Goal:

Region:
Facility Name:
Bed Capacity:
Auditor:
Date of Assessment:
Definition
Met
Not met
Components Standards
1.1
Infection 1.2
1 Prevention and
Control Program 1.3

Leadership 2.1
2
Support 2.2
3.1
Education of Staff
3 3.2
and Patients
3.3
4.1
4.2
4.3
HAI Surveillance
4 4.4
and Data Analysis
4.5
4.6
4.7
5.1
5 Culture of Safety 5.2
5.3
6.1
6.2
6.3
6.4
6.5
6.6
6.7
Compliance to
6 6.8
Best Practices
6.9
6.10
6.11
6
Best Practices

6.12
6.13
6.14
6.15
7.1
Teamwork and
7 7.2
collaboration
7.3

8.1

OR Equipment
and 8.2
8
Environmental
cleaning 8.3

8.4
A systematic approach by empowering healthcare providers to assess readiness for SSI Prevention
potentially life-threatening complications.

Definition
Met
Not met
Standards
The IPC program is based on current scientific knowledge, referenced I O
practice guidelines
The program is appliedand to applicable
all areasnational laws and
of the hospital regulations.
according to the scope 0 0
of service. 0 0
The program's main objective is to reduce the risk of healthcare-
associated infections (HAIs) that involves patients, staff, trainees,
volunteers, families, and visitors.
Infection preventionvisibly & control 0 0
Hospital leadership showteam theiriscommitment
given a full authority to
to SSI prevention
implement the IPC policies and procedures.
through actions like allocating resources, supplies, attending safety 1 0
Ongoing
meetings, SSI prevention
follow up andeducation
actively is incorporated
promoting into training at least
safe practices. 1 0
There is documented
annually for all healthSSI care prevention
personnels education
involved for all clinical
in care staff
of surgical
involved in surgical procedures or caring for surgical
patients (Competencies - preoperative, Intraoperative & post-operative patients. 1 0
There are written policies and procedures for surveillance of health care
phases). 1 0
There is pre-op
associated and post-op
infections, documented
using CDC-NHSN education
definitions given to by
approved patients,
national
families,
MOH and
guidelines caregivers
(e.g., as
VAP/VAE,part of their
CLABSI, role in
CAUTI, SSISSIprevention.
and MDROs 1 0
SSI surveillance
Hospital has is applied according to national MOH andguidelines (i.e.
according
selecting to athe
only 1
system
- 3
for post-operative
hospital's
types of scope
high risk
follow up
of services).
procedures and
communication
most common 0 0
with post-surgical patients (in Surgical OPD and ER) regularly after
surgeries
discharge,during
for anyatsignsleastand6 months).
symptoms of surgical site infections 0 0
(including
The patients
facility has with
a process implants).
in patients,
place to routinely review, analyze, interpret 1 0
Surveillance data (targeted numerators, denominators, and
and
device utilization ratios) are validated by IPC practitioners atsurgeries.
submit SSI data according to high-risk and high volume least once 1 0
monthly.
Surveillance data are regularly collected & reported to MOH through 0 0
Results
There isof surveillance
aapproved
shared are regularly
responsibility betweenanalyzed, interpreted,
multidisciplinary and
teams
national
communicated electronic
to infection surveillance
control committee, platform HCWs (HESN Plus).
and concerned 1 1
(surgeons, nurses, anesthesiologists, and infection control professionals)
departments.
emphasizing that preventing SSIs is everyone's responsibility, not just 1 0
The facility is transparent by sharing data on SSI rates in infection control
individual
committee roles.
and encourages open discussions about successes and 1 0
The facility creates an environment where everyone feels comfortable
challenges.
raising concerns and reporting events without fear of 0 0
IPC practitioners regularly conduct auditing rounds to blame
monitor orand
repercussions.
document (Reporting
adherenceprovides events
to recommended like OVR)practices for surgical sitesurgical 1 0
The IPC department compliance audit feedback to the
infection prevention care bundles (weekly).
HCWs regarding their performance in surgical site infection prevention 1 0
care bundles
Patients recieve regularly
bath orand corrective
shower the nightactions are and
before applied accordingly.
on the day of the 0 0
surgery
No using
preoperative 4% Chlorhexidine
hair removal soap
or use for patients
of electric >2
hair months ifand
clipperssite, hairabove. 0 0
Preoperative
Surgeons do surgical
surgical preparation
hand antisepsis of the
usingskinan atantimicrobial
the incision soap, and
removal
including isuse
necessary.
alcohol-based antiseptic solutions 0 0
scrub hands and forearms for 2 to 5 minutes OR containing Chlorhexidine
waterless surgical hand
gluconate
preparation (CHG) OR iodine.
containing 0.5% chlorhexidine gluconate in 70% alcohol 0 0
The facility has a policy for MRSA screening of the patients before
before
operativetheprocedure
surgical procedure.
and decolonize colonized patients with an anti- 0 1
Perioperative
staphylococcal glycemic
agent incontrol
the is applied with
preoperative use of blood glucose
setting. 0 0
Single-dose
target levels preoperative
less than 150 antimicrobial
mg/dl before, agents
during were
and given
after ONLY
the when
procedure
Operating
indicated rooms
and were maintained
discontinued based onat National
positive pressure
MOH +2.5
Guidelines.Pascal as a 1 0
for the firstwith
minimum tworespect
postoperative
to corridorsdays and in patients
adjacent with
areasand, air
without
change per
diabetes.
hour 15environment
ACH as a minimum with 0 0
The OR is clean, no 20%
dustsisor fresh air soil
visible andandthethe
air supplied
process of
through
environmental cleaning is performed according to MOH degree.
HEPA filter with temprature ranges from 20 to 24 0 1
recommendations regarding the disinfectants and methods of cleaning. 0 1
Surgical attire worn in the semi-restricted and restricted areas of the
surgery department includes the head cover, masks, scrub suit, warm-up
jacket,
There isand shoes.
system to maintain normothermia perioperative (30 mins 0 1
preoperative warming , during and after the operation for 2 hours). 0 1
There
The is a pre-op
surgical team team
adherescommunication
to process,
proper surgical suchtechnique.
sterile as a pre-op 0 1
Proper
briefing,dressing procedure
is in place is prior
in the OR applied to the patient
to incision including
that includes application
discussion on
of all components of aseptic technique.
antibiotic, timing, need for re-dosing; and any special considerations. 1 1
A standardized process is in place to track completion of SSI prevention 1 0
steps
There(i.e.
Floors, a incorporate
iswalls, & ceiling into surgical
are formed
multidisciplinary checklist).
of
team (SSI one piece without
Prevention connections,
Team) to implement SSI 1 1
cracks, or decorative parts, with minimal
Prevention Strategies in the facility. openings that are completely 1 0
sealed, and withstand repeated cleaning and disinfection.
1 0

