A Self-Assessment Guide for Health Care Organizations - IFC

More documents

Recommendations

Info

Standard FSE.2 [Hazardous materials plan] The organization has a plan for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and waste. Intent of FSE.2 The organization identifies and safely controls hazardous materials and waste according to a Hazardous Materials Management Plan (or similar). Such materials and waste include chemicals, chemotherapeutic agents, radioactive substances, hazardous gases and vapors, and other regulated medical and infectious waste. Measurable Element Look for Score Observations What is required 1) The organization identifies hazardous materials and waste and has a current list of all such materials within its facilities. 2) A Hazardous Materials Management Plan provides for: a. the inventory of hazardous materials and waste, b. the proper labeling of hazardous materials and waste, c. safe handling, storage, and use of hazardous materials, d. procedures for coping with spills, exposures and other incidents, e. procedures for reporting and investigating of spills, exposures, and other incidents, f. procedures for proper disposal of hazardous waste, g. proper use of protective equipment, and h. documentation, including any permits, licenses, or other regulatory requirements. How is this element assessed The list of hazardous materials and waste is current and comprehensive, and includes all departments. A Hazardous Materials Management Plan (or similar) describes the processes for all of the required elements. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 64 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 3) Hazardous materials and waste are managed according to the Hazardous Waste Management Plan. How is this element assessed Interviews with staff indicate that they understand the Hazardous Materials Management Plan. Posters and signs remind staff of key procedures. During safety rounds, handling and disposal of hazardous materials and waste is observed to be carried out according to policy. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 65
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 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: 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?