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Auditors

Page content: List of qualified Victorian cleaning standards auditors | An overview of auditing | Types of audits | Who can audit? | Weighting and scoring| List of registered training organisations (RTOs)

List of qualified Victorian cleaning standards auditors

A list of qualified Victorian cleaning standards auditors (QVCSAs) will be compiled following course implementation in 2009.  The following list is a list of recognised interim assessors.

An overview of auditing

This section provides an overview of important processes and principles to consider when undertaking a cleaning standards audit. The department specifies the frequency of auditing that is required and the acceptable quality level (AQL) for each functional area risk category.  For more information about the cleaning standards including elements, functional areas and functional area risk categories go to The cleaning standards for Victorian health facilities 2009.

Types of audits

Internal audits:

As part of quality improvement and patient safety processes, health services require a comprehensive, continuous, systemic approach to monitoring cleaning outcomes within their facilities. Internal audits should be performed in all functional areas across all functional area risk categories. A systemic program of internal auditing, as well as the results of all internal audits undertaken, should be clearly documented.

Cleaning audit scores should be equal to, or higher than, the specified AQL for each functional area risk category. The frequency with which any particular functional area should be audited depends on what functional area risk category it falls under. The table below provides the specified frequency of internal auditing and AQLs for each risk category:

Required frequency of internal auditing and AQLs for each functional area risk category

External audits:

In addition to an ongoing internal cleaning standards auditing program, facility-wide cleaning standards audits, undertaken by an external auditor, are required. As is the case for internal audits, external cleaning audit scores should be equal to, or higher than, the specified AQL for each functional area risk category.

An external cleaning standards audit includes the examination of a health service’s internal auditing program and the results for all internal audits. A health service must be able to demonstrate or produce the following:

• a comprehensive mapping, or catalogue, of all rooms within the health service with accompanying risk profile (this is sometimes referred to as a ‘tree’ or ‘network map’ and may show the health service, then each facility within the health service, then the buildings comprising each facility, followed by the functional areas within each building and finally the individual rooms within each of the functional areas. Some mapping also indicates floors or levels within buildings as a navigational aid for auditors)
  
  
• an auditing frequency schedule, diary or timetable based on the specified frequencies for functional area risk categories
  
  
• reports of all audits undertaken, including variance reports complete with any required rectification and re-auditing of functional areas
  
  
• reporting and feedback processes, including evidence that variance reports are tabled at appropriate meetings such as infection control committee meetings, included in quality reports, and that feedback is given to staff including managers or supervisors of functional areas.

Following Australian Standards in sampling procedures for inspection by attributes, an external audit should include approximately a fifth of the total health facility. However, the external audit should include all functional areas in the very high risk functional area category A and at least 75 per cent of functional areas in the high risk functional area category B.

Who can audit?

There are no restrictions on who can perform internal cleaning standards audits; however, a thorough knowledge of the cleaning standards and an understanding of health facilities processes are required.

Auditors should have appropriate communication and interpersonal skills including cultural sensitivity, conflict resolution and problem solving skills. Auditors should also possess organisational, planning and time management skills as well as the observation, analytical, numeracy and technology skills needed to conduct and report on auditing activities.

In response to the 2007 review of the cleaning standards, the department commissioned the development and accreditation of a course in cleaning standards auditing. From 2010, those conducting external cleaning standards audits for Victorian public health facilities must be a qualified Victorian cleaning standards auditor (QVCSA).

Weighting and scoring

Weighting refers to an aspect of the auditing and scoring process that reflects the importance of various elements within different functional area risk categories.

Although each element should be cleaned to the required standard regardless of where it is located, door handles in a record storage and archive area pose less of an infection risk than door handles in an intensive care unit (ICU) and are therefore weighted accordingly when audited. Likewise the required cleaning standards are important in low risk functional areas such as an administrative area but critically important in very high risk funcwrittetional areas such as an ICU. Therefore functional areas are risk categorised and weighted accordingly when audited.

Weighting also addresses the urgency for rectifying identified problems within each functional area risk category. Weighting is expressed numerically for the purposes of scoring cleaning standards audits. Both the timeframe for addressing problems and the numerical expressions are linked to the concept of risk and required levels of cleaning frequency and intensity.

