Audit

Location/Clinic:

Staff and Medical Staff

Have you received training to support your work?

Do you have education resources and opportunities available to you for professional development?

Do you use contracted staff?

Do you provide orientation to contracted staff?

Do you feel that the organization’s training and education adequately prepare you for preventing adverse events?

Do you know how to respond to an adverse event and other incidents?

Is there a skill-based competence assessment process for staff who work here? what is it?

What competencies are you required to have to work here?

Is the competence of contracted staff evaluated? How?

How do you know what a provider is allowed to do with patients?

Care of the Patient

What is your process to admit new patients?

What methods are used to identify the patient during the registration process?

What education and/or information do you provide to patients at admission and/or in the initial screening/assessment?

How do you ensure and confirm that the patient and family understand

what you share with them at that time?

What do you do for a patient that is non-English speaking?

If the patient presents at admission with any high-risk factors, such as diabetes or self-harm, what additional assessments are performed or ordered for referral, if any?

Does your physical space for admission permit privacy? How to you mitigate if admission is conducted in a noisy, busy area?

What information, education, and material do you provide to the patient at discharge?

How do you know the patient understands what you provided?

How do you follow up with patients after they are discharged? How do you ensure and confirm that patients understand what you share with them during follow-up?

Please explain the process for making the decision to send a patient to the emergency department.

Who orders tests in your organization? How do you document when an order is made?

How are patients informed of any necessary tests before discharge?

How are patients educated about the test?

How do you ensure and confirm that patients understand that information?

How do you educate and train staff on admission, discharge, and transitions of care processes?

How often do you provide staff with updates on these processes?

Assessment and Plan of Care

What kinds of screenings/assessments do you perform? Who conducts them?

How do you determine which screenings/assessments you will perform?

Where do you document screenings/assessments? May I see the documentation?

Can the results of a screening trigger a referral or a full assessment?

How would a member of the treatment team communicate the need for this comprehensive assessment to the appropriate team member?

Do you ever conduct any specialized or specific additional screenings/assessments for patients?

What kind of involvement have you had in the plan of care for this patient? How is this involvement documented?

Can you tell me about the plan of care for this patient?

Suicide risk assessment

What methods or criteria do you use to screen patients at risk for suicide?

When do you conduct suicide risk screenings and assessments?

How are they documented?

What do you do when potential risk factors are identified?

Are staff educated on suicide risk assessment?

Can you describe your process to prevent suicide among the individuals you serve? For example, what kinds of interventions do you employ for individuals at risk for suicide?

Tell me about your environmental risk assessment addressing suicide prevention.

Pain Management

Can you please explain your process for performing pain assessment? How is this documented?

How do you perform initial assessment for pain? When does this occur?

What kind of monitoring and reassessment for pain do you perform?

In addition to medication management, what other pain management techniques are used?

Please tell me your process to document assessment and care planning in relation to ongoing pain management. How is this communicated to staff?

Have you educated patients and family about the pain management process and treatment options? How is this education done?

Abuse and Neglect

What criteria do you use to identify who may be a victim of trauma, abuse, neglect, or exploitation?

When is an assessment performed? How is it documented?

To whom would you communicate suspicions of trauma, abuse, neglect, or exploitation?

How would you report this? when would you file a report of abuse, neglect or exploitation with you local agency?

Describe your understanding of the signs and symptoms of abuse or neglect?

What specific training have you received in recognizing signs and symptoms of abuse or neglect?

Nutrition

Do you have a process for nutrition screening/assessments? Describe.

What types of findings would necessitate a consultation with a dietitian?

Skin and Pressure Ulcers

Do you always assess the patient for skin and pressure ulcer risk? if so, when? how is the assessment documented?

How is the staff educated and trained to perform skin and pressure ulcer assessments? How do you communicate any concerns about skin and pressure ulcers issues during assessment?

What type of escalation do you normally plan for?

Fall Risk

What is the process for assessing a patient for falls risk?

What criteria are used for a falls risk designation?

What do you do if a patient is at risk for falls?

What kind of education do you provide to patients and families about falls risk and prevention?

How are staff members trained in falls risk and prevention? how often is that training provided?

How are patients and families educated about home environment hazards?

Does your organization address the potential of certain medications to trigger falls?

Operative and High-Risk Procedures

Do you have pre procedure interviews with patients/families for planned, non-emergency procedures?

What information do you collect in your pre procedure interview?

What clinical information must be available prior to the procedure?

How do you address preoperative abnormal diagnostic test results?

How do you address critical laboratory or radiologic values?

For patients who are going to receive moderate sedation, deep sedation or general anesthesia, does the provider responsible for the sedation or anesthesia conduct the preanesthesia assessment?

Is a history and physical examination required to be documented before a procedure requiring anesthesia services?

What happens if the H&P does not meet the policy requirements?

What are the rules surrounding documentation of the H&P?

Was patient education about the procedure documented?

Is there a requirement for a properly executed informed consent for this procedure?

Who is responsible for obtaining informed consent?

Informed consent is documented in the medical record according to policy.

The surgical site is marked according to policy.

There is a preprocedure verification process to ensure correct procedure, patient, site, etc.

The preinduction assessment is conducted immediately prior to the procedure.

There is a timeout conducted involving all members of the team actively participating.

The timeout is documented.

Any specimens removed are labeled in the presence of the patient.

All specimens removed are sent to pathology according to policy.

The patient is recovered according to policy.

The patient is discharged from the PACU according to criteria or anesthesia order.

There is an immediate post operative note that addresses:
1. Pre op diagnosis
2. Post op diagnosis
3. Procedure performed
4. Any assistants
5. Patient's condition/complications
6. Estimated blood loss
7. Specimens removed

Transfusions and Blood Products

Is there an order for blood or blood products?

Is there an informed consent for blood or blood products?

Is there a standard process for patient identification prior to transfusion?

Blood is administered according to policy?

Staff can describe the process for possible transfusion reaction identification .

The patient is monitored during transfusion according to policy.

Chemotherapy

Are you certified to administer chemotherapeutic infusions?

Staff articulate safety measures employed to ensure safe administration of chemo?

The use of PPE is done according to policy.

Chemo infusions are matched with positively identified patients and orders.

The patient's medication profile has been reviewed by a pharmacist prior to chemo?

Chemotherapeutic medications are labeled appropriately.

Chemotherapeutic medications are double checked.

Staff can articulate what providers can order chemotherapy.

Staff can articulate what adverse reactions are and what is done in response.

Patients education regarding side effects of chemo are documented.

Comments:

Waived/Point-of-Care Testing

There is oversight responsibility assigned for all testing in the organization, including waived testing.

Patients are positively identified prior to testing.

Staff competency regarding waived testing is assessed at least annually.

Staff properly perform quality controls.

Results of waived testing are documented in the medical record.

Results of waived tests are documented with normal ranges.

Transplants

There is a process for accepting and storing tissue.

The process is documented.

There are tissue logs.

Tissue storage equipment is monitored for proper operation.

There is a process for when tissue storage equipment fails.

There is a two way tracking mechanism for implanted tissue.

Staff verify that the tissue supplier has a current federal and state tissue-bank license.

Environment of Care / Life Safety / Infection Control Observations.

Environment of care / Life safety:

Infection Prevention observations:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.