Conduct Your Own Facility Site Assessment

HAIIP wants to help coach you, the Infection Preventionist (IP), to be confident in your role with performing your own site assessment and become proactive in identifying strengths, closing gaps early, and improve resident safety in your facility before outbreaks or surveys occur.

The following sections are designed to guide you through completing your site assessment and support you in recognizing your facility’s strengths, identifying gaps, and prioritizing areas for improvement. The Centers for Disease Control and Prevention (CDC) Infection Control Assessment and Response (ICAR) Tool, California Department of Public Health (CDPH) How to Conduct an Onsite Infection Prevention and Control Assessment, and HAIIP’s Site Visit Workflow were used to develop this outline.

This should feel exactly like a San Bernardino County Department of Public Health’s (SBCDPH) HAIIP nurse’s actual on-site visit.

This will help facilities:

  • Assess themselves before requesting assessment from the HAIIP Program
  • Identify immediate gaps 
  • Prepare their Infection Preventionist (IP), Director of Nursing (DON), Environmental Services (EVS), and Respiratory Therapist (RT), Wound Care teams 
  • Generate their own action plan 
  • Make the HAIIP nurse’s site visit more focused and have a higher impact in the event the visit is still needed 

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Preparation:

Walking the Floor:

Preparation

Get to know your infection prevention practices at your facility by completing these self-assessment tools:

  1. CDPH Core Self-Assessment
    • Purpose: For the infection preventionist to self-assess their facility’s foundational IP practices
  2. CDPH MDRO Self-Assessment
    • Purpose: For the infection preventionist to self-assess their facility’s management of IP practices
  3. CDPH Ventilator/Respiratory Self-Assessment (if applicable)
    • Purpose: For the infection preventionist to self-assess their facility’s IP practices related to ventilator care

After completing Self-Assessments, continue to Pre-Brief Huddle.

Preparation: Pre-Brief Huddle

Facility IP asks leadership to collaborate. Leadership may include the facility Director of Nursing (DON), Environmental Services (EVS) leadership, Respiratory Therapist (RT) (if vent/trach residents), and Wound Care nurse (if MDRO/wounds). 

Questions to Discuss:  

  • What organisms are currently present?  
  • Any recent outbreaks?  
  • Any ventilator or trach residents in our facility? 
  • Cohorting concerns? 
  • PPE supply issues? 
  • Hand hygiene trends? 
  • Interfacility transfer communication? 
  • What disinfectants are we using to clean & disinfect resident rooms and high touch surfaces? 
    • Are they on the EPA’s registered list P or list K disinfectants?

The pre-brief huddle follows CDC ICAR demographic and infrastructure pre-collection step. 

Healthcare professionals meeting in a nursing home, discussing patient care strategies and emphasizing collaboration and communication.

Preparation: Prepare Before Walking the Floor

Before starting, the IP should print all adherence monitoring tools and bring them on a clipboard/tablet:  

Additional items needed: 

  • Please be sure to also have fluorescent marker or Glo-germ and your black light and extra cotton swabs (these items can be purchased on Amazon) 
  • Pen, unit census list, list of residents on transmission-based precautions that identify MDROs
  • The IP should let the charge nurse and EVS lead know this is a routine quality improvement walkthrough, not punitive 
Cropped shot of a male nurse writing something on a clipboard.

Walking the Floor: Environmental Services (EVS)-focused

A. Start in the Resident Care Environment

  • Choose a resident room that is on transmission-based precautions
  • Walk into resident room exactly as a surveyor or outside reviewer would

B. Direct Observation: Cleaning and Disinfections of a Resident Room (EVS supervisor should be present)

  • The facility IP and EVS supervisor must observe the cleaning of a resident room 
  1. First the facility IP will use the Fluorescent Marker Tool: 
    1. Instructions: Discreetly place fluorescent marker on multiple high touch surfaces/equipment to be cleaned 
    2. Use the CDPH Adherence Monitoring Fluorescent Marker Assessment Tool
  2. Second, either the facility IP or EVS supervisor will use the CDHP Adherence Monitoring Environmental Cleaning and Disinfection Tool
    1. This tool helps to observe for EVS adherence to cleaning and disinfecting of high touch surfaces that are identified in the fluorescent marker tool and verify that proper cleaning and disinfecting practices are being done using the appropriate EPA-registered list of disinfectants, to minimize the risk of cross-contamination and inadequate disinfecting practices. 
    2. Instructional Video on Proper Cleaning and Disinfection of a Resident Room: HAI EVS Room Cleaning Video 

Questions to ask yourself during this observation: 

  • Uses EPA List P for C. auris? 
  • Uses EPA List K for C. diff? 
  • Is the patient room divided, cleaned, and disinfected in 3 zones? 
  • Clean to dirty sequence? 
  • Top to bottom sequence? 
  • Outer to inner sequence? 
  • No household chemicals are used? 
  • No personal clutter or cardboard on EVS cart? 
  • Clean microfiber supply present? 
  • Is the EVS cart organized and set up in a way to minimize cross contamination?  
  • Is hand hygiene being performed throughout the cleaning process, as needed?

Score adherence monitoring percentages as instructed on the CDPH Adherence Monitoring Tools. Set an adherence goal.

Be prepared to discuss opportunities for improvement.

This process objectively shows whether cleaning is effective, not just documented, and is especially powerful for outbreak response, rooms dedicated to patients on transmission-based precautions, MDRO (i.e. C. auris) prevention, and terminal cleaning review. 

