A Self-Assessment Guide for Health Care Organizations - IFC

More documents

Recommendations

Info

Measurable Element Look for Score Observations What is required 5) Patients are identified before providing treatments and performing procedures. As above. How is this element assessed 0 5 10 Why did you give this score ........................................................ ........................................................ 56 IFC Self-Assessment Guide for Health Care Organizations
Standard PS.2 [Effective communication] The organization develops an approach to improve the effectiveness of communication among caregivers. Intent of PS.2 Effective communication, which is timely, accurate, complete, clear, and understood by the recipient, reduces errors, and results in improved patient safety. Communication can be electronic, written, or verbal. The most error-prone communications are patient care orders given verbally, including those given over the telephone. (For example, an error-prone communication is the verbal report back of critical test results, such as a clinical laboratory telephoning a patient care unit to report the results of a STAT test). The organization collaboratively develops a policy and/or procedure for verbal and telephone orders that includes: • the writing down, or entering into a computer, of the complete order (or test result by the receiver of the information), • the receiver reading back the order (or test result), and • the confirmation that what has been written down and read back is accurate. (This practice is sometimes referred to as “Listen, Write and Read”). The policy and/or procedure identify permissible alternatives when the read-back process may not be possible, such as in the operating theater and in emergency situations. Measurable Element Look for Score Observations What is required 1) A collaborative process is used to develop policies and/or procedures that improve the accuracy of verbal and telephone communications. 2) Verbal and telephone orders or test results are written down by the receiver of the order or test result. How is this element assessed Physicians, nurses and other health care workers work together to write and implement policies and procedures regarding verbal and telephone communications. Review minutes of meetings and talk with staff members regarding their involvement. Review the policy and procedure. Review medical records to determine whether the relevant documentation is complete. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 3) Verbal/telephone orders or test results are read back by the receiver of the order or test result. Ask staff members about their practice when receiving a telephone order or test result. ........................................................ ........................................................ 4) The order or test result is confirmed by the individual who gave the order or test result. Ask physicians, lab and radiology staff regarding their process of confirming orders and tests that they relay by phone. ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 57
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 and 52: Standard QMI.4 [Medications use] Me
Page 57: Patient Safety (PS) Standard PS.1 [
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
show all

A Self-Assessment Guide for Health Care Organizations - IFC

Create successful ePaper yourself

Delete template?

Save as template?