HAAD Standards For Licensure And Quality Improvement

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Investigation and Reporting of Events• PCQ.17 –The hospital uses a defined processfor identifying and managing sentinel events– Definition of events to be investigated– Root cause analysis within 45 days– Change procedures• PCQ.18 –Data are analyzed whenundesirable trends and variation areidentified
CommunicationAdmission• CCC.1 –Patients are admitted to receive inpatient carebased on their identified health care needs and thehospital’s mission and resources.– ME 1 – Screening is initiated at the point of first contact within oroutside the hospital.• CCC.3 –Patients with emergency or immediate needs aregiven priority for assessment and treatment.– ME 1 –The hospital has established criteria to prioritize patientswith immediate needs.• CCC.6 – Admission or transfer to or from units providingintensive or specialized services is determined byestablished criteria.– ME 1 –The hospital has established entry and/or transfer criteria forits intensive and specialized services or units.– ME 5 –Patients transferred or admitted to intensive and specializedunits/services meet the criteria and this is documented in thepatient’s record.
Page 1 and 2: HAAD StandardsforLicensure and Qual
Page 5 and 6: HSRC Terms of ReferenceAdministrati
Page 7 and 8: Mandatory Standards• Represent th
Page 9 and 10: General Principles• Ensure the cl
Page 11: Monitoring Requirements• PCQ.8 -M
Page 15 and 16: Transfer of Patients• CCC.10 -The
Page 17 and 18: Transportation• CCC.14 -The proce
Page 19 and 20: LeadershipEthics• LDS.3 -The hosp
Page 21 and 22: Staff Education• LDS.17 -Staff me
Page 23 and 24: Medical Staffing• LDS.19 -The hos
Page 25 and 26: Summary• Approved licensing stand

HAAD Standards For Licensure And Quality Improvement

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