Reporting APR.09.02.01

Safety Reporting

Staff show understanding of reporting processes including through Sanford Connect Patient/Safety Concern, Department of Health, Employee Health (for employee injuries), and TJC.

Emergency Management EM.02.01.01

Emergency Management

Staff show ability to locate the Dolphin system and navigate to find SDS. SDS is available in paper format to those using chemicals who don't have online access (ie. Contracted environmental services)

Eye wash station within 10 seconds of areas using heavy chemicals (high level disinfection). Eye wash weekly log is completed. Spout covers, signage, and temperature gauge is in place.

Negative pressure observed for pertinent "dirty" room(s).

Does staff that doesn't call this their home site have basic orientation to the building and emergency info? (Sanford Health Orientation Guide)

Bathrooms have pull cords that are within 6 in of the floor.

Staff is able to verbalize how they would handle a situation involving an active shooter, a missing person, or violent person.

Environment of Care EC.02.02.05, EC.02.03.01, EC.02.06.01

Environment of Care

Staff show ability to find Dolphin SDS database and navigate to a chemical specific to their work area.

Eye wash station(s) located within approx. 10 seconds of area(s) requiring use.

Pertinent "dirty" utility rooms have negative air pressure.

Staff who work in this site, but don't call it their "home" site have had at least minimal orientation to building and emergency information (fire pulls, fire extinguisher, exits, etc.) Sanford Health Orientation Guide can be utilized.

Patient bathrooms have pull cords that reach to approx. six inches from the ground.

Staff can quickly access bathrooms if locked in the event a patient inside becomes unresponsive or requires help.

No more than 12 oxygen tanks are stored within one building or fire compartment. Tanks are clearly separated or marked indicating full, in use, and empty.

Electrical panels are easily accessible to staff.

All pertinent equipment has up to date Clinical Engineering stickers. Any equipment that does not work properly is taken out of service and repair or replacement is sought.

Human Resources HR.01.01.01, HR.01.02.01, HR.01.06.01, HR.02.01.03

Human Resources

Staff can articulate the process for safety reporting including what types of things are reported and are able to bring up internal safety reporting website (Midas).

Staff members are able to delineate their roles from others. (RN vs. LPN vs. CNA)

If site is ever open without medical staff present, non-medical staff has BLS training.

If any staff members operate in more than one roll, job descriptions and orientation checklists are reflective of all roles.

If staff performs any procedures that require special training (high level disinfection, laser, moderate sedation), skill validation or certification are included in employee records and are produced on site if not completed through the Center for Learning.

Staff can locate provider privilege section on Sanford Connect.

Infection Control IC.02.01.01, IC.02.02.01

Infection Control

Hand Hygiene is observed when appropriate. Sharps containers are not overfilled. Multi dose vials are labeled according to policy, not open in the presence of the patient, and not expired (if applicable).

Staff demonstrate and/or articulate adequate and consistent room cleaning processes.

Med prep areas are as functionally separate as possible, clean, and uncluttered. Staff demonstrates understanding of cleaning practices (at least three times a day and as needed).

Linen and other patient care supplies are stored separate from office and personal items.
No cardboard shipping boxes with patient care supplies. All supplies stored off floor and not closer than 18 in from a sprinkler.

Dirty instruments are moist and in open position. Cleaning supplies are not expired.

Staff that performs high level disinfection explains that solutions are measured consistently and appropriately each time, cleaning of equipment, logging of solutions and test strips are demonstrated. Clean scooped are appropriately stored.

Clinic is cleaned each day of operation with cleaning supplies that have been approved by Sanford Infection Prevention and Sanford Environmental Services. If environmental services is a contracted service, contact is up to date and has an annual evaluation. Cleaning supplies are only accessible to authorized persons. X

Information Management IM.02.01.01, IM.03.01.03

Information Management

Computers are secured when unattended. All PHI is protected from unauthorized viewing.

Documents are free of abolished abbreviations. Staff has awareness of which abbreviations are not to be used.

Leadership LD.03.01.01


Staff expresses a level of comfort with safety reporting. An understanding that safety reporting is encouraged and non-punitive is apparent.

Medication Management MM.01.01.03, MM.01.02.01, MM.02.01.01, MM.03.01.01, MM.03.03.01, MM.04.01.01, MM.05.01.07, MM.06.01.01

Nursing staff demonstrates knowledge about LASA and High Alert Medications. There is apparent separation and labeling of LASA and High Alert Medications.

Clinical Supervisor is aware of inventory of medications and is aware of how to produce list from pharmacy ordering system.

All Medications are secure. Schedule II-V medications are secured to the building infrastructure and access is only available to clinical staff. Keys to access scheduled medications are not going home with staff and or kept behind a code locking system. Perpetual inventory and daily log are complete and up to date.

Fridge and freezer temperature logs are complete, only current month is readily available, action log is with temp logs. Staff understands how to handle out of range temperatures. There is clear separation of lab materials, medications, and patient specimens (if applicable).

Crash cart and/or emergency red bag show completed logs, no expired medications or supplies, only current log readily available.

Nursing staff demonstrate understanding of the process for verbal or telephone orders including writing the order down to read back and verify. Verbal order use is minimized.

Protocols are approved or in process of approval and up to date. Staff understands how to use them.

If samples are dispensed here, logs are complete and only current log is readily available. Dispensing process is demonstrated as per policy.

Medication labeling is demonstrated/explained appropriately by clinical staff. Patient name is present on label when drawing up for another person administering or when preparing meds for more than one patient at a time. If another person is administering a medication that someone else prepared, verbal/visual verification is utilized.

If able to observe medication administration: the five or six rights are completed before administration.

NPSG. NPSG.01.01.01, NPSG.03.04.01, NPSG.03.05.01, NPSG.03.06.01, UP.01.02.01, UP.01.03.01

Two patient identifiers are observed and staff speaks to its importance and consistent use.

Provision of Care PC.01.02.01, PC.01.02.07, PC.02.01.03, PC.02.03.01

Provision of Care

If a procedural setting is observed, all medications and solutions are labeled.

Procedural site identification and marking is occurring per policy.

AVS is provided for patients consistently with up to date information.

Time outs can be demonstrated to meet all required elements per policy. Including activity stopping to pay attention, all in agreement, and correct documentation.

Rooming process observed to be performed per policy consistently.

Staff performs pain assessment per policy with scale used according to age and cognitive ability.

Orders for procedures and medications are obtained and reviewed prior to carrying out.

Patient education is provided in a manner that patients prefer and understand according to learning needs assessment. Patient education is documented including learner(s), readiness to learn, understanding, etc.

Performance Improvement PI.01.01.01

Performance Improvement

Staff is able to articulate performance improvement focuses and projects ongoing within Sanford and, if possible, specific to the site.

Record of Care RC.02.01.01

Record of Care

Staff can speak to the consenting process including knowledge of which procedures they perform that require written consent versus verbal consent and that the procedural its needs to explain risk, benefits, and alternatives before informed consent can be obtained.

Rights and Responsibilities RI.01.01.01, RI.01.01.03

Rights and Responsibilities

Staff can explain how patients find out about their rights and responsibilities.

Staff can demonstrate and/or explain how to manage a visit or phone call with a patient who is unable to speak or understand English (consider deaf as well). Staff is able to locate educational materials in other languages.

Thank you so much for taking the time for this site visit! I appreciate all of your hard work and look forward to hearing back on areas of concern sometime in the next 30 days.

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.