Audit Checklist Based on JCI Standards

1. Infection Control Department

Indicator Audit Parameters Benchmark

- Ensure that an infection control program
Infection Control 100% implementation of the
is established, implemented, and
Program infection control program.
continuously monitored.
- Ensure regular monitoring and 90% or higher compliance
Hand Hygiene
evaluation of hand hygiene compliance rate in hand hygiene
Compliance
among healthcare workers. practices.
- Ensure the hospital conducts
Surveillance of 100% of HAI data collected,
surveillance of HAIs (Healthcare-
Healthcare-Associated analyzed, and reported
associated infections) and reports data
Infections monthly.
regularly.
- Ensure that isolation precautions (e.g.,
100% adherence to
Isolation Precautions airborne, droplet, contact) are properly
isolation protocols.
implemented in high-risk areas.
- Ensure regular review of antibiotic usage 100% adherence to
Antimicrobial
and provide guidance on proper usage to antimicrobial stewardship
Stewardship
prevent antimicrobial resistance. program.

2. Biomedical Department

Indicator Audit Parameters Benchmark

Equipment - Ensure all biomedical equipment is calibrated 100% of critical
Maintenance and and maintained as per manufacturer equipment calibrated
Calibration recommendations and hospital protocols. and maintained.
Preventive - Ensure a preventive maintenance program for 100% of preventive
Maintenance all hospital equipment is followed, including maintenance activities
Schedule regular checks and safety assessments. completed.
Equipment 100% equipment
- Ensure that performance logs for all equipment
Performance performance logs
are maintained and reviewed.
Records maintained.
Training on - Ensure that hospital staff is adequately trained 100% of staff trained in
Equipment Usage on the proper usage of medical equipment. proper equipment usage.
Emergency - Ensure that emergency medical equipment 100% of emergency
Equipment (e.g., defibrillators, oxygen supply) is regularly equipment inspected and
Readiness inspected and fully operational. functional.

3. Operations Department
 Indicator Audit Parameters Benchmark
- Ensure the facility management system
100% of facility-related
addresses operational issues such as fire
Facility Management issues managed and
safety, HVAC, plumbing, and overall building
rectified.
integrity.
- Ensure emergency preparedness plans are
Safety and Emergency in place for disasters, fires, and other 100% emergency drills
Procedures emergencies, including staff training and conducted annually.
mock drills.
- Ensure hospital operations are efficient,
100% of critical systems
Operational Efficiency with minimal downtime for critical services
functioning 24/7.
(e.g., electricity, water supply).
- Ensure compliance with waste segregation, 100% compliance with
Waste Management storage, and disposal protocols, including waste management
hazardous and biomedical waste. standards.
Compliance with Legal - Ensure compliance with local regulations 100% adherence to
and Regulatory and health safety codes for all operational legal and regulatory
Requirements areas. requirements.

4. Housekeeping and Maintenance Department

Indicator Audit Parameters Benchmark

- Ensure daily cleaning schedules are followed 100% daily cleaning
Daily Cleaning of
for patient rooms, bathrooms, waiting areas, compliance in patient care
Patient Areas
and high-touch surfaces. areas.
- Ensure appropriate cleaning supplies and 100% availability of
Cleaning Supplies
equipment are used, including the availability approved cleaning
and Equipment
of cleaning agents and PPE for staff. supplies.
- Ensure that hospital environments are free of
Environmental 100% compliance with
infection risks by maintaining cleanliness and
Hygiene Compliance hygiene standards.
hygiene protocols.
- Ensure housekeeping and maintenance staff 100% of housekeeping
Training and
are regularly trained on infection control, and maintenance staff
Competency
cleaning protocols, and safety measures. trained.
100% of pest control
- Ensure pest control measures are in place
Pest Control measures in place and
and monitored to prevent infestations.
functional.

5. CSSD (Central Sterile Services Department)

Indicator Audit Parameters Benchmark

- Ensure that sterilization protocols are strictly
Sterilization Protocol 100% adherence to
followed, including equipment cleaning,
Compliance sterilization protocols.
sterilization cycles, and storage procedures.
Sterilization - Ensure that sterilization equipment (e.g., 100% compliance with
Equipment autoclaves, washer disinfectors) is maintained equipment maintenance
 Indicator Audit Parameters Benchmark
Maintenance and regularly tested for effectiveness. schedule.
- Ensure that sterile items are stored in clean,
Sterile Storage 100% sterile storage
dry, and appropriate conditions, minimizing
Conditions conditions met.
contamination risks.
- Ensure that sterilization logs are maintained, 100% of sterilization
Monitoring of
including times, temperatures, and equipment records maintained and
Sterilization Records
used, and are reviewed for compliance. reviewed.
Staff Competency in - Ensure staff is trained and demonstrate 100% of CSSD staff
Sterilization competency in sterilization techniques and trained in sterilization
Procedures infection control protocols. procedures.

6. Pharmacy Department

Indicator Audit Parameters Benchmark

Medication - Ensure that medications are stored, labeled, 100% compliance with
Management and and dispensed in compliance with hospital medication storage and
Storage protocols and regulatory standards. dispensing protocols.
- Ensure that prescriptions are verified for 100% prescription
Prescription
accuracy, appropriateness, and dosage before verification before
Verification
dispensing. dispensing.
- Ensure that pharmacy staff receives regular
Pharmacy Staff training and assessments to maintain 100% staff competency in
Competency competency in dispensing medications and pharmaceutical practices.
handling pharmaceutical equipment.
- Ensure that patient safety measures are in 100% adherence to
Patient Safety in
place for high-risk medications, including patient medication safety
Medication Use
identification and double-checking systems. protocols.
Drug Expiry and - Ensure that stock rotation is performed 100% of medications
Stock regularly and expired medications are promptly checked for expiry every
Management removed from inventory. month.

7. Radiology Department

Indicator Audit Parameters Benchmark

- Ensure that radiation safety protocols are
100% compliance with
Radiation Safety followed, including staff use of protective
radiation safety
Protocols equipment and safety measures for patients
protocols.
during imaging.
Radiology - Ensure that radiology equipment is regularly 100% of radiology
Equipment maintained and calibrated to ensure safety and equipment maintained
Maintenance accuracy in imaging. and calibrated.
- Ensure that imaging quality is regularly 100% adherence to
Imaging Quality
monitored for diagnostic accuracy, including film imaging quality control
Control
quality, exposure levels, and positioning. standards.
Patient Privacy and - Ensure patient confidentiality is maintained 100% compliance with
 Indicator Audit Parameters Benchmark
during imaging procedures and results are patient privacy
Confidentiality
securely stored. standards.
- Ensure that radiology staff is adequately trained 100% staff training on
Staff Training and
in safety procedures, equipment usage, and safety and equipment
Competency
imaging techniques. usage.

8. Emergency Department

Indicator Audit Parameters Benchmark

- Ensure that the triage process is conducted
Triage Process 100% triage compliance
efficiently, with patients categorized according to
Compliance per hospital protocols.
severity of symptoms.
Emergency Medical - Ensure that all emergency medical equipment
100% emergency
Equipment (e.g., defibrillators, crash carts) is fully stocked
equipment readiness.
Readiness and ready for use.
- Ensure that emergency care is provided in a 100% of patients seen
Patient Care
timely manner, with patients being seen within within hospital-defined
Timeliness
established timeframes. response times.
- Ensure that infection control measures,
Infection Control in including hand hygiene, PPE use, and cleaning 100% infection control
Emergency Areas protocols, are implemented in the emergency compliance in ED.
department.
Staff Training on - Ensure that staff is trained and demonstrates
100% of staff trained in
Emergency competency in emergency response and patient
emergency procedures.
Procedures management protocols.