Title Page

  • Conducted on

  • Prepared by

  • Ambulatory Clinic:
  • 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?


  • 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:<br>1. Pre op diagnosis<br>2. Post op diagnosis<br>3. Procedure performed<br>4. Any assistants<br>5. Patient's condition/complications<br>6. Estimated blood loss<br>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.


  • 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.


  • 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:

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