Inpatient Admin Interview

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Administrative Interview

  Date

Governing Body

• Describe the relationship with the governing body/executive management

  Yes

  No

  N/A

• How are emergent issues affecting the psychiatric unit conveyed to the governing body/executive management

  Yes

  No

  N/A

• What issues are currently before the governing body/executive management

  Yes

  No

  N/A

• Are emergency issues/requests hadnled within an appropriate time frame

  Yes

  No

  N/A

• What steps are taken if the psychiatric unit is operating over capacity

  Yes

  No

  N/A

• How are family or patient complaints handled

  Yes

  No

  N/A

• Is there an appeals process

  Yes

  No

  N/A

• Are complaints reviewed outside fo the psychiatric unit

  Yes

  No

  N/A

Personnel

• Are there issues that impinge on hiring an adequate number of staff

  Yes

  No

  N/A

• How is coverage handled when there is a staffing shortage

  Yes

  No

  N/A

• What types of staff development programs have taken place in the past year

  Yes

  No

  N/A

• How are new staff oriented to the unit and trained

  Yes

  No

  N/A

• How are staff complaints investigated and resolved

  Yes

  No

  N/A

Quality Management

• Were there any Sentinel Events during this certfication cycle

  Yes

  No

  N/A

• Did the Sentinel Event result in a QI project, describe

  Yes

  No

  N/A

• How does incident reporting take place, describe process

  Yes

  No

  N/A

• Have any serious incidents resulted from restraint/seclusion

  Yes

  No

  N/A

• What quality indicators are you using after checking benchmarks

  Yes

  No

  N/A

• How is UR conducted for the unit

  Yes

  No

  N/A

• What is the unit's recidivism rate? If high, how is it being addressed

  Yes

  No

  N/A

• Are special procedures provided to patients (ie ECT)

  Yes

  No

  N/A