The following table demonstrates the relationship between numerical weighting of functional area risk categories, the level of cleaning frequency and intensity needed to meet the required standard, and the timeframe for rectifying and re-auditing any problems identified through the cleaning standards auditing process.

An audit score sheet is provided in the cleaning standards. A separate audit sheet should be used for each functional area. Examples of a functional area include:

• a general ward area comprising a number of rooms including toilets, bathrooms and showers, sterile and non sterile stock storage areas, utility rooms, day room, pantry and a nurses station
• an operating theatre complex or department comprising recovery, operating theatres, sterile storage area, scrub rooms, anaesthetic areas, toilets and other rooms
• an outpatients area comprising a number of treatment rooms, office area and utility rooms
• a department such as a physiotherapy department comprising a number of treatment rooms, rehabilitation area and offices.

Sampling within a functional area should ensure that all types of rooms are audited (for example, bathrooms, toilets, offices, bedrooms and pantries) and that approximately 20 per cent of the functional area (by square metre area) is audited. The 20 per cent sampling within clinical functional areas should be biased towards clinical and patient areas, and not towards offices and non-clinical rooms within the functional area.

Where a room or area is used for a number of different purposes with different risk weightings, the purpose with the highest risk weighting should be applied when auditing. For example, a treatment room may be used for performing invasive procedures (very high risk category A) on some days as well as for outpatients’ consultation on other days (moderate risk category C). In this example, regardless of the purpose the treatment room is being used for on the actual day of the audit, the treatment room would be audited as a very high risk category A area.

Where there are offices, tearooms and storerooms attached to very high risk category A areas, the design and layout on the area may influence what category these areas should be audited as. 

For general internal and external audits, all 15 elements relevant to a functional area should be assessed. Every element should be assessed as either acceptable or unacceptable based on the written cleaning standard for each element.

Auditors need to exercise discretion and commonsense when making judgements about the acceptability or unacceptability of an element, taking into account the degree of associated risk. For example, one or two scuff marks on a floor, or an isolated smudge on a window does not indicate that that element should fail. The element must consistently fail across the functional area to be recorded as unacceptable; for example, smudges would need to occur on several windows within the functional area for that element to fail. However, in the case of a blood or bodily fluid spill, the element would automatically fail if this was evident once in a functional area.

Auditors should also take into account the condition of the infrastructure in making an assessment. For example, it may be impossible to achieve a uniform lustre on a damaged floor surface. In this case the element is deemed unacceptable but the reason must be noted with a directive to contact the appropriate person to resolve the issue.

A demerit-based system is used for scoring. A functional area starts with 100 points and points are deducted when an element within the functional area fails. The weighting given to each element within different functional area risk categories distinguishes the relative importance and risk. The process of scoring is the same for both internal and external audits.

Scoring a functional area

Using the audit score sheet in the cleaning standards, the auditor(s) record the functional area under audit (for example, ICU), the date and their names. The auditor(s) assess and score each element within the functional area; an element scores zero (0) if it is acceptable resulting in no points being deducted from 100. An element scores one point (1) if it is unacceptable.

When the audit of a functional area has been completed weightings are applied to the elements that scored 1. The cross-reference charts contained in the cleaning standards are used to determine the actual demerit points for each unacceptable element. For example, if the functional area is the ICU and an element that scored 1 (unacceptable) was the ‘patient equipment’ element, the actual demerit points that would be recorded in column D would be 7. If an element that scored 1 (unacceptable) was the ‘pantry fixtures and appliances’ element, the actual demerit points that would be recorded in column D would be 6. All the demerit points recorded in column D are added up and the total is subtracted from 100.

Example: scoring a functional area

(The functional area in this example is the ICU).

In the example above the ICU scored 81.

Scoring a functional area risk category

Once all functional areas have been scored, an average score for each functional area risk category should be obtained for both an internal and an external audit of a health facility. To obtain an average score for each risk category the auditor should add the scores for all functional areas in a risk category together and divide the total by the number of functional areas that were audited.

On the following page is an example of how a functional area risk category is scored.

Example: scoring a functional area risk category

(The functional area risk category used in this example is high risk category B).

In the above example the health facility scored 87 in their high risk functional area category B.

Feedback should be provided to staff in individual functional areas and results of audits should be tabled at appropriated meetings – for example, quality and risk – and included in health service quality reports.

List of registered training organisations (RTOs)

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