A Self-Assessment Guide for Health Care Organizations - IFC

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Measurable Element Look for Score Observations What is required 4) Those responsible for governance regularly receive and act on reports of the Quality Improvement and Patient Safety Program. How is this element assessed Leaders review the quality of clinical and non clinical services on a regular basis, e.g. at least quarterly. Action is taken that is supported by data and objective measures of performance. Cost effectiveness is also part of this review. Leaders track clinical audit results and take actions as indicated. There is a defined process for notifying leaders when a sentinel event has occurred and there is evidence that they are actively involved in resolving such situations. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 5) There is a training program for staff that is consistent with their role in the Quality Improvement and Patient Safety program. A training plan (which may be a one-page table) outlines the quality training for different categories of staff. For instance, leadership receives training in quality awareness, management indicators and data for decision making, general staff are provided basic quality/safety awareness training, and staff involved in quality committees/teams receive more in-depth training on quality improvement methodologies. ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 42 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 6) Leaders identify key measures (indicators) to monitor the organization’s clinical structures, processes and outcomes. These may include the International Patient Safety Goals 35 or similar. Clinical monitoring includes: a. aspects of laboratory services, b. aspects of radiology and diagnostic imaging services, c. medication errors, adverse drug events and near misses, d. infection control, surveillance, and reporting, and e. clinical research (where applicable). 36 How is this element assessed The annual Quality Plan lists the indicators that are being measured for each of the required aspects of care. Minutes of the Quality Improvement and Patient Safety Committee meetings indicate the prioritization process. The organization carries out periodic assessments of its structures, processes and outcomes based on the standards in this Plan. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 7) Managerial/ administrative monitoring includes: a. procurement of routinely required supplies and medications essential to meet patient needs, b. activities as required by law and regulation, c. risk management. The annual Quality Plan lists the indicators that are monitored for each of the required aspects of management. (E.g. indicators for utilization management might include patient numbers, lengths of stay, bed occupancy etc). ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 35 Information on International Patient Safety Goals available at: www.jointcommissioninternational.org/International-Patient-Safety-Goals/ 36 University Research Corp (2005) Health Manager’s Guide: Monitoring the Quality of Hospital Care. Bethesda, MD, USA. Available at: www.qaproject.org IFC Self-Assessment Guide for Health Care Organizations 43
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 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: 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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