Tracer

• Site conducted

  Select

• Location

• Prepared by

• Conducted on

  Date

Clinic Hours

• Are clinic office hours posted & visible from the outside of the building?

  Yes

  No

  N/A

Waiting Room

• Are Patient Rights posted in English and Spanish? Are both versions of Patient Rights available for patients if requested?

  Yes

  No

  N/A

• Is Cover Your Cough Signage Posted?

  Yes

  No

  N/A

• Is the staff familiar with the policy to triage a patient presenting a need for urgent assessment?

  Select Yes No Did not ask staff this question

  • Yes
  • No
  • Did not ask staff this question

Quality Board

• Are the emergency response plan and codes posted?

  Yes

  No

  N/A

• Is the most current Scorecard posted?

  Yes

  No

  N/A

• Does the quality board have a SCOPE of service?

  Yes

  No

  N/A

• Have employee take you to the quality board to point the information out

• Is the staff familiar with the National Patient Safety Goals (NPSG) or know where to find them?

  Yes

  No

  N/A

Flammable Liquids

• Are flammable liquids stored in flame resistant cabinet?

  Yes

  No

  N/A

Oxygen Cylinders

• Secured: On cart or behind chain, in a locked room

• Tagged: Full, In-Use, Empty

• Are oxygen cylinders secured, tagged, checked, and recorded daily properly? Masks/Nasal cannulas are unpunctured?

  Yes

  No

  N/A

Emergency Response

• Is the location of equipment posted?

  Yes

  No

  N/A

• Can staff identify what the equipment (3 Ambu Bags) is in the Orange Bag and available ER Meds?

  Select See ER Location of Equipment in Clinic: Emergency Response Location of Equipment should be completed specific to each clinic and posted where visible to staff. A list of ER Meds and inventory of Orange Bag is included on the bottom half of the form. Other (write answer in the notes below) Incorrect Answer Did not ask staff this question

  • See ER Location of Equipment in Clinic: Emergency Response Location of Equipment should be completed specific to each clinic and posted where visible to staff.
  • A list of ER Meds and inventory of Orange Bag is included on the bottom half of the form.
  • Other (write answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• Is emergency log up-to-date and filled out correctly?

  Yes

  No

  N/A

• Do you know your organizations Emergency Codes and your response to each?

  Select Name Tag Quality Board Various locations in clinic Other (Leave answer in the notes below) Incorrect Answer Did not ask staff this question

  • Name Tag
  • Quality Board
  • Various locations in clinic
  • Other (Leave answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• What do you do when someone calls with an emergency? (i.e. Chest Pain)

  Select Route call to nursing staff to answer immediately or find available nursing staff for call Other (Leave answer in the notes below) Incorrect Answer Did not ask staff this question

  • Route call to nursing staff to answer immediately or find available nursing staff for call
  • Other (Leave answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• Does staff know how to respond to a patient emergency?

  Select Dial 9-1-1 (red phone) and Dial 9-3-1-1 (cisco phone) / Involuntary Detention for Psychiatric Evaluation and admission forms: (as of 7/23/2015) - MHDD5: IL 462-2005 (R-8-13) and MHDD6: IL 462-2006 (R-4-14) Incorrect Answer Did not ask staff this question

  • Dial 9-1-1 (red phone) and Dial 9-3-1-1 (cisco phone) / Involuntary Detention for Psychiatric Evaluation and admission forms: (as of 7/23/2015) - MHDD5: IL 462-2005 (R-8-13) and MHDD6: IL 462-2006 (R-4-14)
  • Incorrect Answer
  • Did not ask staff this question

Restrooms

• No Bulletin Boards / Handouts should be laminated - exception: abuse/neglect tear off

• Are the following posted and in good condition in the restrooms?

  Select Abuse/Neglect Hotline Information Handwashing Signs Missing Signage

  • Abuse/Neglect Hotline Information
  • Handwashing Signs
  • Missing Signage

• Was the emergency pull cord within 6" from the floor?

  Yes

  No

  N/A

• Is the pullcord wipeable? Is it Vinyl?

  Yes

  No

  N/A

• Was the Restroom clean?

  Yes

  No

  N/A

Exam /Procedure/Consult/Treatment/ Ancillary Rooms

• Are these signs posted?

