A Self-Assessment Guide for Health Care Organizations - IFC

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Measurable Element Look for Score Observations What is required 3) The organization respects patients’ health information as confidential. 4) The organization informs patients and families about their rights to refuse or discontinue treatment and the available care and treatment alternatives in a manner that they can understand. How is this element assessed Policies and procedures describe how patients’ health information is protected and how breaches of confidentiality are dealt with. Incidents of breaches and actions taken are recorded. Interviews with patients indicate that they were provided with information regarding their right to refuse treatment. This information might be provided in a written document or verbally. When a patient has refused treatment, documentation on the medical record shows that they are provided information about available care and treatment alternatives. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 5) Patients are aware of their right to voice a complaint and the process to do so. Interviews with patients show that they are aware of their right to make a complaint and how to do so. (This may also include the use of a suggestion box). ........................................................ ........................................................ 26 IFC Self-Assessment Guide for Health Care Organizations
Standard EPR.3 [Informed consent] Patients’ informed consent is obtained through a process defined by the organization and is carried out by trained staff. Intent of EPR.3 One of the main ways that patients are involved in their care decisions is by granting informed consent. To consent, a patient must be informed of those factors related to the planned care required for an informed decision. Informed consent may be obtained at several points in the care process, e.g. when a patient is admitted for inpatient care, and before undertaking certain procedures or treatments for which the risks may be high. The consent process is clearly defined by the organization in policies and procedures. Relevant laws and regulations are incorporated into the policies and procedures. Patients and families are informed as to what tests, procedures, and treatments require consent and how they can give consent (e.g. verbally, by signing a consent form, or through some other means). Patients and families understand who may, in addition to the patient, give consent. Designated staff members are trained in how to inform patients and in how to obtain and document their consent. Measurable Element Look for Score Observations What is required 1) The organization has a clearly defined informed consent process described in policies and procedures. How is this element assessed Policies and procedures define the process for obtaining informed consent. 0 5 10 Why did you give this score ........................................................ ........................................................ 2) Designated staff are trained to implement the policies and procedures. Staff training for implementing the informed consent policy is documented. This may be part of staff orientation. ........................................................ ........................................................ 3) Patients give informed consent consistent with the policies and procedures. Patients are informed of: a. their condition, b. the proposed procedure(s) and treatment(s) and who is authorized to perform them, c. potential benefits and drawbacks to the proposed treatment(s) and possible problems related to recovery, d. possible alternatives to the proposed treatment(s) and possible results of non-treatment, e. the likelihood of successful treatment(s), and f. the identity of the physician or other practitioner responsible for care. Consent forms are completed and located on the patient’s medical record. Interviews with patients indicate that they have received all of the information required for informed consent. ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 27
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 and 22: Measurable Element Look for Score O
Page 25 and 26: Standard CGL.6 [Staff recruitment,
Page 27: Standard EPR.2 [Patient and family
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 73 and 74: Standard FSE.6 [Utilities managemen
Page 75 and 76: 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
Page 81 and 82:
EPR.6 Reproductive health policies
Page 83 and 84:
QMI.4 Medications use 1 Medication
Page 85 and 86:
Baseline Score Score Score Facility
Page 87 and 88:
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
Page 97 and 98:
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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