors inside an over bed table are included in the patient equipment category. Use discretion when auditing painting and pictures in residential care in that some paintings can not be cleaned since the cleaning could ruin the art. Westech Systems, Inc. Auditing Training Manual 1564107 Page 27 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 13. LIGHT FIXTURES Definition - All types of light fixtures including pull cords Conditions Expected - Clean means: free of dust, cobwebs, debris and soil/fluid build up 1. The light fixtures appear to be clean as per the conditions expected, for example but not limited to • OR Lights/arms • Exam Lights/arms • X-Ray view boxes • Wall mounted • Floor Lamp • Desk Lamp • Ceiling Light • Shades and covers • Emergency & Exit lighting 2. Pull cords are clean. 3. No adhesive tape or strings are on the fixture. The specific fail prompts for the above item are o o o o o o o o Debris\bugs Adhesive residue Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Removable Spots - anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Auditing Note: • Switch plates and outlet covers are included in the wall category • The call bell lights that are mounted above a door in a hallway are included in this section • Please be careful when auditing the top of lights above patient beds. In some cases patient’s hide needles up there (use your mirror). Westech Systems, Inc. Auditing Training Manual 1564107 Page 28 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 14. PHONES Definition - All types of telephones, cradle and stalls. Conditions Expected - Clean means: free of dust, removable marks and soil/fluid build up 1. The body, mouth, cradle, ear piece and dial system of the telephone are clean as per the conditions expected 2. The cords are clean and free of soil, adhesive. 3. The back of the telephone holder is free of dust 4. The telephone stall appears to be clean The specific fail prompts for the above item are o o o o o o o Adhesive residue Blood Dust - anything that can be easily removed by dry dusting Finger Marks - any accumulation will be considered unacceptable Removable Spots - anything that will transfer onto a wet paper towel Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Make up Westech Systems, Inc. Auditing Training Manual 1564107 Page 29 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 15. HIGH DUSTING Definition - Horizontal surfaces above five feet Conditions Expected - Clean means: free of dust 1. All of the following horizontal surfaces (certain horizontal surfaces above five feet not counted in previous categories) are free of dust as per the conditions expected, for example but not limited to • Cubicle Curtain Tracks (regular curtain tracks are counted in “window coverings”). • Ceiling Lifts (the ceiling lift track and motor (cassette) is counted as high dusting and the handle and control unit that come down is treated as patient equipment. • Fire Bells • Clocks • Free hanging Signage: Defined as any signage that is hanging from the ceiling or protruding from the wall at a 90 degree angle (you can see both sides of the sign). Fixed signage is part of furnishing/fixtures and can be defined as signage that could be fixed or hanging from a wall like a painting where you can only see one side of the sign. • Electrical and plumbing piping • Emergency showers in labs. • Shower curtain rods • Mounted exit signs (only if not lighted. If lighted it falls under the light category) The specific fail prompts for the above item are o o o o Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Strings or Wire - used to hang decorations/signs and are CLEARLY not in use anymore Auditing Note: • Be careful not to count any of the items in previous categories under high dusting. It’s very important that double dipping is eliminated. The items listed in this category are ones that have not been included in any other section. For example, the top ledge of a picture and all other elements of that picture are listed in the Furnishing/Fixtures category. • As mentioned above hanging signage is counted as high dusting where as signage fixed to a wall is counted in the furnishing/fixtures category. • Any vertical plumbing going up a wall or horizontal piping below five feet are counted in the wall category. • Cubicle curtain tracks are counted in the “high dusting” category but regular curtain tracks are counted in “window coverings”. Westech Systems, Inc. Auditing Training Manual 1564107 Page 30 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 16. BASEBOARDS Definition - All types of baseboards. In areas where the floor material curves up the wall and becomes vertical the vertical portion (no higher than approximately a foot) will be counted as baseboard and not the floor. Conditions Expected - Clean means: free of dust, removable marks, cobwebs and soil/fluid build up 1. Baseboards appear to be clean as per the condition expected 2. The corners and top edges are clean. The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: o o o o o o Baseboards, corners & edges Corners & edges Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Removable Spots - anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Scuff Marks - caused by shoes and equipment Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Auditing Note: • When encountering cobwebs that are attached to the walls and baseboards, these must only be failed in one category • A bumper guard higher than 1 foot above the floor belongs in the wall category and not the baseboard category. • If there is buildup in the corner right beside the baseboard and it continues up the baseboard then fail the baseboard and not the floor. • If there is a dirty line on the floor around the perimeter of the room and the floor is clean everywhere else, fail the baseboard and not the floor. Westech Systems, Inc. Auditing Training Manual 1564107 Page 31 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 17. WASTE CONTAINERS Definition - All types of waste or recycle containers including ashtrays and used sanitary napkin containers found in bathrooms. Conditions Expected - Clean means: free of dust and soil/fluid build up and emptied as appropriate 1. All containers and ashtrays appear to be clean inside and out as per the conditions expected 2. Plastic liners, where required are clean and in place 3. Emptied as appropriate to the location The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: o o o o o o o o Recycling Container Waste Container Adhesive residue Bad Odour - inside the containers where the bags have leaked Blood Dust - anything that can be easily removed by dry dusting Graffiti – Only put this comment in if housekeeping is able to remove it. If it requires maintenance to remove it then enter a comment and don’t fail the item. Overflowing - garbage that is full past the top rim of the container Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Removable Spots - anything that will transfer onto a wet paper towel Soiled - accumulation of wet or dried soil that can’t be removed by dry dusting Auditing Note: • Whenever possible, check inside the container (the plastic bags can leak) and also have a look at the bottom. These