System — Prevention and control of infection
12 of 12 points observed
System tracer — prevention and control of infection · Dr. Tomas Lindqvist
Surveyor Tracer Final Report
Official Joint Commission International accreditation tracer summary
System — Prevention and control of infection
System tracer — prevention and control of infection · Infection Prevention
- Point Compliance
- 82%
- 11 checkpoints scored
- Findings Raised
- 0
- Actionable deficit citations
- Surveyor Sign-off
- Dr. Tomas Lindqvist
- Attested 2026-09-15
Chapter Compliance Telemetry
Standard adherence computed across all observed checkpoints for this trace
- FMS1 checkpointClean50%
- PCI8 checkpoints1 gap75%
- QPS4 checkpoints1 gap75%
- GLD3 checkpointsClean100%
- MOI1 checkpointClean100%
- SQE2 checkpointsClean100%
What you have recorded
12 of 12 points- GovernanceCompliant
Programme ownership and authority
Practice at the bedside matched the written process; the record was complete and timed.
Infection Prevention·5 of 10 records compliant·described·GLDPCI·1 evidence artifact - GovernanceCompliant
Resourcing the programme
Asked two members of staff independently; both described the same process and located the evidence.
Infection Prevention·9 of 10 records compliant·demonstrated·GLD·1 evidence artifact - Process designCompliant
Risk assessment and priorities
Staff demonstrated the step without prompting and produced the record on request.
Infection Prevention·9 of 10 records compliant·demonstrated·PCIQPS·1 evidence artifact - Process designCompliant
Guideline currency
Practice at the bedside matched the written process; the record was complete and timed.
Infection Prevention·5 of 10 records compliant·demonstrated·PCIMOI·1 evidence artifact - Staff competenceCompliant
Orientation and ongoing education
Asked two members of staff independently; both described the same process and located the evidence.
HR·10 of 10 records compliant·described·SQEPCI·1 evidence artifact - Staff competenceCompliant
Demonstrated competence
Staff demonstrated the step without prompting and produced the record on request.
HR·5 of 10 records compliant·demonstrated·SQE·1 evidence artifact - EnvironmentPartial
Sterilisation and reprocessing
Practice was correct where observed, though staff could not locate the governing document on the unit.
Infection Prevention·7 of 10 records compliant·demonstrated·PCI·2 evidence artifacts - EnvironmentPartial
Ventilation and isolation
Two of the sample met the standard in full; the remainder were missing a timed signature.
Infection Prevention·5 of 10 records compliant·demonstrated·PCIFMS·3 evidence artifacts - Monitoring and dataNon-compliant
Surveillance and definitions
Neither the practice nor the record met the standard in the sample reviewed.
Quality·10 of 10 records compliant·demonstrated·PCIQPS·1 evidence artifact - Monitoring and dataNot applicable
Data validation
No patients meeting the criterion were present during the trace.
Quality·QPSMOI·1 evidence artifact - Improvement loopCompliant
Action taken on the data
Asked two members of staff independently; both described the same process and located the evidence.
Quality·5 of 10 records compliant·demonstrated·QPSPCI·1 evidence artifact - Improvement loopCompliant
Reporting to staff and leadership
Staff demonstrated the step without prompting and produced the record on request.
Quality·10 of 10 records compliant·demonstrated·GLDQPS·1 evidence artifact