A Self-Assessment Guide for Health Care Organizations - IFC

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Standard CGL.2 [Senior manager responsible for operations] A designated senior manager or director is responsible for managing the organization and ensuring compliance with applicable laws and regulations. Intent of CGL.2 Effective leadership is essential for a health care organization to be able to operate efficiently and fulfill its mission. A senior manager or director is responsible for the organization’s overall, day–to-day operations. These include the procurement and management of essential supplies, maintenance of the physical facilities, financial management, quality management, patient safety, and other responsibilities. Measurable Element Look for Score Observations What is required 1) A senior manager or director manages the organization’s day-to-day operations, including human, financial and other resources. 2) The senior manager or director ensures compliance with approved policies. How is this element assessed A job description outlines the roles and responsibilities of the senior manager/director. Routine management meetings are held and the minutes show collaboration with department directors/managers in overseeing resource planning, financial management and quality improvement. Documents show that policies approved by the governing body have been implemented. These may include implementation plans, minutes of meetings, monitoring activities and reports to the governing body. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 3) The senior manager or director ensures compliance with applicable laws and regulations. 4) The senior manager or director responds to any reports from inspecting and regulatory agencies. Copies of applicable laws and regulations are available. Compliance with laws and regulations is documented, e.g. reporting of notifiable contagious diseases, radiology safety logs. Reports from inspecting or regulatory agencies, e.g. accreditation, Civil Defence or Radiation Safety Councils, are kept on file. Minutes of meetings or reports show that actions have been taken to rectify any issues arising. ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 18 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 5) The organization’s leaders plan services with recognized leaders in the community and other health care organizations. How is this element assessed Documents demonstrate involvement of community leaders and other health care organizations in planning services, e.g. strategic or program planning. 0 5 10 Why did you give this score ........................................................ ........................................................ Standard CGL.3 [Oversight of contracts] The organization’s leaders provide oversight of contracts for outsourced clinical and support services. Intent of CGL.3 Organizations frequently have the option to either provide services directly or to arrange services through referral, consultation, contractual arrangements, or other agreements. Such services may range from diagnostic imaging services to financial accounting services. In all cases, there is leadership oversight for such contracts, or other arrangements to ensure that the services meet patients’ needs. They are monitored as part of the organization’s quality management and improvement activities. Department managers receive and act on regular reports from contracting agencies and ensure the reports are integrated into the organization’s quality monitoring process when appropriate. Measurable Element Look for Score Observations What is required 1) Contracts and other arrangements are monitored, as appropriate to the nature of the contract, as part of the organization’s quality management and improvement program. How is this element assessed Contracts with any vendor (e.g. housekeeping, laboratories) include expectations for quality and how it will be monitored. Documents show that quality monitoring is done, results are communicated to leadership and actions are taken as needed. All independent contractors providing clinical services (e.g. diagnostic, consultation or treatment) have been formally awarded documented privileges by the organization to provide such services. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 2) Services provided under contracts and other arrangements meet patients’ needs. Results of patient satisfaction surveys or complaints regarding contracted services are documented and followed up. ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 19
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 and 18: The self -assessment template IFC S
Page 19: Clinical Governance and Leadership
Page 23 and 24: 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 71 and 72:
Measurable Element Look for Score O
Page 73 and 74:
Standard FSE.6 [Utilities managemen
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IFC Self-Assessment Guide for Healt
Page 77 and 78:
After the self-assessment Next Step
Page 79 and 80:
Baseline Score Score Score Clinical
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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
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11. Organ donation and transplant T
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Clinical Privileging Committee The
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emergency 1. An unanticipated or su
Page 99 and 100:
privileging The process whereby a s
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Contact Information Health and Educ
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A Self-Assessment Guide for Health Care Organizations - IFC

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