SRH Quality Audit

• Audit Subject:

• Department or Service:

• Location

  Select Access Health Accounting Accountable Care Behavioral Health BioMedical Services Cancer Center Cath Lab Cardiac Surgery Case Management Chaplain Corporate Compliance ECC Employee Health Environmental Svcs Facility Services Fleet Operations Food & Nutrition Grounds HIM Foundation Hospitality Services Human Resources Information Systems Laboratory Laundry & Linen Managed Care Marketing Montgomery Center Patient Access Pharmacy Pt Financial Svcs Quality Mgmt Svcs Radiology Rehabilitation Svcs Respiratory Svcs SC Joint Center SC Spine Center Security Self Excellance Sleep Lab Supply Chain Mgmt Telecommunications Wellness Works Wound Healing Institute 2 Tower 3 Tower 4 Tower 5 Tower 6 Tower 7 Tower Other

  • Access Health
  • Accounting
  • Accountable Care
  • Behavioral Health
  • BioMedical Services
  • Cancer Center
  • Cath Lab
  • Cardiac Surgery
  • Case Management
  • Chaplain
  • Corporate Compliance
  • ECC
  • Employee Health
  • Environmental Svcs
  • Facility Services
  • Fleet Operations
  • Food & Nutrition
  • Grounds
  • HIM
  • Foundation
  • Hospitality Services
  • Human Resources
  • Information Systems
  • Laboratory
  • Laundry & Linen
  • Managed Care
  • Marketing
  • Montgomery Center
  • Patient Access
  • Pharmacy
  • Pt Financial Svcs
  • Quality Mgmt Svcs
  • Radiology
  • Rehabilitation Svcs
  • Respiratory Svcs
  • SC Joint Center
  • SC Spine Center
  • Security
  • Self Excellance
  • Sleep Lab
  • Supply Chain Mgmt
  • Telecommunications
  • Wellness Works
  • Wound Healing Institute
  • 2 Tower
  • 3 Tower
  • 4 Tower
  • 5 Tower
  • 6 Tower
  • 7 Tower
  • Other

• Location

• Conducted on

  Date

• Audited By:

  Select Wesley Allen Ronnie Autry Cliff Collie Janice Cunningham Tony Eakin Rebekah James Cynthia Kinney Terri Mayfield Sonya Sheppard Bridget Still Lindsey Thompson Krista Uldrick Trieste Underhill Sharon Walb Chad Webster Jeffrey Wright

  • Wesley Allen
  • Ronnie Autry
  • Cliff Collie
  • Janice Cunningham
  • Tony Eakin
  • Rebekah James
  • Cynthia Kinney
  • Terri Mayfield
  • Sonya Sheppard
  • Bridget Still
  • Lindsey Thompson
  • Krista Uldrick
  • Trieste Underhill
  • Sharon Walb
  • Chad Webster
  • Jeffrey Wright

• Team Members Present:

Participant

• Attendee:

• Position or Title:

• QSF-SRH-0007, Rev 1.

Quality Objectives (6.2)

• Can you explain the pillar goals of the organization?

• How does your department help the organization reach its goals?

• Not every department will impact all of the pillar goals

• Comments:

Resources

Infrastructure (7.1.3)

• Are there any tools, products, or equipment required for this process?<br>(Scanner, Insulated tools, imaging equipment, lasers, power tools, etc.)

  Yes

  No

  N/A

• Equipment requires inspection or calibration prior to use

Equipment/Device

• Device

• Is there an inspection/calibration sticker present?

  Yes

  No

  N/A

• Remove from service and contact BioMedical Services . Do not use until the equipment has an inspection/calibration completed.

• Is today's date < 12 months from the sticker date?

  Yes

  No

  N/A

• Remove from service and contact BioMedical Services . Do not use until the equipment has an inspection/calibration completed.

• Is the work area in suitable condition?

  Yes

  No

  N/A

• Location of finding:

• Notify Facilities and/or management of issues found.

• (Look for dirt, dust, noise, congestion, missing outlet covers, stained ceiling tiles, trip hazards, etc.)

• Comments:

Competency, Training, and Awareness (7.2)

• Are there any certifications, licenses, or training requirements for team members who perform these tasks?<br>

  Yes

  No

  N/A

• Team member HR file:

Team Member

• Team member initials:

• This team member is required to maintain a license or certification.

  Off

  On

• Is the team member's license/certification valid?

  Yes

  No

  N/A

• What steps are being taken to address the situation?

• This team member is not required to maintain a license or certification to perform his/her job duties.

  Off

  On

• How does the department ensure that the team member has adequate experience or training for his/her position?

• On-the-job (OTJ) experience/training can be considered adequate if there is a skills/competency evaluation.