are areas that are sometimes missed. • If the garbage inside the container is full to the point that it’s over the top of the rim, this will be categorized as overflowing, and would be unacceptable • If a waste container is empty and the liner was not changed or it’s visibly soiled by food, debris, gum and\or liquids this item should fail Westech Systems, Inc. Auditing Training Manual 1564107 Page 32 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 18. SINK/TUB/SHOWER Definition - All types of sinks, tubs, showers, assist bars (in the shower area only) and soap, paper and sanitary napkin dispensers. Conditions Expected - Clean means: free of dust, debris, mineral deposits, soap or soil/fluid build up 1. The sink, tub, or shower, showerhead, pipes and fixtures appear to be clean as per the conditions expected • Fixtures and shower heads are free of mineral deposits. • All surfaces appear to be clean. Walls in the shower or tub area appear to be clean and are free of soap or mineral build-up. • The floors in the shower area appear to be clean and are free of soap or mineral build-up. • There is no soil/fluid build up under or around the outer edges of the sink • No soil/mineral deposits in the drain catch and the drain catch is clean. The overflow trap appears to be clean. • There is no evidence of mould or mildew. • Bright metal surfaces – taps, handles and fixtures, dispensers and hold bars appear to be clean. • Shower curtain (no matter what the material type) – appears to be clean and hung correctly. • Glass shower doors – are clean and free of removable residue, streaks and finger marks • Dispensers – are clean and stocked appropriately. The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: o o o o o o o o o Sink Tub Shower Walls behind toilet Assist rails Underside Inadequate Supplies Bad Odour – Possibly coming from mildew. A certain amount of odour is acceptable since deodorants are not allowed to be used in most health care facilities. Blood Cobwebs – any accumulation of dust that forms a webbing effect to a surface Dust – anything that can be easily removed by dry dusting Mineral Deposits – leaking water taps, or the walls in shower/tub areas will present a blue/green discoloration on the surface Removable Spots – anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Soiled – accumulation of wet or dried soil that can’t be removed by dry dusting Soiled/ Fluid Build-up – heavy accumulation of soil on top of dried soil Westech Systems, Inc. Auditing Training Manual 1564107 Page 33 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Auditing Note: • • • • Check the piping under a sink for dust and cobwebs. The walls directly around the shower and tub will be part of this category. Usually a three or four foot surrounding area should be sufficient (use common sense). Check the underside of all dispensers to make sure they are being cleaned on a daily basis. The area around the sink (counter space) is counted in the furnishing/fixtures category. • Waterless alcohol based disinfectant dispensers found throughout the hospital should be audited in this category. The auditor should be looking for both cleanliness and whether the dispenser is adequately filled. • The hand soap used in dispensers can be a variety of colors with red or green being the most popular. When dispensed onto the hand, it has a white foamy appearance irregardless of what color it is. When inspecting the underside of a dispenser and you encounter a red or green colored build up, a sticky white foam or crusty white porous substance, this will clearly demonstrate that this area has not been cleaned for sometime. • Microsan dispensers that are located in corridors or other areas where a Sink/Tub/Shower are not present, will still be audited in this category. When these dispensers are found in a clean or dirty condition, the area will either receive a pass or fail for a Sink Westech Systems, Inc. Auditing Training Manual 1564107 Page 34 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 19. TOILETS/URINALS/HOPPERS/FLOOR DRAINS Definition – All types of toilets (including raised seats), urinals, hoppers/bed pan flushers and assist bars (in the toilet area only). Toilet paper and any other dispensers in the stall area are included in this category. Conditions Expected – Clean means: free of dust, mineral deposits and soil/fluid build up 1. 2. 3. 4. 5. 6. 7. 8. The front, back, sides, seat and bowl interior appear to be clean as per the conditions expected The flush handle appears to be clean Mineral deposits are not visible in the bowl, the flush rim and around the jets Bolt caps and hinges are free of dirt. Fastenings to the wall or floor show no soil deposit Floor drains are free of mineral deposits, body hair, fluff etc. Dispensers – are clean and stocked appropriately. Floor area right behind the toilet is clean. The specific fail prompts for the above item are Note - That in this category the first fail prompt (square bullet) is actually sub equipment that helps you to further define what is wrong in this category: o o o o o o o o o o Toilets Urinals Hopper Floor Drain Floor Behind Toilet Wall Behind Toilet Flush Rims Assist Rails Inadequate Supplies Bad Odour - usually coming from dried urine. A certain amount of odour is acceptable since deodorants are not allowed to be used in most health care facilities. Blood Cobwebs - any accumulation of dust that forms a webbing effect to a surface Dust - anything that can be easily removed by dry dusting Feces/Urine Mineral Deposits - can be a water line or streaks inside the bowl coming from the jets, deposits under the flush rims or blue/green discoloration of the floor drains Removable Spots - anything that will transfer onto a wet paper towel Removable Residue - Any noticeable wiping marks caused by inappropriate cleaning technique (dirty cloths) and or inappropriate cleaning solution dilution Soiled/ Fluid Build-up - accumulation of wet or dried soil that can’t be removed by dry dusting Soiled Buildup - heavy accumulation of soil on top of dried soil Auditing Note: • • The stall partitions are audited in the wall category. When checking toilets and urinals, an inspection mirror will be needed to inspect the flush rim and jet areas. Westech Systems, Inc. Auditing Training Manual 1564107 Page 35 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • • • • • • A certain amount of odour is acceptable in washrooms since most sites in BC abide by a non scent policy and are not permitted to use deodorizers and urinal pucks. Check for streaks of urine on the underside of wall mounted urinals and the fronts of toilets The floor area directly behind a floor mounted toilet and a 6 inch area around it will be audited as part of the toilet The wall area behind the toilet (that is the same width as the toilet) will be included in this category The assist rails around the toilet will be included in the toilet category. When auditing a bathroom in a patient room or office include the bathroom as part of the patient room or office audit. If you have a separate room in your database for a bathroom within a patient room please ignore it or remove it from the database (or assign it a no duty room