Ventilation system operates all the time and never shuts down even in
long holidays, and air is introduced from the ceiling and exhausted near 1 0
the floor.
OR environment is maintained clean and there are clear procedures for
cleaning and disinfection by allocated housekeeping staff after each 1 0
surgical procedure and at least daily.
Storage areas in the OR are organized and well maintained and
distribution of sterile items following the first in -the first out (FIFO) 1 0
principle.
ess for SSI Prevention and reduce the risk of these costly and

Total Scores

D Scoring Comments D N
TRUE 1 0
TRUE 1 0

TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
FALSE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0
FALSE 1 0
FALSE 1 0
TRUE 1 0
TRUE 1 0
TRUE 1 0

TRUE
1 0
TRUE
1 0
TRUE
1 0
TRUE
1 0
Total
Score #DIV/0!
SSI Road Map Assessment Instructions:
1. SSI Roadmaps provide hospitals and health systems with
evidence-based recommendations and standards for
developing topic-specific prevention and quality
improvement programs. They are intended to align process
improvements with outcome data. Road maps reflect
published literature, guidance from relevant professional
organizations and regulatory agencies, and identified proven
practices.
2. The SSI Prevention Team will be responsible for auditing
and identifying whether current work meets the intention
behind each Roadmap component.

3. Please choose either (Met) or (Not met) for Roadmap

4. Baseline SSI Roadmap assessment should be performed

5. The baseline SSI Road map assessment must be