A Self-Assessment Guide for Health Care Organizations - IFC

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Measurable Element Look for Score Observations What is required 2) The organization uses a clearly understood mark for surgical site identification and involves the patient in the marking process. 3) The organization uses a process to verify that all documents and equipment needed are on hand, correct, and functional. How is this element assessed Ask surgery staff members regarding the process that they use for marking the site. Make observations during safety rounds. Review completeness of the checklist used by surgical staff to ensure all documents, equipment etc are in order. Ask surgical staff members regarding the process that they use to ensure all elements are confirmed. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 4) The organization uses a checklist and time-out procedure just before starting a surgical procedure. As above ........................................................ ........................................................ 60 IFC Self-Assessment Guide for Health Care Organizations
Standard PS.5 [Health care associated infections] The organization develops an approach to reduce the risk of health care associated infections. Intent of PS.5 Infection prevention and control are challenging in most health care settings, and rising rates of health care associated infections are a major concern for patients and health care professionals. Infections common to all health care settings include catheter-associated urinary tract infections, blood stream infections and pneumonia (often associated with mechanical ventilation). Central to the elimination of these and other infections is proper hand hygiene. Internationally acceptable hand hygiene guidelines are available from the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (US CDC) – see resources referenced in earlier footnotes 44 to 48. The organization has a collaborative process to develop policies and/or procedures that adapt or adopt currently published and generally accepted hand hygiene guidelines, and for the implementation of those guidelines within the organization. Measurable Element Look for Score Observations What is required 1) The organization has adopted or adapted currently published and generally accepted hand hygiene guidelines. How is this element assessed Review the policy and procedures adopted. References used (e.g. WHO, US CDC, JCI) should be cited on the procedure and dated. 0 5 10 Why did you give this score ........................................................ ........................................................ 2) The organization implements an effective hand hygiene program. Make routine observations of hand hygiene practices. Clinical units should collect data for all levels of staff and report findings to the Infection Control/Prevention Committee. ........................................................ ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 61
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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 57 and 58: Patient Safety (PS) Standard PS.1 [
Page 59 and 60: Standard PS.2 [Effective communicat
Page 61: Standard PS.4 [Correct site, proced
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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