Walking the Floor: Hand Hygiene (HH)-focused

A. Perform Dedicated Hand Hygiene (HH) Adherence Monitoring

  • The IP should complete a focused hand hygiene adherence monitoring round during your own site assessment 
  • The goal is to observe whether staff clean their hands at the right moments, use the right product, and for the right reason 
  • Use the CDPH Adherence Monitoring Hand Hygiene Tool to gather the facility hand hygiene adherence percentage 
  1. What to observe:
    1. Watch staff in real time during medication pass, wound care, resident repositioning, entering and exiting resident rooms, device care, etc. 
    2. Assess whether hand hygiene is performed:
      • Before touching the resident 
      • Before a clean or aseptic task 
      • After body fluid exposure risk 
      • After touching the resident 
      • After touching the resident environment 

These are the WHO 5 Moments of Hand Hygiene, which align well with CDPH adherence principles.

Utilize the CDPH CDPH Adherence Monitoring Hand Hygiene Tool: Observe 10 hand hygiene opportunities among facility staff.

For example, did your staff conduct hand hygiene during the following opportunities:

  • Before resident contact 
  • After glove removal 
  • After touching environment 
  • Before wound care 
  • After respiratory equipment 

Score adherence monitoring percentages as instructed on the CDPH Adherence Monitoring Tool. Set an adherence goal.

 You should aim for Green:

  • Green = 90-100% 
  • Yellow = 80-89%
  • Red = <80%
  1. Be Prepared to Discuss Missed Opportunities

This is the time to assess your facility and the barriers that may exist such as:

  • Alcohol-based hand rub (ABHR) dispensers are not immediately accessible or convenient for the workflow 
  • Staff are wearing gloves from prior tasks and not using HH before another task 
  • Empty ABHR dispensers
  • Staff do not apply enough ABHR to their hands for proper disinfection

As the IP, be prepared to give real-time coaching and guidance to staff when appropriate, for example: 

“I noticed the gloves stayed on after touching the bedrail before wound care. Let’s clean hands and reglove before touching the wound supplies.” 

Walking the Floor: Contact Precautions-focused and PPE Use

A. Perform Contact Precautions Adherence Monitoring

  1. The IP should directly observe staff and use the adherence monitoring tool to document the data.

During room entry, care, and exit, observe the following:

  • Room entry and exit 
  • Check for posting of correct isolation signage
  • PPE cart/cabinet stocked outside room 
  • Gowns and gloves readily accessible 
  • Trash receptable available 
  • ABHR immediately outside room 
  • Dedicated equipment present; or if shared equipment, disinfect outside room after use 

During care, observe the following: 

  • Hand hygiene (HH) before donning PPE 
  • Proper doffing sequence 
  • Correct gown and glove application 
  • PPE worn for all required contact with resident/environment 
  • No touching face, phone, or clean supplies with contaminated gloves 
  • Glove changes between dirty and clean tasks with HH 
  • Glove changes between residents 
  • Wound care supplies protected from contamination 
  • Shared equipment kept outside room unless disinfected 
  • No same PPE across cohort pods or residents 

Score adherence monitoring percentages as instructed on the CDPH Adherence Monitoring Tool. Set an adherence goal.

  1. Be Prepared to Discuss Missed Opportunities
    1. Give “Just in Time” training by providing education and feedback when the employee needs it or during their workflow.
    2. Try and quickly identify knowledge gaps and process barriers. 
    3. Ask staff about the resident on precautions and gauge if more education needs to be given to staff. Questions that can be asked are: 
      1. What disinfectant do you use after the equipment leaves the room?
      2. Who can initiate precautions? 

If adherence percentage is below your facility’s goal, the IP should repeat weekly adherence monitoring and share with staff.

This helps the IP assess whether frontline staff can immediately follow precautions without barriers. 

Healthcare worker wearing a face mask, face shield, gown, and gloves.

Walking the Floor: Wound Care-focused

A. Perform Wound Care Adherence Monitoring

  • Observe wound care practices step-by-step to identify infection prevention gaps and improve wound healing. 
  • The IP should complete a focused wound care adherence observation round using the CDPH Adherence Monitoring Wound Care Tool during actual dressing changes or wound treatment. 
  • The purpose is to ensure wound care is performed using aseptic techniques, clean to dirty workflow, correct PPE, and contamination prevention practices. 
  1. What to observe before wound care begins: 
    1. Hand hygiene before gathering supplies
    2. Clean wound care surfaces prepared
    3. All supplies gathered before starting 
    4. Dressing supplies protected from contamination 
    5. PPE available and correctly selected 
    6. Clean gloves available in correct size 
    7. Trash and linen receptacle available nearby 
    8. Wound cart clean and organized
    9. No supplies stored on contaminated surfaces 
  1. What to observe during dressing change: 
    1. Hand hygiene (HH) before donning gloves 
    2. Correct PPE used
    3. Proper donning of PPE
    4. Removal of old dressings without contaminating clean supplies 
    5. Gloves changed after dirty dressing removal 
    6. HH before clean dressing application 
    7. No touching surrounding surfaces with contaminated gloves 
    8. Shared items not placed on resident bed 
  1. What to observe after wound care: 
    1. Dispose all soiled dressings safely 
    2. Proper doffing of PPE
    3. Perform HH immediately after doffing 
    4. Disinfect reusable wound care surfaces 
    5. Clean and disinfect wound cart after use 
    6. Perform HH 

Score adherence monitoring percentages as instructed on the CDPH Adherence Monitoring Tool. Set an adherence goal.

Be prepared to discuss immediate missed opportunities. 

Assess wound Adherence Percentage using the tool and share findings and opportunities to improve with staff. 

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