A Self-Assessment Guide for Health Care Organizations - IFC

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After the Self-Assessment Next Steps STEP 4: Score Performance and Identify Gaps After completing the assessment, the team should calculate the scores and review the findings. The aim of this exercise is to identify the gaps toward meeting the standards in order to make improvements and take corrective actions. The process for doing this is described below. The responses for each standard are summed to determine the level of achievement, as follows: 1. Enter the scores for each question/element in the Self-Assessment Template on the following pages. The Scoring Key is: 0 = the organization does not meet the criterion 5 = yes, some elements are in place, but the criterion is not fully satisfied 10 = yes, the criterion is fully satisfied 2. Add the 0, 5 and 10 scores for all of the measurable elements. 3. Determine overall achievement by adding together the scores for all the standards and dividing by 1,600* (the total score possible). * Note - The Highest Possible Score will be less if there are standards that are not applicable (e.g. IVF, organ transplantation). Subtract 10 from the Highest Possible Score for each element that is not applicable. The reason that the following score-tables have a “Baseline Score” column along with additional Score columns is to allow progress to be tracked over time, i.e. as future assessments are undertaken. 76 IFC Self-Assessment Guide for Health Care Organizations
Baseline Score Score Score Clinical Governance and Leadership CGL.1 Governance documents, e.g. bylaws, policies/ procedures 1 Structure described 2 Strategic and operational plans 3 Budget 4 License to operate CGL.2 Senior manager responsible for operations 1 Manages day-to-day operations 2 Assures compliance with policies 3 Assures compliance with laws and regulations 4 Responds to reports of inspecting and regulatory agencies 5 Plans services with community and other providers CGL.3 Oversight of contracts 1 Quality oversight of contracts 2 Contract services meet patient needs CGL.4 Departmental scope of services and policies and procedures 1 Scope of service; policy and procedures 2 Coordination and integration of services 3 Criteria for professional staff qualifications 4 Process for clinical privileging CGL.5 CGL.6 Department directors recommend space, equipment, etc 1 Department directors recommend space, equipment, etc 2 Processes to respond to resource shortages Programs for recruitment, retention and staff development 1 Program for recruitment and retention 2 Staff orientation program 3 Staff personal development and continuing education plan 4 Employee health and safety program Total Highest Possible = 210 Percent achievement % % % IFC Self-Assessment Guide for Health Care Organizations 77
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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
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The self -assessment template IFC S
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Clinical Governance and Leadership
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Measurable Element Look for Score O
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Measurable Element Look for Score O
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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 39 and 40: Measurable Element Look for Score O
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 73 and 74: Standard FSE.6 [Utilities managemen
Page 75 and 76: IFC Self-Assessment Guide for Healt
Page 77: After the self-assessment Next Step
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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