CSSD Audit Checklist

Hospital Name: Visit Date:

Total Standards Audited: Total Compliance %:
Total fulfilled Standards:

Checklist for CSSD for SHC – Sindh Healthcare Commission Preparation and its Quality Indicators

Minor Major High Risk

Structural
Y N Y N Y N Y N
1. Is this unidirectional flow for dirty linen, tools, soiled (Traffic flow in the area proceed
⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
from dirty to clean with separate entrances/ exists for each)
2. There is ⃞ One ⃞ Two ⃞ Three or ⃞ Four Zone CSSD ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
3. Organization Chart and Qualification profile of the staff ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
4. Room temperature Device and Record ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
5. Humidity control Device and Record ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
6. Chemical Indicators and cross check ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
7. CSSD equipotent maintenance record (register or logbook) ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
8. Instrument and equipment list with assets control number (NOT fixed assets) ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
9. Signage in CSSD is properly displayed in two languages including hygiene ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
10. Fire safety – Extinguishers CO2 is available – Cross Check Expiry? ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
11. CSSD is controlled area with + air and – air process ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
12. Adequate facilities and equipment for cleaning, disinfection, drying, packing and
⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
sterilization are available.
13. Finishing, wall, ceiling and furniture are according to infection control requirements. ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
14. Gowning area is available prior to entry to clean area. ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
15. Appropriate documentation for the HVAC (Heat Ventilation air Conditioning system)
for (temperature, humidity, positive pressure in clean areas / negative pressure for ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
decontamination area, air changes /hour) is available.
16. Hand washing and disinfection facilities are available and being properly used as required
⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
by staff and visitors
17. The trolleys used for different area are clean and labelled ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞

External Quality Audit 09 April 2023 Page:1 | 3

CSSD Audit Checklist
18. Trolleys in the textile areas are properly covered ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
19. All chemical solution used in the washer disinfectors are within the expiry dates ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
20. Proper functioning of interlocking hatch ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
21. Enzymatic detergents are used in the manual cleaning with the use of soft brush & cold
⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
water
22. Surgical instruments are being disinfected, dried and arranged in the proper way ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
23. Instruments are being properly packed with indicator tape placed outside each pack, expiry
⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
date is clearly and properly printed on each pack
24. Each sterilization process is properly validated (Bowie Dick test -Biological test -Physical
⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
Parameters-Chemical indicators)
Minor Major High Risk
Policies & Process
Y N Y N Y N Y N
1. Written, approved & updated SOPs are available ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
2. System validation / calibration Record, print out, register ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
3. Infection Control Policy/SOP ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
4. Training Record of CSSD staff including housekeeping ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
5. What are the fundamental steps for sterilization process? ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
6. Linen & instrument packing are done separately ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
7. Staffs are abided by official working hours brake time, food and drink are not allowed ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
except in designated room
8. Potentially contaminated equipment handled & transported safely ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
9. SOP on Autoclave operation & maintenance ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
10. What is issuance process of sterile sets to ENT, Gynae, Dental & Ortho. ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
11. Housekeeping tools and equipment (designated for only CSSD) ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
12. Compliance of ‘Hand and Hygiene’ in CSSD ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
13. Autoclave maintenance record (register or logbook) ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
14. What is cleaning procedure of CSSD and record (register or sheet) ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
15. Approved and Signed JDs of the staff and communicated at recruitment time ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
16. What are label contents on sterile sets. ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
17. What is the expiry of sterilized equipment sets? ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
18. How are storage conditions maintained for sterilised sets? ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
Minor Major High Risk
Out Come
Y N Y N Y N Y N
1. Sentinel Event Record with corrective measure in CSSD ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞

External Quality Audit 09 April 2023 Page:2 | 3

CSSD Audit Checklist
2. Internal and External Audit Report – corrective measures record? ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
3. What is recall procedure if process is found faulty? ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
4. How would check biological indicator growth ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
5. Infection Control Surveillance Plan – CSSD perspective ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
6. All staff is putting on clean uniforms and proper protective attire ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
7. Waterproof apron, face mask, face shield are properly used ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
8. All visitors are putting on clean protective gowns ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
9. Sterile packs are being stored in clean dust free store ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
Minor Major High Risk
Cleanliness and tidiness well observed in
Y N Y N Y N Y N
a. Equipment and instruments ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
b. Receiving area ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
c. Packing area ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
d. Sterile area ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
e. Sterile store ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
f. Un-sterile store (raw material store) ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
g. Transportation carts ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞
10. No processing of single use items ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞ ⃞

External Quality Audit 09 April 2023 Page:3 | 3