A Self-Assessment Guide for Health Care Organizations - IFC

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Standard FSE.3 [Emergency management plan] The organization develops and maintains an Emergency Management Plan (or similar) and program to respond to likely community emergencies, epidemics, and natural or other disasters. Intent of FSE.3 Emergencies, epidemics, and disasters may directly affect the organization. These might range, for example, from earthquake damage to patient care areas, to a flu outbreak that prevents staff from coming to work. To respond effectively, the organization develops an Emergency Management Plan and a program to manage such emergencies. Measurable Element Look for Score Observations What is required 1) The organization has identified the major internal and external disasters and major epidemic events which pose significant risks of occurring. How is this element assessed A document lists all the major internal and external disasters and epidemics that could pose a risk to the organization. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ 2) The organization plans its response to likely disasters. The plan sets out processes for a. determining the type, likelihood and consequences of hazards, threats, and events, b. determining the organization’s role in such events, c. communicating strategies for events, d. the managing of resources during events, including alternative sources, e. the managing of clinical activities during an event, including alternative care sites, and f. the identification and assignment of staff roles and responsibilities during an event. A disaster plan addresses actions to take for all the identified risks ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 66 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 3) The Emergency Management Plan is tested annually. Staff members participate in at least one emergency-preparedness test per year. How is this element assessed Staff training in the Emergency Management Plan is documented. The annual test of the Plan is documented with an analysis of the findings and a corrective action plan. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ IFC Self-Assessment Guide for Health Care Organizations 67
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PROMOTING STANDARDS IN THE PRIVATE
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Contents Foreword 2 Acknowledgement
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Acknowledgements This Guide was dev
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introduction IFC Self-Assessment Gu
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Why are Standards Important Why sho
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Leadership Systems Data Where to Be
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Preparing for the self-assessment I
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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 and 66: Facility Safety and Emergency Manag
Page 67: Measurable Element Look for Score O
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
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Page 102: Contact Information Health and Educ
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A Self-Assessment Guide for Health Care Organizations - IFC

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