Information
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Audit Title
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Conducted on
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Prepared by
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Location
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FC: Fully Capable / No risks identified
C: Capable / Minor risks identified
CL: Capable with Limitations / Major risks identified
1 - Hospital Management
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III - Be able to perform, direct and guide IAW the applicable clinical processes in order to ensure medical support at the highest possible standard of medical care at all times
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> Is the hospital management able to perform, direct and guide IAW the applicable clinical processes in order to ensure medical support at the highest possible standard of medical care at all times?
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III.1.1 - Be aware of the assigned tasks, responsibilities and restrictions within the functional area
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> Is the hospital management aware of their assigned task?
> Is the hospital management aware of their responsibilities?
> Is the hospital management aware of the restrictions? -
III.1.2 - Be aware of and be able to apply the Medical Rules of Eligibility
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> Are the Medical Rules of Eligibility available and known?
> Are the Medical Rules of Eligibility applied correctly? -
III.1.3 - Guide effective functioning of medical modules, systems and processes within the hospital
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> Is the hospital management able to guide effective functioning of medical modules?
> Is the hospital management able to guide effective functioning of medical systems?
> Is the hospital management able to guide effective functioning of medical processes? -
III.1.4 - Be able to control the medical, logistical and personnel related processes within the hospital
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> Is the hospital management able to control the medical related processes within the hospital?
> Is the hospital management able to control the logistical related processes within the hospital?
> Is the hospital management able to control the personnel related processes within the hospital? -
III.1.5 - Be able to advise on the manning of the medical and supporting elements within the hospital to ensure medical support IAW the assigned tasks
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> Is the hospital management able to advise on the manning of the medical and supporting elements within the hospital to ensure medical support IAW the assigned tasks?
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III.1.6 - Be able to disseminate all necessary information to the parties involved
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> Is the hospital management able to disseminate all necessary information to the parties involved?
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III.1.7 - Be aware of the procedures and matching report formats to request medical care
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> Is the hospital management aware of the procedures to request medical care?
> Is the hospital management using the matching report formats? -
III.1.8 - Be able to prepare, plan and execute MASCAL situations
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> Is there a MASCAL-plan?
> Is personnel informed and tasked?
> Is the hospital management able to prepare MASCAL situations?
> Is the hospital management able to plan MASCAL situations?
> Is the hospital management able to execute MASCAL situations?
> Is personnel reacting according to the MASCAL-plan? -
III.1.9 - Be able to coordinate and manage ground medevac assets in case of patient transfers, medevac ops, region coverage and base incidents
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> Is the hospital management able to coordinate and manage medevac assets in case of patient transfers?
> Is the hospital management able to coordinate and manage medevac assets in case of medevac ops?
> Is the hospital management able to coordinate and manage medevac assets in case of region coverage?
> Is the hospital management able to coordinate and manage medevac assets in case of base incidents? -
III.1.10 - Have evacuation plans visible in hardcopy
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> Are evacuation plans available in hardcopy?
> Are evacuation plans visible for all personnel? -
III.1.11 - Be aware of and able to conduct the KIA procedure
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> Is the hospital management aware of the KIA procedure?
> Is the hospital management able to conduct the KIA procedure? -
III.1.12 - Be aware and able of the current procedure and means in case of fire
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> Is personnel aware of the current procedure in case of fire?
> Is personnel able to use the available means in case of fire? -
III.1.13 - Have suitable working schedules in accordance with the assignments
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> Are working scedules known by personnel?
> Are the sceduales in accordance with the assignments?
> Is a HOTO being performed when changing shifts? -
III.1.14 - Be able to conduct a full scale evacuation
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> Is the hospital management able to conduct a full scale evacuation?
> Is the full scale evacuation according to the evacuation plan? -
III.1.15 - Be aware of the emergency response plan
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> Is hospital management aware of the emergency response plan?
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III.1.16 - Personnel uses personal protection gear IAW regulations
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> Is personal protection gear available in accordance with the regulations?
> Is personnel using the protection gear when necessary? -
III.1.17 - Be aware of and be able to report IAW prescribed regulations and SOP's
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> Is the hospital management aware of the prescribed regulations and SOP's?
> Is the hospital management able to report in accordance with the prescribed regulations and SOP's? -
III.1.18 - Be aware of national caveats which may effect hospital management
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> Are the national caveats which may effect hospital management known?
