A Self-Assessment Guide for Health Care Organizations - IFC

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The Self-Assessment Template STEP 1: Get Organized Self-Assessment – Quality and Safety Date _______________________________________________________________________________________________________ Name of facility _______________________________________________________________________________________________ ____________________________________________________________________________________________________________ Location: (town, district/province) _________________________________________________________________________________ ____________________________________________________________________________________________________________ Name(s) of assessor(s) __________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 16 IFC Self-Assessment Guide for Health Care Organizations
Clinical Governance and Leadership (CGL) Standard CGL.1 [Governance documentation] Governance responsibilities and accountabilities are described in bylaws, policies and procedures, or similar documents that guide how they are to be carried out. Intent of CGL.1 There is an entity (e.g. a holding company, a foundation, an owner), or a group of individuals (e.g. a board) that is responsible for overseeing the organization’s operation and is accountable for providing quality health care services to its community or to the population that seeks care. Measurable Element Look for Score Observations What is required 1) The organization’s governance structure is described in written documents. How is this element assessed A document or set of documents describes the mission, vision and values, purpose and goals, and structure of the organization (including the organizational chart). Also roles/responsibilities of the Chief Executive Officer, Board, etc. The title of the document may be “bylaws”, “administrative manual”, etc. The organization’s mission is made public, e.g. posted. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 2) Strategic and management plans and operating policies and procedures are developed and approved by the organization’s governing body. Strategic and operational plans are written. The approval of the strategic and operational plans is documented in the minutes of the governing body. (The governing body may be the Board of Directors, or other such group). ........................................................ ........................................................ ........................................................ 3) An annual budget is developed and approved to allocate the resources required to meet the organization’s mission. An annual budget is developed. The approval of the budget is documented in the minutes of the governing body. ........................................................ ........................................................ 4) A license to operate the organization, as required, is obtained and posted. A license to operate the facility, and any other licenses that are required, are displayed in public view. ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 17
Page 1 and 2: PROMOTING STANDARDS IN THE PRIVATE
Page 3 and 4: Contents Foreword 2 Acknowledgement
Page 5 and 6: Acknowledgements This Guide was dev
Page 7 and 8: introduction IFC Self-Assessment Gu
Page 9 and 10: Why are Standards Important Why sho
Page 11 and 12: Leadership Systems Data Where to Be
Page 13 and 14: Preparing for the self-assessment I
Page 15 and 16: Facility Safety and Emergency Manag
Page 17: The self -assessment template IFC S
Page 21 and 22: Measurable Element Look for Score O
Page 25 and 26: Standard CGL.6 [Staff recruitment,
Page 27 and 28: Standard EPR.2 [Patient and family
Page 29 and 30: Standard EPR.3 [Informed consent] P
Page 31 and 32: Standard EPR.4 [Ethical management]
Page 33 and 34: Standard EPR.5 [Organ and tissue do
Page 35 and 36: Standard EPR.6 [Reproductive health
Page 37 and 38: Standard EPR.7 [Termination of preg
Page 41 and 42: Quality Measurement and Improvement
Page 43 and 44: Standard QMI.2 [Leaders’ collabor
Page 51 and 52: Standard QMI.4 [Medications use] Me
Page 57 and 58: Patient Safety (PS) Standard PS.1 [
Page 59 and 60: Standard PS.2 [Effective communicat
Page 61 and 62: Standard PS.4 [Correct site, proced
Page 63 and 64: Standard PS.5 [Health care associat
Page 65 and 66: Facility Safety and Emergency Manag
Page 69 and 70:
Measurable Element Look for Score O
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Measurable Element Look for Score O
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Standard FSE.6 [Utilities managemen
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IFC Self-Assessment Guide for Healt
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After the self-assessment Next Step
Page 79 and 80:
Baseline Score Score Score Clinical
Page 81 and 82:
EPR.6 Reproductive health policies
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QMI.4 Medications use 1 Medication
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Baseline Score Score Score Facility
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STEP 5: Develop an Action Plan The
Page 89 and 90:
IFC Self-Assessment Guide for Healt
Page 91 and 92:
Appendices IFC Self-Assessment Guid
Page 93 and 94:
11. Organ donation and transplant T
Page 95 and 96:
Clinical Privileging Committee The
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emergency 1. An unanticipated or su
Page 99 and 100:
privileging The process whereby a s
Page 102:
Contact Information Health and Educ
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A Self-Assessment Guide for Health Care Organizations - IFC

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