KRMC PS Go To Gemba

• Audit Title

• Client / Site

• Conducted on

  Date

• Personnel

ENVIRONMENT OF CARE

• No items stored under sinks?

  Yes

  No

  N/A

• Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.

  Yes

  No

  N/A

• Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.

  Yes

  No

  N/A

• Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.

  Yes

  No

  N/A

• Hazardous chemicals and flammable agents are labeled and stored properly.

  Yes

  No

  N/A

• Eyewash stations: Inspection tags are present and up to date.

  Yes

  No

  N/A

• Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)

  Yes

  No

  N/A

• Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.

  Yes

  No

  N/A

• Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.

  Yes

  No

  N/A

• No outer shipping carton boxes in patient care areas.

  Yes

  No

  N/A

• No expired items.

  Yes

  No

  N/A

• Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker.

  Yes

  No

  N/A

EMERGENCY PREPAREDNESS

• Can staff locate medical gas zone shutoff valves.

  Yes

  No

  N/A

INFORMATION MANAGEMENT

• Confidential Patient Information:<br>Cannot be overheard or seen by unauthorized persons:<br> * Computer terminals signed off when not in use.<br> * Patient information is not discussed in public areas.<br> * Labels and PHI are obliterated before discarding in the trash.

  Yes

  No

  N/A

• No clipboards displayed as sign-in sheets when multiple patient names on the list.

  Yes

  No

  N/A

LIFE SAFETY

• Appropriate storage of boxes and pt care items:<br> * Not directly on floor.<br> * 18" clearance from sprinkler head.<br> * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.

  Yes

  No

  N/A

• Oxygen or other combustible compressed gas cylinders are stored properly:<br> * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)<br> * Limited to 12 E-cylinders per smoke compartment.<br> * Greater than 12 stored in a secured room.

  Yes

  No

  N/A

• Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be actively accessed to be in use.

  Yes

  No

  N/A

• Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.

  Yes

  No

  N/A

• Fire extinguishers have been inspected monthly.

  Yes

  No

  N/A

• Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)

  Yes

  No

  N/A

• Fire doors are not blocked or propped and when closed there is positive latching.

  Yes

  No

  N/A

• Exit signs are illuminated.

  Yes

  No

  N/A

• Evacuation route posted & current.

  Yes

  No

  N/A

• Everyone has ID badges and worn appropriately:<br> * Staff and Visitors

  Yes

  No

  N/A

• Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

  Yes

  No

  N/A

• Floors, ceilings, walls, and other surfaces intact and free from holes.

  Yes

  No

  N/A

PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS

• Are PSG posted on unit.

  Yes

  No

  N/A

STANDARD PERFORMANCE IMPROVEMENT

• Are units quality improvement dashboards posted on unit.

  Yes

  No

  N/A

• Is unit's PI project data posted.

  Yes

  No

  N/A

PROVISION OF CARE TREATMENT AND SERVICES

• Are there any alarms sounding that staff is not attending to in a timely manner.

  Yes

  No

  N/A

INFECTION PREVENTION

• Food and drink in designated areas:<br> * No evidence of it in patient rooms/area, perches, hazardous chemical storage area, laboratory specimen area.

  Yes

  No

  N/A

• Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * No unapproved lotions

  Yes

  No

  N/A

• PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>

  Yes

  No

  N/A

• Patient food & drinks: No expired items.

  Yes

  No

  N/A

• Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol<br> * Not overfilled<br> * Covered when transported<br>

  Yes

  No

  N/A

• Soiled Linen: Properly stored and not overfilled.

  Yes

  No

  N/A

• Separation of clean vs. dirty supplies & equipment:<br> * Clearly marked<br> * Clean items if stored in soiled utility are covered & clearly marked

  Yes

  No

  N/A

• Patient care supplies:<br> * Not expired, damaged, soiled.

  Yes

  No

  N/A

• Linen and Linen Carts: Covered and carts have solid bottoms.

  Yes

  No

  N/A

• Sharps Waste:<br> * Placed in puncture resistant sharps container.<br> * Disposed of when 3/4 full or "full" indicator<br> * Mounted appropriately

  Yes

  No

  N/A

• General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids

  Yes

  No

  N/A

• Air vents: Clean

  Yes

  No

  N/A

• All items in PT care area that are not disposable are able to be wiped down.

  Yes

  No

  N/A

• Curtains, drapes or blinds clean.

  Yes

  No

  N/A

• Ice machines clean.

  Yes

  No

  N/A

• Water fountains clean and functioning.

  Yes

  No

  N/A

MEDICATION MANAGEMENT

• Medication rooms are clean and uncluttered.

  Yes

  No

  N/A

• Visual inspection of medication containers: No Issues.

  Yes

  No

  N/A

• Area free of distractions.

  Yes

  No

  N/A

• Medication is appropriately labeled.<br> * Expiration dates, directions, etc..

  Yes

  No

  N/A

• All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

  Yes

  No

  N/A

• Controlled substances stored to prevent diversion.

  Yes

  No

  N/A

• Medications stored appropriately to maintain stability.

  Yes

  No

  N/A

• Medications, formula, & solutions not expired beyond expiration date.

  Yes

  No

  N/A

• Opened multi-dose vials dated and initialed. Not expired.

  Yes

  No

  N/A

• Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * Extra locks kept secured.<br> * All supplies & drugs that are on the inventory list are on the cart.<br> *. Cart is clean.<br> *. O2 tank is >1/2 full

  Yes

  No

  N/A

• Syringes are labeled when in use.

  Yes

  No

  N/A

• Medication refrigerator: Only contain medications for current patients.

  Yes

  No

  N/A

• Medication Carts: Doors and drawers are locked.

  Yes

  No

  N/A

RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

• Patients and families properly informed of their rights.<br> *. Rights and Responsibilities statement

  Yes

  No

  N/A

WAIVED TESTING / POINT OF CARE TESTING

• Point of Care testing lab controls documented and control solution labeled & dated.<br> *. Reagents, i Stat analyzes, glucometers, GEMS

  Yes

  No

  N/A

• Point of Care Testing Quality Control:<br> *. Consistently and correctly documented<br> *. Dates missing initials<br> *. Performed by qualified person<br> *. Out of range is followed<br> *. Logged numbers match bottle ID numbers<br>

  Yes

  No

  N/A

DESCRIBE THE UNITS RESPONSE TO YOUR ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

• Have a space designated for the team to conduct interviews and file reviews.

  Yes

  No

  N/A

• Promptly deliver materials required for review to the tracer team.

  Yes

  No

  N/A

• Any additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A