type). A bathroom off a hallway is treated as a separate room and as such will be audited as its own entity. If the bathroom is shared between two rooms then only audit the bathroom once. Westech Systems, Inc. Auditing Training Manual 1564107 Page 36 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT * & All the functional areas in a hospital will be assigned one of four Risk Areas as defined below. All the rooms within these functional areas will be assigned the same Risk Category. In addition every room in these functional areas will also be assigned a room type. All areas adjoining the different functional areas defined below will receive the same level of cleaning in the specific area. For instance an office located beside an operating room will receive the same high level of cleaning as the operating room and will also be defined as a risk category one room. Moreover, an office in an administration area would receive a lower level of cleaning. Thus depending where an office is located it could be assigned any of the four risk categories defined below. Washrooms as well could be defined as any one of the risk level’s below. It should be emphasized though that elements specific to a washroom such as toilets, urinals, & sinks will also have a high weight associated with them since they are expected to be cleaned at a high level no matter what area they are in. 1. Very High Risk Functional Areas: (RED) • Operating Rooms (OR), OR Sterile Core, Post Anesthetic Recovery (PAR), Intensive Care Units (ICU), Burn Units, Neonatal ICU, Cardiac ICU, Angio Suites, Labour & Delivery Rooms (LDR), Special Care Nurseries (SCN), Emergency Rooms (ER), Minor OR\procedures 2. High Risk Functional Areas: (YELLOW) • • Ambulatory Care & Clinics, Medical Day care, Inpatient Units (Inpatient Units include medical, surgical, pediatric, maternity/nursery, neurology, and palliative wards), Sterile Processing (SPD), Radiation Treatment Areas. Cardiac Care Units (CCU), Chemotherapy, Renal Dialysis, Surgical day Care All washrooms (all washrooms should be risk 2 unless they are part of a patient room that is in a lower or higher risk group or in an area that is risk 1), main lobbies, public entrances (Include up to twenty feet radius extending from exterior doorways), cafeterias\retail, elevators, main stairwells, kitchen, waiting areas, children’s play areas, 3. Moderate Risk Functional (GREEN) • Rehabilitation Areas, Residential Care Units/Facilities, Psychiatric Units, Transitional Care Units, Laboratories, Morgues Diagnostic Imaging, Pharmacies, Outpatient Clinics, Soiled Utility Rooms, Special Treatment Areas (cast rooms, etc), On call rooms 4. Low Risk Functional Areas (BLUE) • Laundry\Linen areas, Offices, Staff Locker Areas, Central Stores, Receiving & Distribution Areas, Libraries, Meeting Rooms, Seldom used Stairwells, Loading Docks, External Surrounds, Health Records, Physical Plant Rooms. 5. Very Low Risk (GREY) • Interstitial space, parkade deck, telephone rooms, electrical, boiler, mechanical, restricted areas Westech Systems, Inc. Auditing Training Manual 1564107 Page 37 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Still For Discussion: • Ophthalmology OR are they Very High under Minor OR/procedures. Ophthalmology treatment clinics (out patient clinic area) are they Very High or High – or are they Moderate under out patient clinics? • Cardiac Short Stay – are they Very High as this unit is like PAR • Should the Nursery on maternity wards be added to impatient units in High Risk? • Should Renal Dialysis (RDU) remain in very high? • Should Surgical Day Care remain in Very High Risk? What risk category would a Research Wing at a Cancer Clinic be put into? • There should be a comprehensive list for each risk category – instead of a synopsis i.e. Minor OR/procedures – there should be specific areas identified – this would stop any confusion. Each Health Authority could send a list of specific names used for this area. There could also be the same done for Special Treatment areas, Diagnostic Imaging and Outpatient clinics etc. • VIHA wants Renal Unit, Surgical Day Care and Cardiac Short Stay to remain in the Very High Risk category. • VIHA wants cafeteria retail & dining rooms to be in High Risk. Westech Systems, Inc. Auditing Training Manual 1564107 Page 38 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT + • The following section is broken into tasks that are either completed on the computer or the palm pilot. ! , • Plug the palm USB cable into the computer and into the palm pilot. • Press the power button on the top right to turn the palm pilot on. Check the palm battery indicator to make sure the palm is fully charged (if it is not charged it takes just over two full hours to fully charge it when it is almost out of power). • Double check that the time and date on both the palm pilot and computer is correct. To do this on the computer click on the date – time icon on the desktop. On the palm pilot click on the “pref” icon and then the time and date button (this setting should be set correctly however it is important to double check every now and then). • Turn on the laptop and click on the SA –AUDIT icon on the desktop. o • Look at the top of the screen and make sure that the correct facility database is loaded, i.e., “SA Audit ~ Burnaby Hospital Fraser Health Authority”. If it is not go to the “Database” menu and choose the appropriate facility. After you do this make sure the correct name is now at the top of the screen. To send the database to the palm pilot so that you can begin auditing click on the palm pilot tab. The SECOND THING YOU NEED TO DO IS CLICK THE CORRECT “PALM USER ID” which is on the left hand side of the screen. Each palm pilot has a user ID stuck on the back. For instance, the user ID for a palm in the example below is “Westech Palm -25”. This step is extremely important. Westech Systems, Inc. Auditing Training Manual 1564107 Page 39 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • Click on “Send Database to Palm” When this option comes up make sure that you click on the database that you want to send to the palm pilot (you can send more than one database to the palm pilot. See example below. • Verify that the Palm User id is correct and then click on o.k. You will then be asked to • Overwrite any data in the palm (in other words this step assumes that you have previously retrieved audits since you are about to overwrite what is ever in the palm pilot); if this is the case click yes for the second time. The “please hotsync the palm now” screen will come up at which time you should press the hotsync button on the palm pilot. You should then hear a noise indicating that the connection has been made. The hotsync will be complete once you hear this noise again. Westech Systems, Inc. Auditing Training Manual 1564107 Page 40 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT The following pages will display a step by step guide that will help you get setup to perform an audit. By following this guide, you will learn the preloaded room specific database procedure as well as the Edit Room procedure. When using the Edit Room feature, a detailed table explaining the functional areas