UM WalkRounds Cross Audit - General Standards

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

NURSING (3 standards, 2 sub-standards and 17 sub-points)

• NR.4 Nursing reference manuals and policies are readily available and accessible to all nursing units [How to locate Regulatory Document (policies and procedures)in the intranet)] (Observation & Staff Interview)

  Met

  Not Met

  N/A

• NR.6 Sufficient nurses are available to meet the needs of patients. (Observation)

  Met

  Not Met

  N/A

NR.12.1 The nursing department ensures the availability of equipment and supplies necessary for the safe and effective provision of care. This includes, but is not limited to, the following: (Observation)

• NR.12.1.1 Scales appropriate to the age group and mobility needs of the patient

  Met

  Not Met

  N/A

• NR.12.1.2 Stretchers with safety straps

  Met

  Not Met

  N/A

• NR.12.1.3 Equipment for taking vital signs

  Met

  Not Met

  N/A

• NR.12.1.4 Wheelchairs with safety straps

  Met

  Not Met

  N/A

• NR.12.1.5 Sharp boxes

  Met

  Not Met

  N/A

• NR.12.1.6 Foot stools

  Met

  Not Met

  N/A

• NR.12.1.7 Lifting devices

  Met

  Not Met

  N/A

• NR.12.1.8 Soft restraints

  Met

  Not Met

  N/A

• NR.12.1.9 Bed rails

  Met

  Not Met

  N/A

• NR.12.1.10 Devices for treatment and prevention of skin breakdown

  Met

  Not Met

  N/A

• NR.12.1.11 Patient call bell

  Met

  Not Met

  N/A

• NR.12.1.12 Oxygen and suction

  Met

  Not Met

  N/A

• NR.12.1.13 Glucometer

  Met

  Not Met

  N/A

• NR.12.1.14 Nebulizers

  Met

  Not Met

  N/A

• NR.12.1.15 Blood warmers

  Met

  Not Met

  N/A

• NR.12.1.16 ECG machines

  Met

  Not Met

  N/A

• NR.12.2 The Nursing department has a process to maintain adequate supplies and linen to meet patient needs. (Observation)

  Met

  Not Met

  N/A

• NR.12.2.1 Critical levels are identified. (Observation)

  Met

  Not Met

  N/A

INFECTION PREVENTION & CONTROL (IPC) – (11 standards and 5 sub-standards)

• IPC.13 Sharps are discarded in appropriate containers. (Observation)

  Met

  Not Met

  N/A

• IPC.15 Facility design and available supplies support isolation practices. ESR (Observation)

  Met

  Not Met

  N/A

• IPC.24.1 Hospital environment, lockers, and cabinets are clean. (Observation)

  Met

  Not Met

  N/A

• IPC.24.2 Food is stored under sanitary conditions and is consumed in designated places. (Observation)

  Met

  Not Met

  N/A

• IPC.24.3 Food refrigerators are clean and are used only for food storage. (Observation)

  Met

  Not Met

  N/A

• IPC.24.4 There are separate clean and dirty utility areas in each patient care area. (Observation)

  Met

  Not Met

  N/A

• IPC.25 There is a system to handle blood/body fluids spills (Observation)

  Met

  Not Met

  N/A

• IPC.26 The hospital implements a program that is consistent with laws and regulations for safe disposal of medical waste. (Observation)

  Met

  Not Met

  N/A

• IPC.32.1 Personal protective equipment (gown, gloves, masks, and protective eyewear) are readily available in all patient care areas. (Observation)

  Met

  Not Met

  N/A

• IPC.33 The hospital supports appropriate hand hygiene practices. (Observation)

  Met

  Not Met

  N/A

• IPC.34 The hospital provides sufficient hand hygiene facilities. (Observation)

  Met

  Not Met

  N/A

• IPC.39 The hospital implements evidence-based interventions to prevent ventilator–associated pneumonia. (Staff Interview)

  Met

  Not Met

  N/A

• IPC.40 The hospital implements evidence-based interventions to prevent surgical site infection. (Staff Interview)

  Met

  Not Met

  N/A

• IPC.41 The hospital implements evidence-based interventions to prevent catheterassociated urinary tract infection. (Staff Interview)

  Met

  Not Met

  N/A

FACILITY MANAGEMENT & SAFETY (12 standards, 20 sub-standards and 32 sub-points )

• FMS.6 Warning and directive signs are posted inside the hospital as appropriate. (Observation)

  Met

  Not Met

  N/A

• FMS.6.1.1 Signs for the radioactive materials including warning signs for pregnant women

  Met

  Not Met

  N/A

• FMS.6.1.2 Signs for wet floors during cleaning

  Met

  Not Met

  N/A

• FMS.6.1.3 No smoking signs

  Met

  Not Met

  N/A

• FMS.6.1.4 Signs and warning lights for x-ray room(s)

  Met

  Not Met

  N/A

• FMS.6.1.5 Signs to restrict cellular phones in sensitive areas as appropriate, e.g., MRI or critical care units