  Select Pain Scale Monitor Reminders Missing Signage

  • Pain Scale
  • Monitor Reminders
  • Missing Signage

• There was no PHI left out

  Yes

  No

  N/A

• Is the under sink storage clear? (exception: cleaning supplies)

  Yes

  No

  N/A

• Is there a sink clearance of ~ approx 18"? Or is a splashguard in place?

  Yes

  No

  N/A

• No expired items were found in the exam room

  Yes

  No

  N/A

• No unsecured workstation?

  Yes

  No

  N/A

• Sharps container is not filled beyond fill line

  Yes

  No

  N/A

• No unsecured needles / syringes /sharps

  Yes

  No

  N/A

• No unsecured medications

  Yes

  No

  N/A

• Surfaces, countertops, and beds are free of damage/clutter

  Yes

  No

  N/A

• Floors and Walls are clean and free of damage/clutter?

  Yes

  No

  N/A

• Curtain is on correct rotation?

  Yes

  No

  N/A

• How do you know a lead apron is safe to use?

  Select Aprons should be closely inspected before each use Tested annually under fluoroscopy or by x-ray if fluoroscopy unit is not available Other (write the answers in the note below) Incorrect Answer Did not ask staff this question

  • Aprons should be closely inspected before each use
  • Tested annually under fluoroscopy or by x-ray if fluoroscopy unit is not available
  • Other (write the answers in the note below)
  • Incorrect Answer
  • Did not ask staff this question

• How often are lead aprons tested to ensure integrity?

  Select Annually Bi-annually Incorrect Answer Did not ask staff this question

  • Annually
  • Bi-annually
  • Incorrect Answer
  • Did not ask staff this question

Lab

• Is a 2 patient identifier in use?

  Yes

  No

  N/A

• Is there a sink clearance of ~ approx 18"? Or splashguard in place?

  Yes

  No

  N/A

• No expired items were found in the lab

  Yes

  No

  N/A

• Logs are up-to-date and filled out correctly

  Yes

  No

  N/A

• Sharps container is not filled beyond fill line

  Yes

  No

  N/A

• Surfaces and countertops are free of damage/clutter?

  Yes

  No

  N/A

• Floors and Walls are clean and free of damage/clutter?

  Yes

  No

  N/A

• No unapproved personal items/ food or drink?

  Yes

  No

  N/A

• How is patient-specific information protected?

  Select Secure PHI away from the public Not discussed in hallways Use of shred bins Other (Leave answer in the notes below) Incorrect Answer Did not ask staff this question

  • Secure PHI away from the public
  • Not discussed in hallways
  • Use of shred bins
  • Other (Leave answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• Curtain is on correct rotation ?

  Select Yes No N/A

  • Yes
  • No
  • N/A

Clinical Work Stations & Staff Questions

• Is the location of emergency equipment, response plan, and code posted?

  Yes

  No

  N/A

• Is their area clean of unapproved items?

  Yes

  No

  N/A

• Are workstations secure?

  Yes

  No

  N/A

• How is patient specific information protected?

  Select Secure PHI away from the public Not discussed in hallways Use of shred bins Other (Leave answer in the notes below) Incorrect Answer Did not ask staff this question

  • Secure PHI away from the public
  • Not discussed in hallways
  • Use of shred bins
  • Other (Leave answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• What do you do when a patient or family member has a complaint?

  Select Listen and address the concern, if possible. If unable to resolve, refer to appropriate resources, i.e.: supervisor, manager, guest relations, or admin Document a QCR Other (Leave a note with the answer) Incorrect Answer Did not ask staff this question

  • Listen and address the concern, if possible. If unable to resolve, refer to appropriate resources, i.e.: supervisor, manager, guest relations, or admin
  • Document a QCR
  • Other (Leave a note with the answer)
  • Incorrect Answer
  • Did not ask staff this question

• How have you been involved in the improvement activities of your organization?

  Select A1c and LDL testing; BP Checks Call turn-around-time survey Processing incoming phone calls (busy signal, abandon rate, wait time) Other (Leave answer in the notes below) Incorrect Answer Did not ask staff this question

  • A1c and LDL testing; BP Checks
  • Call turn-around-time survey
  • Processing incoming phone calls (busy signal, abandon rate, wait time)
  • Other (Leave answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• What happens when a patient can't read or speak English or is hearing impaired

  Select Contact Interpretation or Use VINSE Contact the hearing impaired service Incorrect Answer Did not ask staff this question

  • Contact Interpretation or Use VINSE
  • Contact the hearing impaired service
  • Incorrect Answer
  • Did not ask staff this question

• What is the best thing to do to prevent infections?