• Comments:

• Orientation checklists, licenses, annual competencies, certifications can verify required training was completed

• Is there documentation that states what corrective action will be taken if required training is not maintained?

  Yes

  No

  N/A

• Documentation:

• Comments:

Policy (7.3)

• Can you explain the SRH Quality Policy?

• How do you and your department demonstrate the values of the Quality Policy?

• The Quality Policy is located on page 15 in the Quality Manual.

Communication (7.4)

• How does the department communicate goals, information, changes, and grievances to team members?

General Documentation Requirements (7.5)

• Are there any documents are required for this process?<br>(Policies, Procedures, Forms, Electronic Maintenance Records)

  Yes

  No

  N/A

• Examples:

• Are all required documents maintained on the Intranet (SharePoint)?

  Yes

  No

  N/A

• Review of Policies/Procedures

Policy/Procedure

• Date Ranges: Policies=3yrs, Forms=6yrs, External Documents: Annually, Order Sets= 2yrs (QSP-SRH-0001)

• Policy/Procedure Title and Number:

• Formulated/Publish date:

• Revision level:

• Is the document compliant with review/revision dates?

  Yes

  No

  N/A

• Are all documents maintained on the retention list (QSF-SRH-0003 Documented Information Master List)

  Yes

  No

  N/A

• Comments:

Operation

Process Walk-through and Explanation

• Summary of the process:

• This may require walking through a department or work area and may require PPE

• Ensure fire extinguishers are not blocked, O2 cylinders are secured when not in use, Bio-hazard containers are secured.

• Notes:

• Additional Process questions

Question

• Question:

• Answer:

Customer Communication (8.2.1)

• Is there a process for obtaining and responding to feedback from customers/patients? <br>

  Yes

  No

  N/A

• Customers may be other departments or team members

• This process is performed by an outside entity (Vendor or Contract Service).

  Off

  On

Externally Provided Products and Services (8.4)

• Has the outside entity been validated by the organization?<br>

  Yes

  No

  N/A

• Contract evaluation, extension, or renewal can verify this

Control of Production and Service Provision (8.5)

• Are controls in place to verify that the intended outcome/result of this process is achieved?<br>

  Yes

  No

  N/A

• Example:

• Examples are policies & procedures, protocols, order sets, forms, etc.

• Are there controls in place to prevent human error?

  Yes

  No

  N/A

• Example of control:

• Color coding, segregation, incompatibility of connectors, verification, etc.

• This process involves patient-related products (8.5.2)

  Off

  On

• Patient-related products can be narcotics, implants, surgical sponges, etc.

• Is there a procedure for providing identification and traceability of patient-related products?

  Yes

  No

  N/A

• Explanation of process:

Patient Property (8.5.3)

• A patient's personal property may be involved

  Off

  On

• Can team members describe how property belonging to a patient is maintained while in the care of SRH?

  Yes

  No

  N/A

• Is there a policy/procedure that covers this?

Preservation of Products or Services (8.5.4)

• Are products properly preserved according to applicable standards or regulations

• Refrigerator Temps are within limits, Maintenance labels are up-to-date, Inspections are current

• Comments:

Control of Nonconforming Outputs (8.7)

• Is there a process for addressing product failures (equipment, supplies, services)?

  Yes

  No

  N/A

• Describe the process:

• Is there a process for handling customer complaints/grievances?

  Yes

  No

  N/A

• Explain this process:

Performance Evaluation (9)

• Are there any defined department performance goals? (Yes or N/A)

  Yes

  No

  N/A

• How do you evaluate performance in order to achieve certain results?

• Explain how the goals are set and measured:

• If goals are not being met, what corrective actions are taken?

• Are the results reported to higher levels for review?

  Yes

  No

  N/A

• Where are the results reported to?

• PIC, PEC, MEC, Board Review, Management Review, etc.

• Do you share both 'wins' and 'areas needing improvement' with other departments who share similar goals or frustrations?

Improvement (10)

• Is there a procedure for addressing staff grievances and complaints?

  Yes

  No

  N/A

• Documentation of process:

• Are opportunities for improvement identified and addressed?

  Yes

  No

  N/A

• Example(s) or procedures:

• Is feedback solicited from team members on how a task could be improved or streamlined?

  Yes

  No

  N/A

• Example(s) or methodology:

• Suggestion box, leader engagement, idea board, etc.

After the audit is complete:

• Enter any Nonconformity, OFIs and Noteworthy Efforts that were identified during the audit.

• NC or Finding

Finding

• Requirement that was not met:

• Evidence that the requirement was not met:

• Opportunities for Improvement

OFI

• OFI:

• Noteworthy Efforts

NE

• NE:

• Other Applicable Notes/Comments:

• Auditor Name and Signature

Auditor

• Name

• Add signature

  Sign