and room listings will be located in a separate part of the manual Figure 1: Button A: Home- when this is used, it will always bring you back to the Main Menu. Remember, when performing an audit, if this icon is used it will erase the current audit you are doing Button B: Menu Button C: HotSync-when sending data from the laptop to the palm pilot or when retrieving data from the palm and sending it to the laptop, this button will be used Button D: On/Off Button E: Scroll up & Down Figure 2 – SA Audit When the On/Off (Figure 1 Button D) or the Home (Figure 1 Button A) on the palm pilot is used, this is the first menu that will be seen. Tap the SA Audit icon to start the audit process Westech Systems, Inc. Auditing Training Manual 1564107 Page 41 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 3 – Select a Building Select a building site by tapping the down arrow under “Select a building” Scroll through listings and highlight the proper site The highlighted site will now appear in this area Figure 4 – Select an Auditor Select an auditor by tapping on the down arrow under “Select an auditor” Scroll through the names or auditor numbers and highlight yours Your name or auditor number will now appear in this area Tapping the Close box will take you back to the main Menu When you tap the Begin box it will take you to the following screen Figure 5 – Select a Room to Audit This screen will only appear when a room specific data based is being used, otherwise it will be blank or it will have a list of Templates The first column is the room number which will be the same as the room number listed on the floor plans being used The second column will display the room use and/or room name possibly with the physical room number that is on the door depending on how the database is set up. This will display all the rooms contained in the selected database, which could be thousands. To narrow room listing down to a manageable number, tap the Menu button (Figure 1 Button B) and select “Narrow room list” and the next screen will appear Westech Systems, Inc. Auditing Training Manual 1564107 Page 42 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 6 – Narrow Room List This will eliminate the need to scroll through a huge list of rooms in order to find the one you wish to audit The “Narrow room list” is only used if the preloaded room specific data base contains numerous rooms This “Narrow room list” will only come up when you are in the first screen that shows all of the rooms The room use will show all the different types of rooms the building has If you were to tap on the up arrow beside “Location (all)” and then highlight the floor where you are located and then tap the Select box the following screen will appear Figure 7 – Narrow the Room/Area List With the “Burrard bldg 4 Flr being selected, you can now narrow the search even further, (if needed) by choosing a selection from the Functional Area by tapping on the up arrow beside it and then selecting Intensive Care Unit. Tap Select and the next screen will appear. Figure 8 – Narrow the Room/Area List When the Continue box is tapped on this screen, it will give you an example of all of the rooms in the Intensive Care Unit on the 4 Floor of the Burrard Building. See the next screen. A room to audit can now be selected from this list. When a mistake has been made or you want to make changes to the set parameters, tap the Reset box, and it will erase all the setting and let you start again. Westech Systems, Inc. Auditing Training Manual 1564107 Page 43 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 9 – A Room to Audit th An ICU room on the 4 Floor Burrard Building can now be selected (do not select a room with a star beside it) Tap the Audit button and it will take you to your first inspection element which is Doors If you tap the back button, it will send you to the main menu from here you must follow the information in Figures 3 – 8 to get back to where you were When you have completed the desired number of room in this area tap the Menu button and Narrow Room List for your next set of rooms Figure 10 – Give the Elements a Pass or Fail The first audit inspection element that will appear is Doors By tapping one of the boxes you will either Pass or Fail the item If the area passes it will go to the next inspection element on the list If the area does not have doors, then tap the Skip box and it will go to the next inspection element on the list which is Walls Figure 11 – Select a Prompt Comment Selecting the Fail box will bring up a list of Fail Prompts One or multiple items can be selected These items will be placed into a holding basket just above the Remove box Westech Systems, Inc. Auditing Training Manual 1564107 Page 44 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 12 – Select a Prompt Comment In brackets, the (3) indicates that three items from the list have been selected and one of those items is "FINGER MARKS” By tapping the down arrow a list of all selected items will come up If you wish to remove one or all of these items, first select which one is to be removed and then tap the Remove box. Repeat for each item. When satisfied, tap the finished button and it will take to the next inspection element, walls If you notice something else you wish to add or delete from Doors, tap the Prev button on the Walls screen, tap the Fail prompt. This will take you back to the select a prompt comment area for Doors Use the finish button to return to walls Figure 13 – Sub Equipment & Fail prompts Walls, Patient Equipment and Furnishing/Fixtures are the only inspection elements that will contain two separate categories of fail prompts. The first prompts that come up when you fail patient equipment are the sub categories of equipment such as commodes, I.V Poles, etc and after you select these items the next elements are the fail prompts telling why the item failed such as dust, soiled, etc. Figure 14 – Select a Prompt Comment The first section contains the sub categories of equipment within the category The second section contains the possible fail prompts One or multiple items can be selected Pick from the sub categories of equipment first and then pick the reason the sub equipment failed (i.e. feces-urine, etc). I.e., Commode, Wall mounted equipment, Lifts-traction bars, cobwebs, feces/urine, dust. These item will be sorted alphabetically Westech Systems, Inc. Auditing Training Manual 1564107 Page 45 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Menu Button Options When you tap the menu button (Figure 1 Button B) while performing an audit, a drop down screen will appear displaying three separate options that can be used. How do I audit this item? Enter Comment or Cancel Current Audit. Figure 15 – How Do I Audit This Item? When unsure as to what is involved with auditing a particular inspection element, tap the Menu button (Figure 1 Button B) this will bring up the “How do I audit this item” screen Select “How do I audit this item?” and a screen will come up giving a brief description of what is contained in the inspection element you are requesting information on, in this case it’s the patient equipment category Once there is a better understanding