A Self-Assessment Guide for Health Care Organizations - IFC

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Measurable Element Look for Score Observations What is required 10) Only those permitted by the organization and by relevant licensure, laws and regulations prescribe or order medications. 11) Medications prescribed or ordered are recorded for each patient and dose. How is this element assessed A policy and procedure outline who by law, etc. are permitted to prescribe/order medications. Each patient has a medication record and each dose of medication is recorded. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 12) Medications are prepared and dispensed in clean and safe areas; the process adheres to law, regulation and professional standards of practice. 13) Staff preparing sterile products are trained in aseptic techniques. During safety rounds, areas for preparing and dispensing medications are observed to be clean and separate from potential contaminants. Documentation in personnel files shows that staff preparing sterile products have been trained in aseptic techniques. Observation of practice confirms compliance. ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 14) There is a standardized medication dispensing and distribution system in the organization Observation and interviews with staff indicate that the same process is used throughout the organization for dispensing and distributing medications. A recall process is outlined, e.g. when medications are pulled from the market. ........................................................ ........................................................ ........................................................ 15) Medications are appropriately labeled after preparation. During rounds, medications are noted to be properly labeled. ........................................................ 16) Medication effects on patients are monitored, including adverse effects. Documentation on medical records indicates the response to medications. E.g. if pain medication is given, the patient’s pain relief is noted; if antibiotics are given, documentation indicates whether the infection resolves. ........................................................ ........................................................ ........................................................ 52 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 17) Adverse effects are reported in the time frame required by policy. How is this element assessed A policy/procedure describes reporting of adverse effects of medications. Adverse effects are monitored, e.g. by completing an incident report. 0 5 10 Why did you give this score ........................................................ ........................................................ 18) Medication errors and near misses are reported in a timely manner using an established process. A policy/procedure defines medication errors and near misses. A process for reporting and measuring error rates is implemented. ........................................................ ........................................................ 19) The organization uses reported information on medication errors and near misses to improve medication use processes. Data show that medication errors are being reported, and actions taken to reduce risks. ........................................................ ........................................................ 20) An antibiotic policy is developed and implemented by clinical teams in collaboration with microbiology staff. Policies and protocols are developed to guide appropriate use of antibiotics, e.g. antibiotic surgical prophylaxis. Adherence to the policies are monitored. ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 53
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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 and 52: Standard QMI.4 [Medications use] Me
Page 53: Measurable Element Look for Score O
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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A Self-Assessment Guide for Health Care Organizations - IFC

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