A Self-Assessment Guide for Health Care Organizations - IFC

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Measurable Element Look for Score Observations What is required g. the use of verbal and telephone medication orders and the process to verify such orders, h. the types of orders that are weight based, such as for children, i. the types of orders that require additional information, such as vital signs or lab results, j. destruction of medications known to be expired or outdated, and k. special precautions and double verification while handling high risk medications - the list of which should include insulin, chemotherapy drugs, radioactive drugs, concentrated electrolytes, anticoagulants, and sedatives. 49 How is this element assessed 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 2) The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations. A copy of applicable laws and regulations are available in the pharmacy. The pharmacists and assistants are aware of the laws and regulations. These requirements are included in the policies and procedures. ........................................................ ........................................................ ........................................................ 3) An appropriately licensed, certified, and trained individual supervises all activities. Personnel records indicate that a licensed pharmacist supervises the pharmacy. ........................................................ ........................................................ 49 Best Practice Committee of the Health Care Association of New Jersey, Medication Management Guideline. Hamilton, New Jersey, USA. Available at www.hcanj.org/bestpractices.htm and at the National Guideline Clearinghouse: www.guideline.gov 50 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required How is this element assessed 0 5 10 Why did you give this score 4) A list of medications for prescribing and ordering is available and is appropriate to the organization’s mission, patient needs, and services provided. A formulary or other document lists the medications available. ........................................................ ........................................................ ........................................................ 5) There is a process established for when medications are not available that includes a notification to prescribers and suggested substitutions. A policy/procedure describes the process to be followed when medications are not available, e.g. notification of physician, identifying alternatives. ........................................................ ........................................................ ........................................................ 6) Medications are protected from loss or theft throughout the organization. A policy describes how medications are managed to prevent loss or theft. ........................................................ ........................................................ 7) Medications are stored under conditions suitable for product stability. Observations made in areas where medications are kept show that medications are stored properly. The temperatures of refrigerators are monitored daily; range limits are listed, and staff know what to do when the temperature is out of range. The “first in/first out” rule is applied to avoid wastage due to expiration. ........................................................ ........................................................ ........................................................ ........................................................ 8) Controlled substances are accurately accounted for according to applicable law and regulation. A log/record is kept for managing controlled substances. ........................................................ ........................................................ 9) Emergency medications are available in the units where they will be needed or readily accessible within the organization to meet emergency needs. During rounds, the emergency carts/boxes are found to be locked and the stocking sheets accurately completed. Adequate stocks of life critical medications are consistently maintained. ........................................................ ........................................................ ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 51
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 and 44: Standard QMI.2 [Leaders’ collabor
Page 51: 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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