of how to perform the audit, tap OK and it will take you back to where you were Figure 16 – How Do I Audit This Item? Here is another example of “How do I audit this item?” This explains the high dusting category. It will also make reference to items which are not included in this category Tap OK and it will send you back to the high dusting category Figure 17 – Enter Comment At anytime during the audit, you can enter a comment in the overall comment area by tapping the menu button and then tapping Enter Comment from the drop down menu. The following screen will appear Westech Systems, Inc. Auditing Training Manual 1564107 Page 46 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 18 – Overall Audit Comment Before all of the inspection elements have either been Passed, Failed or skipped , this screen will appear This feature allows comments to be added that were not covered in the prompt specific category or safety/maintenance issues may be recorded If the room specific database is not being used, then room number and location comments can be added Tap the centre of the screen and the following box will appear If there are no inspection comments required, tap the OK box Figure 19 – Keyboard Using the keyboard, type in comments such as “Broken toilet seat” When finished, and you are happy with the comment, tap the Done box. This will save the typed comments and it will display the same screen pictured above which will include any comments that were added. If editing is needed, tap the centre of the screen, make any necessary changes, tap Done and then OK Figure 20 – Want to Cancel Current Audit At anytime during an audit you can quickly exit the current audit by tapping the OK button. This will cancel the current audit without saving it all other saved audits will be okay. When doing this, it will take you back to the room listings area where you can make another room selection. If you wish to continue auditing, then tap the Cancel button and this will bring you back to your current position Westech Systems, Inc. Auditing Training Manual 1564107 Page 47 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 21 – Press the Home Button by Accident If at anytime during the audit the Home button (Figure 1Button A) is activated, this screen will come up. The only way out is to tap the OK box. Once this is done, you will be sent back to the Menu screen (Figure 2) and that audit will be lost. Any completed audits that were previously saved will be okay. You must now complete the steps shown in figures 3-9 When these steps have been completed you will see the next screen Figure 22 – Give the Elements a Pass or Fail The first audit inspection element that will appear is Doors By tapping one of the boxes you will either Pass or Fail the item If the area passes it will go to the next inspection element on the list If the area does not have doors, then tap the Skip box and it will go to the next inspection element on the list which is Walls Complete an audit by selecting Pass, Fail or Skip for each of the 19 inspection elements th Figure 23 – 19 Inspection Element The last inspection element is Toilet\urinal\hopper From here you are able to go back and check any of the previous inspection elements by tapping the Prev button. Changes can be made along the way When going back to toilets, you MUST tap the Next button. If the skip button is tapped any Pass Fail comments will be erased When back to the Toilet screen, tap the Next button and it will take you to the Overall Comments screen. Any of the typed comments that were previously added will be there. Any further comments can be added by following the instructions in Figures 18 - 19. Tap OK when finished Westech Systems, Inc. Auditing Training Manual 1564107 Page 48 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 24 – Saving an Audit If you are still not satisfied with the audit and you feel more changes are needed, tap the No box and it will take you back to the Toilet\Urinal\Hopper screen. From here you can go back into each inspection item by using the Prev/Next boxes and make any necessary changes, or use the menu icon and select the Enter Comment from the drop down screen to get back to the Overall Audit Comments area. When you are satisfied, tap the Yes box and this will save everything for the audit that was just completed and the following screen will appear Once the yes button has been used, you will not be able to make any further changes to this audit until it is uploaded to the computer Figure 25 – Select an Area to Audit The audit that was just completed is shown on the list with a Star beside it. The Star indicates a completed audit. If by accident, you chose the room with the Star beside it again and tap the Audit box, the program will allow this room to be audited again. This duplicate audit can be removed by using the remove audit feature. The History box allows you to view the completed audits (editing is no longer an option) Tap the History box and the following screen will appear Figure 26 – History Screen All of the saved audits will show up on this screen. They will be listed by Room number and the date and time it was completed If the same room number is listed multiple times this indicates that it was audited more than once. The date may be the same depending which day it was used again, but the time will definitely be different. There is no way of fixing this except by deleting one of the duplicated audits after you retrieve them to the computer. If you want to look further into the completed audit, highlight the room you want to look at and tap the View box and then tap the View box beside Scoring The following screen will appear Westech Systems, Inc. Auditing Training Manual 1564107 Page 49 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 27 – History Screen This will display all of the inspection elements that were audited. Any items that were previously skipped, will be omitted from this list The 9 indicates a passed item and the 1 indicates a failed item Tap the Done box and then tap the Done box again and it will take you back to the “Select an area to audit” screen (Figure 25) Highlight a room (that does not have a star beside it) and begin a new audit Figure 28 – Edit Room On the fly editing can be done with the Edit Room feature by making changes to the existing information or for adding rooms that are not in the database. Tap the Menu button and then tap Edit Room and a screen will appear that allows you to change or enter a room number, room name, the risk category, the high level functional area as well as the type of room. If you find a room that is under construction or there is an error in cad you can click on SF4 and insert the proper room type which in this case could be “under construction” If a room is missing from the database it can be quickly added here by first finding a room in the room listings area that is next to the missing room. Highlight this room, use Edit Room, change all of the information and then tap save. The room listings screen will now have this new room number and related information added into the palm. This newly added room can now be audited. When the audits are retrieved to the PC, this