  Met

  Not Met

  N/A

FMS.6.2 There are directive signs posted as appropriate in the hospital and include:

• FMS.6.2.1 Signs indicating the hospital name and main entrances/exits

  Met

  Not Met

  N/A

• FMS.6.2.2 Directional signs

  Met

  Not Met

  N/A

• FMS.6.2.3 Signs to direct staff and patients to the different services in the hospital

  Met

  Not Met

  N/A

• FMS.6.2.4 Fire exit signs

  Met

  Not Met

  N/A

• FMS.6.2.5 Signs to identify floor level at staircases and in front of elevators

  Met

  Not Met

  N/A

• FMS.6.2.6 Signs to instruct staff, patients, and visitors in restricted areas

  Met

  Not Met

  N/A

• FMS.6.2.7 MRI patient safety measures and steel restriction signs

  Met

  Not Met

  N/A

• FMS.6.2.8 Signs for populations with special needs

  Met

  Not Met

  N/A

FMS.8.1 The patients’ bathrooms and showers are provided with the following safety measures: (Observation)FMS.8.1 The patients’ bathrooms and showers are provided with the following safety measures: (Observation)

• FMS.8.1.1 non-slipping floors’ surfaces

  Met

  Not Met

  N/A

• FMS.8.1.2 Bars to support patients

  Met

  Not Met

  N/A

• FMS.8.1.3 Bell or a system to call for help

  Met

  Not Met

  N/A

• FMS.8.1.4 Lock system that allows opening from outside

  Met

  Not Met

  N/A

• FMS.9 The hospital ensures that all its occupants are safe from radiation hazards. ESR (Observation)

  Met

  Not Met

  N/A

• FMS.10 Patients and staff are protected from unnecessary exposure to laser beams in areas where it is used. Observation

  Met

  Not Met

  N/A

• FMS.14.3 Each department dealing with hazardous materials has Material Safety Data Sheets (MSDS) relevant to its current list of hazardous materials. (Staff Interview & Observation)

  Met

  Not Met

  N/A

• FMS.14.4 Each department using hazardous materials has proper personal protective equipment (PPE) and spill kits to handle any spill or exposure. (Observation)

  Met

  Not Met

  N/A

• FMS.20 Fire extinguishers are available in the hospital and are properly distributed. (Observation)

  Met

  Not Met

  N/A

• FMS.20 Fire extinguishers are available in the hospital and are properly distributed. (Observation)

  Met

  Not Met

  N/A

• FMS.23 There are fire exits that are properly located in the hospital. (Staff Interview & Observation)

  Met

  Not Met

  N/A

• FMS.24.1 The hospital implements a strict “No Smoking” policy. (Observation)

  Met

  Not Met

  N/A

• FMS.24.2 There are no obstructions to exits, fire extinguishers, fire alarm boxes, emergency blankets, safety showers, and eye wash stations. (Observation)

  Met

  Not Met

  N/A

• FMS.24.4 Storage areas are properly and safely organized: (Observation)

  Met

  Not Met

  N/A

• FMS.24.4.1 Shelves and racks are sturdy and in good condition

  Met

  Not Met

  N/A

• FMS.24.4.2 No items stored directly on the floor (a minimum of ten centimeters is left to manage spills)

  Met

  Not Met

  N/A

• FMS.24.4.3 Items should be stacked on a flat base

  Met

  Not Met

  N/A

• FMS.24.4.4 Heavier objects are close to the floor and lighter/smaller objects are higher

  Met

  Not Met

  N/A

• FMS.24.4.5 Items are not stacked so high to block sprinklers or come in contact with overhead lights or pipes (a minimum distance of fifty centimeters from ceiling level)

  Met

  Not Met

  N/A

FMS.31 The hospital ensures that emergency power covers the critical areas in case of failure

• FMS.31.1 The hospital has an emergency power that covers at least the following critical areas: (Observation)

  Met

  Not Met

  N/A

• FMS.31.1.1 Operating room

  Met

  Not Met

  N/A

• FMS.31.1.2 Labor and delivery

  Met

  Not Met

  N/A

• FMS.31.1.3 Critical care units

  Met

  Not Met

  N/A

• FMS.31.1.4 Alarm system

  Met

  Not Met

  N/A

• FMS.31.1.5 Fire pumps

  Met

  Not Met

  N/A

• FMS.31.1.12 Medications stores

  Met

  Not Met

  N/A

• FMS.31.1.13 Emergency room

  Met

  Not Met

  N/A

FMS.32 The hospital ensures proper maintenance of the medical gas system. ESR (Staff Interview & Observation)

FMS.32.1 The medical gas system is regularly tested for:

• FMS.32.1.1 Pressure

  Yes

  No

  N/A

• FMS.32.1.2 Leaks

  Yes

  No

  N/A

• FMS.32.1.3 Functionality of valves, alarms, pressure gauge, and switches

  Yes

  No

  N/A

FMS.35 The hospital ensures proper air flows (positive, negative, balanced) in the required locations. (Observation)