> Is the information about the national caveats up-to-date? -
III.1.19 - Have knowledge of the available communication and information systems
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> Are the available communication and information systems well connected and ready for use?
> Is hospital management trained to use these available communication and information systems? -
III.1.20 - Control the effective functioning of applicable modules, systems and processes
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> Are the national caveats which may effect hospital management known?
> Is the information about the national caveats up-to-date? -
III.1.21 - Be able to use the available communication means
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> Are the available communication means well connected and ready for use?
> Is hospital management trained to use these available communication means? -
III.1.22 - Ensure a correctly wired hospital incl labels
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> Is the hospital correctly wired?
> Are labels being used?
2 - Patient regulation and administration
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III.2.1 - Have knowledge of the available communication and patient registration means
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> Does personnel have knowledge of the available communication means?
> Does personnel have knowledge of the available patient registration means? -
III.2.2 - Ensure the use of the communication and patient registrations means IAW applicable regulations
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> Is the use of communication and patient registration means IAW applicable regulations ensured?
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III.2.3 - Be able to receive and transmit patient information timely and effectively IAW effective regulations
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> Is personnel able to receive patient information timely and effectively IAW effective regulations?
> Is personnel able to transmit patient information timely and effectively IAW effective regulations? -
III.2.4 - Ensure the update of all information according to the executed patient transfer
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> Is personnel able to ensure the update of all information according to the executed patient transfer?
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III.2.5 - Ensure Tracking and Tracing of patients
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> Is tracking and tracing of patients be insured?
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III.2.6 - Be able to update and verify patient information when possible
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> Is personnel able to update patient information when possible?
> Is personnel able to verify patient information when possible? -
III.2.7 - Be able to respond timely to patient movement requests (in any form) IAW PECC procedures
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> Is personnel able to respond timely to patient movement requests (in any form) IAW PECC procedures?
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III.2.8 - Ensure the regular update and visualisation of bed status, PMR's and patient T&T
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> Is the the regular update ensured of bed status?
> Is the the regular update ensured of PMR's?
> Is the the regular update ensured of patient T&T?
> Is visualisation ensured of bed status?
> Is visualisation ensured of PMR's?
> Is visualisation ensured of patient T&T?
3 - Medical Logistics - Supervise stock levels in transport assets and manage store
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III.3.1 - Control stock of drugs
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> Is stock of drugs being controlled?
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III.3.2 - Control oxygen stock and other medical material
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> Is stock of oxygen being controled?
> Is stock of other medical material being controled? -
III.3.3 - Manage stores
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> Is stock managed?
> Is stock supplemented? -
III.3.4 - Manage clinical waste
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> Is medical waste being managed according to SOP?
4 - Medical Logistics - Drugs, Medcal Supply and Good Distribution Practise
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III.4.1 - Be able to deploy the capacity to provide sufficient medical supply tailored to the number and type of MTF’s to be supported
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> Is the medical logistic able to deploy the capacity to provide sufficient medical supply tailored to the number and type of MTF’s to be supported?
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III.4.2 - Be able to advise the commanders of the supported units and medical modules in the domains of pharmacy and medical (re)supply
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> Is the medical logistic able to advise the commanders of the supported units and medical modules in the domains of pharmacy and medical (re)supply?
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III.4.3 - Be able to manage the stock and the distribution of medical material. Be able to verify calibration and repair or replace malfunctioning equipment
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> Is the medical logistic able to manage the stock?
> Is the medical logistic able to distribute medical material?
> Is the medical logistic able to verify calibration?
> Is the medical logistic able to repair or replace malfunctioning equipment? -
III.4.4 - Be able to ensure the quantitative and qualitative reception and distribution of blood and blood products. (if applicable)
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> Is the medical logistic able to ensure the quantitative reception of blood and blood products? (Storage-space)
> Is the medical logistic able to ensure the quantitative distribution of blood and blood products? (Capacity)
> Is the medical logistic able to ensure the qualitative reception of blood and blood products? (Check & Test)
> Is the medical logistic able to ensure the qualitative distribution of blood and blood products? (Durability) -
III.4.5 - Be able to ensure the re-supply of medical gases
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> Is the medical logistic able to ensure the re-supply of medical gases?
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III.4.6 - Be able to advice on the handling of medical waste
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> Is medical logistic able to advise on the handling of medical waste?
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III.4.7 - Be able to respond to MASCAL
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> Is medical logistic able to respond to MASCAL?
> Is medical logistic informed and tasked?