added room info will be added to the database. Figure 29 – Sort Fields Type and SF 1, SF 2, SF 3 and SF 4 refer to the following: Type: Risk Category SF1: High Level Functional Area SF2: Functional Area SF3: Location SF4: Room Use. Westech Systems, Inc. Auditing Training Manual 1564107 Page 50 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 30 – Edit a Room After all areas have been filled in, tap the Save box and a screen will appear telling you that Room Number JP 4500 has been added. Tap the OK box and then tap Cancel (this will only happen if the Room Number has been changed) Figure 31 – Edit a Room The following template room “003” has a default of a “template” room type. In order to be able to audit using this room number you will need to assign the room a specific risk category. If you don’t assign the room a risk category then the following screen will come up. Figure 32 – No Inspection Elements Error Message This is telling you that all of the necessary information was not filled in and until you do this, Template 003 does not exist Tap OK and it will take you back to the previous screen where the necessary information can be entered When everything has been correctly added the following screen will be seen Westech Systems, Inc. Auditing Training Manual 1564107 Page 51 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Figure 33 – Select a Room to Audit When using the Edit Room feature, this is what the screen will look like once a new room has been created. The Template rooms in this list refer to blank rooms with no information that can be used to speed up the process if you do not have a hospital specific database. Westech Systems, Inc. Auditing Training Manual 1564107 Page 52 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT * • % After you have finished auditing, its now time to retrieve the audits from the palm and put them on to the computer. Plug the palm into the PC. From the desk top, open the SA Audit Software, click on the palm pilot tab (MAKE SURE YOU SELECT THE CORRECT PALM USER ID) and then the “Retrieve Audits” tab. Press the hot sync button on the palm (make sure the palm is on prior to pressing the button). You should get a message on the bottom of the screen showing how many audits have been retrieved. When retrieving audits it doesn’t matter which database is currently loaded. The program will upload the results from multiple sites and send the proper data to the proper database. Westech Systems, Inc. Auditing Training Manual 1564107 Page 53 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT * % - * When an audit has been completed, you can now run a report and analyze the data that was collected. Go to the SA Audit screen and click on the Reports tab. Click the Audit history tab. There you will see two areas to choose from, Summary and Details. The Summary tab will generate reports by room number, date of audit, room type, high level functional area, functional areas, building floor, room use or by auditor. The Details tab will generate reports by prompts scored, prompt ratio report, corrective action plan, corrective action plan by high level functional area, corrective action plan by functional areas, corrective action plan by building floor or corrective action plan by room use. Under the same reports tab, another area is Table Listings. Here reports can be generated by rooms, prompt comments, high level functional areas, functional areas, building floor, room use, auditors, prompts or schemes. , - The auditing program will not allow you to start an audit until you have set up your auditor ID. This can be done by selecting the Options tab from the SA Audit screen. Then go to the Edit Tables, from this screen select Auditors. When the Edit Auditors ID comes up you are able to add your Auditor ID number as well as your name. After the data has been entered, click on the Update tab and your Auditor number and name will be saved in the system. The various tabs contained on the SA Audit screen will be used for the following functions when that tab is clicked • • • • • • • Options – gives basic setup features such as setting up a new auditor ID Reports – generates detailed reports on the completed audits Database – makes it possible to change the database from one facility to another and to backup databases. Help – tells you what version of the SA Audit program is being used Audits – displays the audits individually by room number or all at once by the date Audit Detail – shows the prompt scores for each inspection element contained in each audit Palm Pilot – used to transfer data between the PC and the Palm Westech Systems, Inc. Auditing Training Manual 1564107 Page 54 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT • • "$ Graphs – displays graphs that show auditing trends by date, room number, room type or auditor Setup – ability to change system settings (please consult with an I.T professional prior to making any changes). * ( ! "$ To e-mail a report you have to first export the report from SA Audit to either a Word document or Excel Spreadsheet. To do this go through the same procedures that you normally would go through to print a report. When you get to the screen your you normally click on the printer icon (see screen capture below) press the envelope with the arrow instead. After you press the envelope icon the following screen will come up. Make sure you click on the format dialogue box and pick either a “word for windows document” or “excel file”. After you click on o.k. on the screen in the above example the following dialogue box will come up. Your next task is to click on “my document” create a new folder if you want or pick an existing folder and then rename the report appropriately (always wise to put in the date). Westech Systems, Inc. Auditing Training Manual 1564107 Page 55 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Once you save the document in the word or excel format you can edit it or e-mail it. Westech Systems, Inc. Auditing Training Manual 1564107 Page 56 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT ! It should be noted that the following tables will differ slightly at the different facilities across BC. Specifically: • Sort Field One: The high level functional areas should remain the same at all facilities • Sort Field Two: The hospital specific functional areas will be different at all facilities based on whether or not an existing database was used to initially populate your audit database. If an existing database was not used your table will closely resemble the listing below. • Sort Field Three: The building floor sort field is entirely facility specific and is not listed below. An example could be Burrard-Four which stands for Burrard Building fourth floor. • Sort Field Four: The hospital room use sort field will be different at all facilities based on whether or not an existing database was used to initially populate your audit database. If an existing database was not used your table will closely resemble the listing below. , . % , ACUTE CARE AREAS ADMINISTRATION CRITICAL CARE AREAS COMMON SUPPORT AREAS DAY CARE SERVICES DIAGNOSTIC CARE RESIDENTIAL CARE VERIFY DATA , - AMBULATORY CARE ANGIO SUITES AUTOPSY BIOMED BONE MARROW TRANS BURN UNIT CARDIAC CARE UNIT CARE PROGRAM CENTRAL STORES CENTRAL SUPPLY CHEMICAL-ALCOHOL TRT CYTOLOGY DIAGNOSTIC IMAGING DISTRIBUTION AREAS EATING DISORDER ELECTRODIAGNOSTIC LB ELEVATORS EMERGENCY ENDOSCOPY , LINEN RECEIVING LOADING DOCKS LOBBIES MEDICAL DAYCARE MEDICAL GENETICS MEETING ROOMS MISCELLANEOUS NEONATAL ICU NON STERILE SUPPLY NUCLEAR MEDICINE OPERATING ROOMS OPTHALMOLOGY CLINICS ORTHOPEDICS OUTPATIENT CLINICS PHARMACIES PLANT ROOMS POST ANESTH RECOV PSYCHIATRIC RADIATION TREATMENT Westech Systems, Inc. Auditing Training Manual 1564107 Page 57 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT RENAL DIALYSIS ENGINEER WORKSHOPS ENTRANCES EXTERNAL SURROUNDS FOOD AREA HEALTH RECORDS STOR HIV INPATIENT UNITS INTENSIVE CARE UNIT ISOLATION AREAS LABORATORIES LABOUR & DELIVERY LAUNDRY LIBRARIES , , * BEAUTY SALON CAFE-RETAIL AREA CAFETERIA CAST ROOM CHANGE AREA CHAPEL CHEMOTHERAPY COMPUTER LAB CONFERENCE-MEETING COOLER CORRIDOR-HALLWAY DIAGNOSTIC AREAS DICTATION-CHARTING DINING ROOM ELEVATOR ENTRANCE EXAM ROOMS FILE STORAGE GIFT SHOP GYM-PATIENT GYM-STAFF HOSTEL HOUSEKEEPING CLOSET ICU BED INTERNS CALL ROOM KITCHEN-MAIN KITCHEN-PANTRY LABOR AND DELIVERY LABORATORY LAUNDRY LIBRARY LINEN HOLDING AREA LOBBY RESEARCH RESIDENTIAL SOILED ROOMS SPECIAL CARE NURSERY SPECIAL TREAT AREAS STAIRWELLS STERILE SUPPORT AREAS SURGICAL DAY CARE TRANSITIONAL CARE WAITING AREAS VERIFY DATA ) . PATIENT ROOM ACUTE PATIENT ROOM REHAB PATIENT ROOM PATIENT ROOM PSYCHIATRY PAT RM RESIDENTIAL PATIENT RES DINING PHOTO COPY ROOM PLANT OPERATIONS PLAYROOM POWER PLANT PROCEDURE ROOM QUIET ROOM RECEPTION RECREATION RESIDENT REHAB RENAL SCRUB SINK SHIPPING RECEIVING SHOWER-TUB ROOM SLEEP ROOM SMOKE ROOM STAIRWELL STERILE CORE STERILE PROCESSING STORAGE-EQUIPMENT STORAGE-MISC STRETCHER-TREAT BAY TREATEMENT ROOM UTILITY-CLEAN UTILITY-SOILED WAITING AREA WAREHOUSE WASHROOM-PATIENT Westech Systems, Inc. Auditing Training Manual 1564107 Page 58 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT LOCKER ROOM LOUNGE-DOCTOR LOUNGE-PATIENT LOUNGE-STAFF MECHANICAL MEDICATION ROOM MORGUE MULTIPURPOSE ROOM NURSE STATION NURSERY OFFICE OPERATING ROOM OPERATING THEATRE OUTSIDE PATIO PATIENT RECOVERY WASHROOM-PUBLIC WASHROOM-STAFF WASTE COLLECTION VERIFY DATA ERROR IN CAD UNDER CONSTRUCTION Westech Systems, Inc. Auditing Training Manual 1564107 Page 59 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT CARTS-HAMPERS COMMODE SEATING DESK-TABLE-COUNTERS IV POLE-PUMP-SUCT WALL MOUNTED EQUIP PICS-B BOARDS-SIGNS LIFTS-TRACTION BAR PC MON-TV-APPLIANCE OVERBED TABLES SHARPS CONTAINERS SHELV-CAB-LOCK-CUP WHEEL-GERI-CHAIRS WR STALL PARTITION ADHESIVE RESIDUE BAD ODOUR BLOOD COBWEBS DEBRIS DUST DUST BALLS FECES-URINE FINGER MARKS GLOSS NOT APPROP GRAFFITI MINERAL DEPOSITS SHARPS OVER 3/4 OVERLFLOWING REMOVABLE RESIDUE REMOVABLE SPOTS SCUFF MARKS SOILED SOIL- FLUID BUILDUP STRINGS OR WIRE REQUIRES ATTENTION CARTS - HAMPERS COMMODE COUCHES - STOOLS - CHAIRS DESKS - TABLES - COUNTERS IV POLES - PUMPS - SUCTION WALL MOUNTED EQUIPMENT PICTURES - BULLETIN BOARDS - WALL SIGNAGE LIFTS - TRACTION BARS COMPUTER MONITORS - TELEVISIONS - APPLIANCES OVERBED - BEDSIDE TABLES SHARPS CONTAINERS SHELVING - CABINETS - LOCKERS - CUPBOARDS WHEEL - GERI -CHAIRS WASHROOM STALL PARTITIONS ADHESIVE RESIDUE BAD ODOUR BLOOD COBWEBS DEBRIS PRESENT DUST DUST BALLS FECES - URINE FINGER MARKS GLOSS NOT APPROPRIATE GRAFFITI MINERAL DEPOSITS SHARPS CONTAINERS OVER 3/4 FULL OVERLFLOWING REMOVABLE RESIDUE REMOVABLE SPOTS SCUFF MARKS SOILED SOILED - FLUID BUILDUP STRINGS OR WIRE REQUIRES ATTENTION Westech Systems, Inc. Auditing Training Manual 1564107 Page 60 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT * ' RISK1 RISK2 RISK3 RISK4 TMP ZND * R1-VERY HIGH RISK R2-HIGH RISK R3-MODERATE RISK R4-LOW RISK TEMPLATE NO DUTY ' Scheme: NORMAL - NORMAL INSPECTION Room Type: RISK1 - R1-VERY HIGH RISK Prompt Description Type 10100 10200 10300 10400 10500 10600 10700 10800 10900 10950 11000 11100 11200 11300 11400 11500 11600 11700 11800 20100 DOORS WALLS CEILINGS VENTS\REGISTERS\HOO HARD FLOORING CARPET\MATS INT- WINDOW\GLASS WINDOW COVERING CUBICLE CURTAIN BEDS\STRETCHERS\EXA PATIENT EQUIPMENT FURNISH\FIXTURES LIGHT FIXTURES PHONES HIGH DUSTING BASEBOARDS WASTE CONTAINERS SINK\TUB\SHOWER TOILET\URINAL\HOPPER LOCATION-COMMENTS S S S S S S S S S S S S S S S S S S S P Weight 7 7 4 9 9 9 7 7 9 9 9 8 7 9 7 5 7 9 9 0 Scheme: NORMAL - NORMAL INSPECTION Room Type: RISK2 - R2-HIGH RISK Prompt Description Type 10100 10200 10300 10400 10500 10600 10700 10800 10900 10950 11000 DOORS WALLS CEILINGS VENTS\REGISTERS\HOO HARD FLOORING CARPET\MATS INT- WINDOW\GLASS WINDOW COVERING CUBICLE CURTAIN BEDS\STRETCHERS\EXA PATIENT EQUIPMENT S S S S S S S S S S S Westech Systems, Inc. Auditing Training Manual 1564107 Weight 6 6 3 9 9 9 4 6 6 9 9 Page 61 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 11100 11200 11300 11400 11500 11600 11700 11800 20100 FURNISH\FIXTURES LIGHT FIXTURES PHONES HIGH DUSTING BASEBOARDS WASTE CONTAINERS SINK\TUB\SHOWER TOILET\URINAL\HOPPER LOCATION-COMMENTS S S S S S S S S P 7 6 9 6 4 6 9 9 0 Scheme: NORMAL - NORMAL INSPECTION Room Type: RISK3 - R3-MODERATE RISK Prompt Description Type 10100 10200 10300 10400 10500 10600 10700 10800 10900 10950 11000 11100 11200 11300 11400 11500 11600 11700 11800 20100 DOORS WALLS CEILINGS VENTS\REGISTERS\HOO HARD FLOORING CARPET\MATS INT- WINDOW\GLASS WINDOW COVERING CUBICLE CURTAIN BEDS\STRETCHERS\EXA PATIENT EQUIPMENT FURNISH\FIXTURES LIGHT FIXTURES PHONES HIGH DUSTING BASEBOARDS WASTE CONTAINERS SINK\TUB\SHOWER TOILET\URINAL\HOPPER LOCATION-COMMENTS S S S S S S S S S S S S S S S S S S S P Weight 8 8 5 9 9 9 8 8 6 6 6 8 8 9 8 6 8 9 9 0 Scheme: NORMAL - NORMAL INSPECTION Room Type: RISK4 - R4-LOW RISK Prompt Description Type 10100 10200 10300 10400 10500 10600 10700 10800 10900 10950 11000 11100 11200 11300 11400 DOORS WALLS CEILINGS VENTS\REGISTERS\HOO HARD FLOORING CARPET\MATS INT- WINDOW\GLASS WINDOW COVERING CUBICLE CURTAIN BEDS\STRETCHERS\EXA PATIENT EQUIPMENT FURNISH\FIXTURES LIGHT FIXTURES PHONES HIGH DUSTING S S S S S S S S S S S S S S S Westech Systems, Inc. Auditing Training Manual 1564107 Weight 5 3 1 5 5 5 4 3 3 3 3 2 2 5 4 Page 62 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT 11500 11600 11700 11800 20100 BASEBOARDS WASTE CONTAINERS SINK\TUB\SHOWER TOILET\URINAL\HOPPER LOCATION-COMMENTS S S S S P Westech Systems, Inc. Auditing Training Manual 1564107 3 5 9 9 0 Page 63 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT # ) - . # If new reports or features are created for the system then Westech will e-mail the contact at each health authority to instruct them to update the system. The following are the steps that are required to update the system. 1. Download the latest SA Audit Update.exe from tclean.com. Click on 1. “Software downloads” 2. “Stand Alone Audit” (on the right) 3. The blue text “Download now”. When the “file download” box comes up save the file to your USB Key or to your desktop depending on where your SA Audit software resides. Make sure you write down the latest version of the SA Audit program for the computer and the palm pilot (they are different; in the example below SA Audit on the Computer is version 1.5.28 and SA Audit for the Palm is 1.5.12). 