A Self-Assessment Guide for Health Care Organizations - IFC

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
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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.
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IFC Self-Assessment Guide for Health Care Organizations 21