A Self-Assessment Guide for Health Care Organizations - IFC

Contents
Foreword 2
Acknowledgements 3
1. INTRODUCTION 5
About IFC 6
Purpose of this Guide 6
Why are Standards Important 7
Governance and Standards 7
Principles of Quality Improvement 8
Where to Begin 9
Resources 9
2. PREPARING FOR THE SELF-ASSESSMENT 11
STEP 1: Get Organized 12
STEP 2: Orient the Team 12
STEP 3: Conduct the Assessment 12
3. THE SELF-ASSESSMENT TEMPLATE 15
Clinical Governance and Leadership (CGL) 17
Ethics and Patient Rights (EPR) 24
Quality Measurement and Improvement (QMI) 39
Patient Safety (PS) 55
Facility Safety and Emergency
Management (FSE) 63
4. AFTER THE SELF-ASSESSMENT – NEXT STEPS 75
STEP 4: Score Performance and Identify Gaps 76
STEP 5: Develop an Action Plan 85
STEP 6: Communicate the Findings/Actions 85
STEP 7: Sustain the Gain 86
APPENDICES 89
Appendix I: IFC Code of Conduct for
Health Care Organizations 90
Appendix II: Outline Terms of Reference for Key
Committees in Health Care Organizations 92
Appendix III: Glossary 94
IFC Self-Assessment Guide for Health Care Organizations 1