Do staff know the departments scope of service?
Does the departments scope of service include Admission/Treatment/Discharge process?
Do staff know where to access policies and procedures?
Can staff verbalize how policies and procedures are maintained?
Do staff know how to verify it is the most current policy?
Can staff verbalize how to verify they have the most current version of a policy?
Is only the most current information displayed on the bulletin board?
Can staff verbalize how ,leadership communicates important information to them?
Can the staff verbalize our mission and vision?
Can staff verbalize how they were oriented to the hospital?
Can staff verbalize how their competency is assessed and maintained?
Have staff received periodic in-services or training regarding their job responsibilities?
What were some topics?
Can staff verbalize who is responsible for the supervision of students when they provide patient care and who is responsible for the patient?
Do staff know what to do if they feel they cannot provide care to a patient due to religious or cultural values?
Process or procedure audited:
Is there a documented policy and procedure for the process audited? Review the document
Can staff verbalize how to verify that it is the most current version?
Can staff verbalize if training is required for this process ?
Are training records/certificates available if training is required?
Can staff walk you through the process?
Can staff verbalize PI activities for their department ?
What are the activities and what has improved?
Do you have the tools, equipment and resources to perform this process?
Are there any corrective, preventive or improvement opportunities we can help you with?
What can we help with?
Is a corrective or preventive action required
Which action is required?
Cause of the nonconformity
Person or position responsible for implementation of action plan
Results of actions taken
Determine actions needed by
Review of effectiveness