A Self-Assessment Guide for Health Care Organizations - IFC

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
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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).
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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