  Select Wash Hands Incorrect Answer Did not ask staff this question

  • Wash Hands
  • Incorrect Answer
  • Did not ask staff this question

• What is the procedure for reporting a safety problem?

  Select Report to manager Use of QCRs Other (write answer in notes below) Incorrect Answer Did not ask staff this question

  • Report to manager
  • Use of QCRs
  • Other (write answer in notes below)
  • Incorrect Answer
  • Did not ask staff this question

• How do you maintain information security?

  Select Secure or log off computer Use Shred Bin Other (Leave answer in the notes below) Incorrect Answer Did not ask staff this question

  • Secure or log off computer
  • Use Shred Bin
  • Other (Leave answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• "contain" in hospital and "clear" in clinics

• Describe steps you should take if you discover a fire?

  Select R.A.C.E. Evacuation routes identified Other (Write answer in the notes below) Incorrect Answer Did not ask staff this question

  • R.A.C.E.
  • Evacuation routes identified
  • Other (Write answer in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• How do you verify patient identity before administering medication, collecting blood, or other specimens, or performing other procedures/treatments?

  Select Two patient identifiers verified with the physician orders Incorrect Answer Did not ask staff this question

  • Two patient identifiers verified with the physician orders
  • Incorrect Answer
  • Did not ask staff this question

• Can staff identify the TIME OUT Process, Universal Protocol & Informed Consent and how it is obtained - Have staff pull 2 PROCEDURES FOR REVIEW

  Select Yes No Did not ask staff this question

  • Yes
  • No
  • Did not ask staff this question

• How do you know the medical equipment is safe to use?

  Pass

  Fail

  N/A

• Who tests the equipment?

  Pass

  Fail

  N/A

Logs

• Are logs up-to-date and filled out correctly?

  Yes

  No

  N/A

• Are older logs stored away from current logs?

  Yes

  No

  N/A

Medication

• Are medication preparation areas clean & clear of clutter?

  Yes

  No

  N/A

• There are no expired medications

  Yes

  No

  N/A

• Misc Findings/Notes (If it is a note and not a finding, notate it but answer with N/A)

  Findings

  N/A

• How are medications secured?

  Select Secure means under constant surveillance or locked Other (write response in the notes below) Incorrect Answer Did not ask staff this question

  • Secure means under constant surveillance or locked
  • Other (write response in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• Tall Man Lettering, storing LASA & HRHA drugs apart / Have staff show you where the lists are posted and explain the purpose they serve

• What is being done to reduce the risk of medication errors?

  Select LA/SA meds are segregated and labeled Other (write response in the notes below) Incorrect Answer Did not ask staff this question

  • LA/SA meds are segregated and labeled
  • Other (write response in the notes below)
  • Incorrect Answer
  • Did not ask staff this question

• VFC Refrigerator require an alarm to be TURNED ON at all times a physical temperature log, water bottles in fridge & freezer labeled "DO NOT DRINK" / Refrigerator for patient nutrition - all items maintained in patient nutrition refrigerator MUST be shelf stable.

• Refrigerator monitor alarm is ON at ALL TIMES?

  Yes

  No

  N/A

• If they need a log, is it updated and filled out correctly?

  Yes

  No

  N/A

• No prescription pads are in the exam room or laying out

  Yes

  No

  N/A

• Syringes are located in a secure area

  Yes

  No

  N/A

• Are medications secured/locked properly?

  Yes

  No

  N/A

• Is the locked cabinet accessible?

  Yes

  No

  N/A

Storage Areas

• There are no outside shipping labels?

  Yes

  No

  N/A

• Linen is in proper locations, covered, and stored separately.

  Yes

  No

  N/A

• Sterile Supplies are current, intact, and not soiled. Clean/sterile patient care related items are not properly stored. (NOT under sinks, on windowsills, on the floor or with soiled items)

  Yes

  No

  N/A

• There are no expired items

  Yes

  No

  N/A

• Barriers are in place if bottom shelf in storage area is open (i.e. mesh wire) At least 6" off floor.

  Yes

  No

  N/A

• There are no Misc Findings/Notes (If it is not a finding, notate it but answer with N/A)

  Findings

  N/A

• Is so, storage of supplies are 18" from the sprinkler and 6 inches off the floor.

  Yes

  No

  N/A

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