Cleaning Standards for Victorian Health Facilities

Frequently asked questions

Which health facilities are required to complete the external and non external cleaning standards audits and report results to the department?

All public hospitals are required to report their cleaning standards data. Community health services and residential aged care services are excluded.

How do hospitals submit cleaning audit data?

The eForms for submitting cleaning audit data are available on the Department of Health Cleaning Standards website approximately two weeks prior to the submission date.

What is the difference between an external cleaning audit and a non external cleaning audit?

The auditing processes for non external cleaning audits are the same as external cleaning audits. The only difference is ‘who’ conducts the audit. Refer to Q 4 and Q5.

Who is able to perform the external audit?

The external audit is to be performed by a person/s who is a qualified Victorian cleaning standards auditor (QVCSA), having completed the appropriate training at a registered training organisation (RTO). This person cannot be an employee of the public hospital.

Who is able to perform the non-external audits?

Non external audits are to be conducted by a QVCSA, having completed the appropriate training at a RTO. This person can be an employee of the public hospital or a contracted external auditor.

Who is able to perform routine internal audits (i.e. those not reported to the department)?

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

Who is a qualified auditor?

A qualified auditor is a person that has successfully completed a Victorian Cleaning Standards Auditors course at a RTO.

A list of QVCSAs is available on the Auditors’ page. Please note that this list is not a complete list of all QVSCAs and public hospitals may engage a QVCSA that is not listed.

What if we do not have a qualified auditor in our organisation?

The options are to nominate a person to become a qualified auditor by undertaking the accredited course through a RTO. This person can then conduct the two non-external audits per year. Alternatively, the non external audits can be contracted to a qualified external auditor.

A list of trained QVCSAs is available on the Auditors’ page.

To assist with resource issues, when public hospitals are arranging for external cleaning standards audits, are they able to ‘swap’ staff?

Yes, swapping of QVCSA staff may occur as long as it is not the same person undertaking the audit every year.

While all auditors can be expected to act professionally and objectively, using the same ‘swapped’ auditor all the time may pose a risk. The risk is that, over time, some objectivity may be lost as there is never any ‘outside’ comparison with assessment and scoring.

Due to this it is recommended that a different external auditor is used each time. For non external audits public hospitals may choose to swap accredited staff at campus or organisational level.

Do hospitals have to audit the entire health facility for an external or non external audit?

No, a sample of areas from 20% of the total health care facility should be included in the audits.

The standard says that an external cleaning standard audit should include all functional areas in the very high risk functional area category A and at least 75% of functional areas in the high risk functional area category B – does this mean every room in the very high risk functional area is to be audited?

No, it means a sample of the rooms in every very high risk functional area category A and a sample of rooms in at least 75% of high risk functional areas category B should be audited. A sample should be equal to 20% of the functional area.

In the months of the three reporting audits (one external, two non external) do we need to conduct the scheduled internal audits?

Yes, for those three months internal audits should be undertaken to maintain a level of quality assurance. However, areas audited in the external and non external audits may be added to the internal audit results for example, instead of 50% of areas to be internally audited, do 30% and add the 20% from the external or non external audits.

Can QVCSAs deduct points for chipped paint, or is it a maintenance issue?

No, chipped paint is a maintenance issue and points should not be deducted for any maintenance issue. However a maintenance request ensuring the problem is repaired should be lodged in accordance with the hospital’s policy.

Do I have to report each campus of my public hospital on an individual eForm?

No, one report for a public hospital is required. You are required to calculate the average of each risk category and report the public hospital score (see example below).

How do I calculate the scores for each category at my public hospital which is comprised of three campuses?

An example is:

A public hospital has three campuses – each campus has a functional category A area. To determine the overall score for Category A, each overall campus score is added together then divided by the number of campuses.

Category A results for:

Campus X	94
Campus Y	90
Campus Z	99
Total for X, Y + Z = 283/3 = 94.3	94.3

The total score of 283 is divided by 3 (being the number of campuses) providing an overall public hospital score of 94. This is the score to be entered into the department’s data submission form.

Do public hospitals that achieve more than 90% AQL in very high risk functional areas category A, more than 85% AQL in high risk functional areas category B and more than 85% AQL in moderate risk area category C pass the cleaning audit?

Not necessarily, even though the AQL was achieved, from 2010 public hospitals must also be able to provide evidence supporting internal audits, for example, cleaning schedules and mapping.in addition to the AQL to pass the audit.

What happens if the hospital fails the AQL in a functional category?

When a public hospital fails a functional area category, the rooms that have failed to achieve the acceptable quality level (AQL) should be cleaned immediately. Public hospitals included in the Statement of Priorities are obligated to reaudit the rooms that failed the AQL within sixty (60) days.

Are ensuites counted as separate rooms?

No, an ensuite is attached to a single patient room and is therefore counted as part of that patient's room.