A Self-Assessment Guide for Health Care Organizations - IFC

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Standard CGL.4 [Departmental services specification] The directors of each clinical department identify, in writing, the scope of services to be provided, policies and procedures for carrying out work, and the criteria for the department’s professional staff. Intent of CGL.4 Each department has a document called a “Scope of Services” that describes the goals and services provided by the department. The scope also includes the types of staff required to assess and meet patient care needs. The document describes how clinical services are coordinated within each department as well as with other departments and services. Unnecessary duplication of services is avoided or eliminated to conserve resources. Policies and procedures are written to standardize clinical care. A consistent format is used for departmental documents. Measurable Element Look for Score Observations What is required 1) The scope of service and policies/procedures describe the current services provided by each department. How is this element assessed Each department has a written scope of services that describes the services provided in the department, hours of operation, main diagnoses and procedures, support services available, organizational structure (management, medical, nursing), etc. Each department has a set of policies and procedures specific to their departmental functions and processes. In clinical departments, these processes address patient assessments, admission and discharge criteria, discharge planning, transfer and referrals, and coordination with other departments. Organization-wide protocols are incorporated in the department manuals, such as fire safety, adverse event handling, infection control, emergency preparedness etc. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 20 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 2) There is coordination of services: a. within each department (e.g. through regular staff meetings, reporting mechanisms, development of admission/ transfer/ discharge criteria), and b. between departments. How is this element assessed Coordination is described in the departmental scope of services and policies/procedures. This could include regular staff meetings, grand rounds, interdisciplinary team meetings; reporting processes (e.g. shift reports). Coordination between key departments is also described, e.g. between an orthopedic unit and a physiotherapy department, or these might include outside services, e.g. the emergency department describes their process for coordinating with ambulance services. Admission and discharge criteria are written for each inpatient department. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 3) The department director develops and applies criteria related to the required level of education, skills, knowledge and experience of the department’s professional staff. 4) The director ensures that there is a process for authorizing all medical professionals to admit and treat patients, commensurate with their training and qualifications (clinical privileges). Job descriptions describe education, skills and knowledge required. A library of recognized medical qualifications is developed. Annual performance appraisals document staff competency. This information is used to plan staff training and development. A list of the clinical privileges for each physician is available in the departments and other areas where they work. ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 21
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 and 20: Clinical Governance and Leadership
Page 21: 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 39 and 40: Measurable Element Look for Score O
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 73 and 74:
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
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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
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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
Page 95 and 96:
Clinical Privileging Committee The
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emergency 1. An unanticipated or su
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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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