2. Run the update.exe file from the USB key (or desktop) and follow all the instructions. This step will update the SA Audit program on the computer (to run this file simply double click on the blue icon). 3. After updating the SA Audit program on the computer update the SA Audit program on the palm pilot by doing the following: a. Start SA Audit on your computer Westech Systems, Inc. Auditing Training Manual 1564107 Page 64 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT b. Click on the Palm Pilot tab (see below) 4. Click on the Option menu on the top left. 5. Click on the Palm Pilot option under the Option menu and then pick on the “load audit program” option. 6. Then follow the specific instructions on the screen. Keep in mind that when the program asks you for the Palm User I.D it is referring to the name of your Palm Pilot and NOT your Auditor I.D. 7. Start the SA Audit program on the Laptop and press Palm Pilot tab and then choose “Send a database to Palm”. 8. Make sure that both the computer and Palm have the correct version number by doing the following: a. Latest Computer SA Audit Version Number is on the screen when you first load the program b. Latest Palm Pilot SA Audit Version Number is on the screen when you first load the program (after you have loaded the database as described above in step 7). & # "/ ! • To following steps will enable you to easily create a backup file of the different databases you are using. Specifically the system will automatically create a backup ZIP file (compressed file) and give it a name with the current date and time. • Make sure you are in the right database you want to backup by ensuring the name is on the top bar. If the correct database is not listed on the top bar then click on the “change current database” option. Pick the right database. • Once the correct database is loaded click on the database tab again and choose the backup database option. The program will automatically create a database zipped with the hospital name and the current date and time stamp. This file will be stored in the winzip folder under the folder where you databases are stored. The next time you backup a file the previous backup file will be moved to the archive folder under the winzip folder. Westech Systems, Inc. Auditing Training Manual 1564107 Page 65 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT In the following example the databases are stored in the FHA directory and the zip file with the database name with time and date got stored in the FHA\Winzip directory. In this example, the same database was backed up a minute later and you can see that the file is put in a FHA\Winzip\Archive directory. • To e-mail the zip file simply go to Outlook and insert the newly created zip file. Always make sure you check the time and date to ensure that you are sending the right file. If you don’t have e-mail on your computer copy the zip file to a USB key. Westech Systems, Inc. Auditing Training Manual 1564107 Page 66 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT $ Future Maintenance Comments: • When testing mark and spots make sure that they are not removable • Ability to assign multiple maintenance comments to each inspection element. • Area under construction – put in overall comment section • We should be selective as what we put in here. • Sprinkler heads & bugs in the light lenses are fair play, it is a cleaning issue. But the auditor should put these items in the maintenance comments as well as failing the item if it is bad enough. • Ceiling tile that need replacing MANAGEMENT ISSUES • If a building has an area that is more prone to dirt than this area will require more attention. • We have to stick to a set standard for measuring cleanliness. • We are doing cleaning audits, operationally we have to adjust for items that are not cleaned by housekeeping such as rental TV’s and phones Other Issues • The larger and less important the item will have more latitude • Maybe take out 85/15 rule • Maybe a list of show stoppers depends on item you are looking at, if you go into an area where a VRE clean happened the 85/15 means nothing. • Walls with residue from cleaning: at the end of the day it has to looked like it has been cleaned. Define what is excessive residue . • Minimal amounts of residue is o.k, but not in a high profile area, Glass surfaces such as windows, mirrors, TV and monitor screens etc. should be streak free. • Maybe define where the 85/15 rule does apply. • Maybe the ruling depends on the area type. • Westech Systems, Inc. Auditing Training Manual 1564107 Page 67 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT & 0 ' , Health Authority/Site:__________________ Building Name:__________________ Risk Category (1, 2, 3 or 4):_____ Functional Area:__________________________ Room Name__________________________ Room Number___________________ Comment Code Inspection Element Put a check mark under the appropriate column, skip if not applicable 1 DOORS 2 WALLS 3 CEILINGS 4 VENTS\REGISTERS\HOOD 5 HARD FLOORING 6 CARPET\MATS INT- WINDOW\GLASS\ MIRROR WINDOW COVERING 7 8 11 CUBICLE CURTAIN BEDS/EXAM TABLES STRETCHERS PATIENT EQUIPMENT 12 FURNISH\FIXTURES 13 LIGHT FIXTURES 14 PHONES 15 HIGH DUSTING 16 BASEBOARDS 17 WASTE CONTAINERS 18 SINK\TUB\SHOWER 19 TOILET\URINAL\HOPPERS FLOOR DRAINS 9 10 Pass Fail Code If an item “fails” put one of the following numbers corresponding to the comment in the “Code” Column. 1-Adhesive Residue 2- Bad Odour 3- Blood 4- Cobwebs 5- Dust 6Dust Balls 7- Debris 8- Feces/Urine 9-Finger Marks 10- Graffiti 11- Mineral Deposits 12- No Appropriate Gloss 13- Overflowing 14- Removable Residue 15-Removable Spots 16-Scuffs Marks 17-Sharps over ¾ 18-Soiled 19-Soiled Buildup 20-String or Wire 21-Requires Attention Comments:__________________________________________________________ Westech Systems, Inc. Auditing Training Manual 1564107 Page 68 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Name of Auditor:____________________________ Date:____________________ Westech Systems, Inc. Auditing Training Manual 1564107 Page 69 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT ' * 1 Each health authority should append a list of any specific cleaning requirements not covered in this manual. Some of the typical items that may or may not be the responsibility of the housekeeping department are as follows: In some areas only the floors, garbage and/or counters are cleaned by housekeeping. Sprinklers Exposed pipes Laundry equipment Telecommunication rooms Computer rooms Sharp containers Computer Keyboards Computer CPU’s The inside of lights (i.e., bugs in lights) Appliances such as fridges and microwaves Isolettes and bassinettes. Carpet stains Graffiti Filling and cleaning dispensers o Sanitary napkins o Toilet paper o Paper towel o Soap Toys Etc. Westech Systems, Inc. Auditing Training Manual 1564107 Page 70 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY Revision Seven D - DRAFT Access Panel Door Folding Grille Westech Systems, Inc. Auditing Training Manual 1564107 Page 71 of 71 Attachment A to Appendix 4E – Cleaning Outcome Standards (RJH) EXECUTION COPY