Title Page
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Conducted on
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Prepared by
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Ambulatory Clinic:
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Location/Clinic:
Staff and Medical Staff
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Have you received training to support your work?
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Do you have education resources and opportunities available to you for professional development?
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Do you use contracted staff?
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Do you provide orientation to contracted staff?
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Do you feel that the organization’s training and education adequately prepare you for preventing adverse events?
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Do you know how to respond to an adverse event and other incidents?
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Is there a skill-based competence assessment process for staff who work here? what is it?
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What competencies are you required to have to work here?
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Is the competence of contracted staff evaluated? How?
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How do you know what a provider is allowed to do with patients?
Care of the Patient
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What is your process to admit new patients?
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What methods are used to identify the patient during the registration process?
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What education and/or information do you provide to patients at admission and/or in the initial screening/assessment?
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How do you ensure and confirm that the patient and family understand
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what you share with them at that time?
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What do you do for a patient that is non-English speaking?
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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?
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Does your physical space for admission permit privacy? How to you mitigate if admission is conducted in a noisy, busy area?
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What information, education, and material do you provide to the patient at discharge?
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How do you know the patient understands what you provided?
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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?
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Please explain the process for making the decision to send a patient to the emergency department.
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Who orders tests in your organization? How do you document when an order is made?
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How are patients informed of any necessary tests before discharge?
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How are patients educated about the test?
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How do you ensure and confirm that patients understand that information?
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How do you educate and train staff on admission, discharge, and transitions of care processes?
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How often do you provide staff with updates on these processes?
Assessment and Plan of Care
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What kinds of screenings/assessments do you perform? Who conducts them?
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How do you determine which screenings/assessments you will perform?
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Where do you document screenings/assessments? May I see the documentation?
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Can the results of a screening trigger a referral or a full assessment?
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How would a member of the treatment team communicate the need for this comprehensive assessment to the appropriate team member?
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Do you ever conduct any specialized or specific additional screenings/assessments for patients?
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What kind of involvement have you had in the plan of care for this patient? How is this involvement documented?
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Can you tell me about the plan of care for this patient?
Suicide risk assessment
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What methods or criteria do you use to screen patients at risk for suicide?
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When do you conduct suicide risk screenings and assessments?
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How are they documented?
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What do you do when potential risk factors are identified?
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Are staff educated on suicide risk assessment?
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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?
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Tell me about your environmental risk assessment addressing suicide prevention.
Pain Management
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Can you please explain your process for performing pain assessment? How is this documented?
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How do you perform initial assessment for pain? When does this occur?
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What kind of monitoring and reassessment for pain do you perform?
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In addition to medication management, what other pain management techniques are used?
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Please tell me your process to document assessment and care planning in relation to ongoing pain management. How is this communicated to staff?
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Have you educated patients and family about the pain management process and treatment options? How is this education done?
Abuse and Neglect
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What criteria do you use to identify who may be a victim of trauma, abuse, neglect, or exploitation?
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When is an assessment performed? How is it documented?
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To whom would you communicate suspicions of trauma, abuse, neglect, or exploitation?
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How would you report this? when would you file a report of abuse, neglect or exploitation with you local agency?
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Describe your understanding of the signs and symptoms of abuse or neglect?
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What specific training have you received in recognizing signs and symptoms of abuse or neglect?
Nutrition
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Do you have a process for nutrition screening/assessments? Describe.
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What types of findings would necessitate a consultation with a dietitian?
Skin and Pressure Ulcers
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Do you always assess the patient for skin and pressure ulcer risk? if so, when? how is the assessment documented?
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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?
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What type of escalation do you normally plan for?
Fall Risk
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What is the process for assessing a patient for falls risk?
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What criteria are used for a falls risk designation?
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What do you do if a patient is at risk for falls?
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What kind of education do you provide to patients and families about falls risk and prevention?
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How are staff members trained in falls risk and prevention? how often is that training provided?
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How are patients and families educated about home environment hazards?
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Does your organization address the potential of certain medications to trigger falls?
Operative and High-Risk Procedures
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Do you have pre procedure interviews with patients/families for planned, non-emergency procedures?
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What information do you collect in your pre procedure interview?
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What clinical information must be available prior to the procedure?
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How do you address preoperative abnormal diagnostic test results?
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How do you address critical laboratory or radiologic values?
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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?
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Is a history and physical examination required to be documented before a procedure requiring anesthesia services?
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What happens if the H&P does not meet the policy requirements?
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What are the rules surrounding documentation of the H&P?
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Was patient education about the procedure documented?
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Is there a requirement for a properly executed informed consent for this procedure?
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Who is responsible for obtaining informed consent?
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Informed consent is documented in the medical record according to policy.
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The surgical site is marked according to policy.
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There is a preprocedure verification process to ensure correct procedure, patient, site, etc.
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The preinduction assessment is conducted immediately prior to the procedure.
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There is a timeout conducted involving all members of the team actively participating.
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The timeout is documented.
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Any specimens removed are labeled in the presence of the patient.
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All specimens removed are sent to pathology according to policy.
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The patient is recovered according to policy.
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The patient is discharged from the PACU according to criteria or anesthesia order.
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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
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Is there an order for blood or blood products?
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Is there an informed consent for blood or blood products?
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Is there a standard process for patient identification prior to transfusion?
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Blood is administered according to policy?
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Staff can describe the process for possible transfusion reaction identification .
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The patient is monitored during transfusion according to policy.
Chemotherapy
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Are you certified to administer chemotherapeutic infusions?
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Staff articulate safety measures employed to ensure safe administration of chemo?
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The use of PPE is done according to policy.
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Chemo infusions are matched with positively identified patients and orders.
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The patient's medication profile has been reviewed by a pharmacist prior to chemo?
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Chemotherapeutic medications are labeled appropriately.
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Chemotherapeutic medications are double checked.
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Staff can articulate what providers can order chemotherapy.
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Staff can articulate what adverse reactions are and what is done in response.
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Patients education regarding side effects of chemo are documented.
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Comments:
Waived/Point-of-Care Testing
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There is oversight responsibility assigned for all testing in the organization, including waived testing.
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Patients are positively identified prior to testing.
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Staff competency regarding waived testing is assessed at least annually.
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Staff properly perform quality controls.
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Results of waived testing are documented in the medical record.
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Results of waived tests are documented with normal ranges.
Transplants
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There is a process for accepting and storing tissue.
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The process is documented.
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There are tissue logs.
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Tissue storage equipment is monitored for proper operation.
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There is a process for when tissue storage equipment fails.
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There is a two way tracking mechanism for implanted tissue.
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Staff verify that the tissue supplier has a current federal and state tissue-bank license.
Environment of Care / Life Safety / Infection Control Observations.
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Environment of care / Life safety:
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Infection Prevention observations:
