A Self-Assessment Guide for Health Care Organizations - IFC

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Ethics and Patient Rights EPR.1 Credential verification of professional staff 1 Licensure, education and training verified 2 Separate records for professional staff 3 Records reviewed at least every 3 years EPR.2 Processes to support patient and family rights 1 Policies and procedures that support patient rights 2 Vulnerable groups are protected against abuse 3 Health information is confidential 4 Patients/families informed of their rights 5 Patients can voice complaints EPR.3 Informed consent 1 Informed consent policy/procedure 2 Staff trained to obtain informed consent 3 Informed consent given for high-risk procedures/ treatments 4 Process when others can grant informed consent EPR.4 Framework for ethical management 1 Ethical and legal norms established 2 Disclosure of organizational ownership 3 Honest portrayal of service offered 4 Accurate billing of services 5 Discloses and resolves financial conflicts of interest 6 Staff are supported in dealing with ethical issues 7 Safe reporting of ethical and legal concerns EPR.5 Organ and tissue donation and transplantation 1 Patient/family supported in making decisions to donate 2 Organ and tissue donation policies and procedures 3 Staff are trained in policies and procedures 4 Valid informed consent from live donors 5 Organization cooperates with community organizations Baseline Score Score Score 78 IFC Self-Assessment Guide for Health Care Organizations
EPR.6 Reproductive health policies and procedures (IVF) 1 IVF services are integrated into MCH services 2 Policies and procedures for services support women's rights 3 Staff are trained in examination, diagnosis, referral and transfer 4 Procedures and equipment are standardized 5 Patients are provided with full information 6 Donors are provided with full information 7 IVF registry maintained 8 Register linked with national health registries EPR.7 Termination of pregnancy services 1 Services are integrated into MCH services 2 Policies and procedures for services support women's rights 3 Staff trained in screening, exam, diagnosis, referral and transfer 4 Procedures and equipment are standardized EPR.8 5 Patients provided with full information Clinical research trials 1 Benefits and ethical issues fully considered prior to proceeding. 2 Research committee oversight 3 Appropriate pts identified and informed how to gain access 4 Research policies and procedures 5 Informed consent obtained 6 Patients informed about refusal to participate Total Highest Possible = 430 Percent achievement % % % IFC Self-Assessment Guide for Health Care Organizations 79
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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,
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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 and 78: After the self-assessment Next Step
Page 79: Baseline Score Score Score Clinical
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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