• FMS.35.1 operating room(s)

  Met

  Not Met

  N/A

• FMS.35.2 labor and delivery

  Met

  Not Met

  N/A

• FMS.35.3 isolation room(s)

  Met

  Not Met

  N/A

• FMS.35.4 critical care unit(s)

  Met

  Not Met

  N/A

• FMS.35.5 clean and dirty utility

  Met

  Not Met

  N/A

• FMS.35.6 janitorial closet

  Met

  Not Met

  N/A

• FMS.35.8 triage and trauma management areas

  Met

  Not Met

  N/A

FMS.36.5 Temperature and humidity are controlled and regularly monitored inpatient rooms. (Observation)

• FMS.36.1 operating and recovery room(s)

  Met

  Not Met

  N/A

• FMS.36.2 nursery

  Met

  Not Met

  N/A

• FMS.36.3 critical care unit(s)

  Met

  Not Met

  N/A

• FMS.36.5 inpatient rooms

  Met

  Not Met

  N/A

MEDICATION MANAGEMENT (14 standards and 1 sub-standard)

• MM.5 The hospital has a system for the safety of high-alert medications. ESR (Staff Interview & Observation)

  Met

  Not Met

  N/A

• MM.6 The hospital has a system for the safety of look-alike and sound-alike (LASA) medications. ESR (Staff Interview & Observation)

  Met

  Not Met

  N/A

• MM.8.3 The hospital formulary is accessible to all those involved in medication management. (Staff Interview & Observation)

  Met

  Not Met

  N/A

• MM.11 The hospital has a safe and secure system for the storage of regular medications and nutrition products in stores, pharmacies, and patient care areas. (Observation)

  Met

  Not Met

  N/A

• MM.12 The hospital has a safe and secure system for storage of refrigerated and frozen medications, biologicals, and vaccines in stores, pharmacies, and patient care areas (Observation)

  Met

  Not Met

  N/A

• MM.13 The hospital has a safe and secure system for the storage and safe management of hazardous medications and pharmaceutical chemicals (Observation)

  Met

  Not Met

  N/A

• MM.14 The hospital has a system for ensuring stability of medications available in multi-dose containers. (Observation)

  Met

  Not Met

  N/A

• MM.15 The hospital has a system for ensuring accessibility, availability, monitoring, and security of emergency medications (Observation)

  Met

  Not Met

  N/A

• MM.16 The hospital has a safe and secure system for managing medications in the patient care areas. (Observation)

  Met

  Not Met

  N/A

• MM.18 There is a system for storing narcotics, psychotropic and other controlled medications in accordance with relevant laws and regulations. (Observation)

  Met

  Not Met

  N/A

• MM.32 The hospital has a system for labeling medications (Tallman Lettering) (Observation)

  Met

  Not Met

  N/A

• MM.40 The hospital has a process for detecting, managing and reporting adverse drug reactions (ADRs). (Staff Interview)

  Met

  Not Met

  N/A

• MM.41 The hospital has a process for monitoring, identifying, and reporting significant medication errors, including near misses, hazardous conditions, and at-risk behaviors that have the potential to cause patient harm. ESR (Staff Interview)

  Met

  Not Met

  N/A

• IPSG 3.2 The hospital develops and implements a process to manage the safe use of concentrated electrolytes (Observation)

  Met

  Not Met

  N/A

QUALITY MANAGEMENT & PATIENT SAFETY (6 standards and 2 sub-standards)

• QM.10.4 Information is communicated to the appropriate stakeholders in a way they can understand and use. (Staff must be aware of their unit an hospital KPIs) (Staff Interview)

  Met

  Not Met

  N/A

• QM.14 The hospital has an incident (occurrence/variance) management mechanism that supports improvements of care processes. (KFMC = Datix) (Staff Interview)

  Met

  Not Met

  N/A

• QM.15 The hospital has a process to handle sentinel events Staff Interview

  Met

  Not Met

  N/A

• QM.17 The hospital has a process to ensure correct identification of patients. ESR (Observation)

  Met

  Not Met

  N/A

• QM.18 The hospital has a process to prevent wrong patient, wrong site, and wrong surgery/procedure. ESR (Observation)

  Met

  Not Met

  N/A

• QM.19 The hospital ensures availability and safety of infusion pumps

  Met

  Not Met

  N/A

• QM.19.2 Infusion pumps have "free-flow" protection. (Staff Interview)

  Met

  Not Met

  N/A

PROVISION OF CARE (2 standards)

• PC.25 Policies and procedures guide the handling, use, and administration of blood and blood products. ESR (Observation)

  Met

  Not Met

  N/A

• PC.30 Restraints are applied safely and in accordance with professional standards and applicable laws and regulations. (Observation)

  Met

  Not Met

  N/A

PATIENT & FAMILY RIGHTS (4 standards and 1 sub-standard)

• PFR.1.6 The hospital ensures that patients are informed about their rights and responsibilities. (displayed/ posted in patients’ room, nursing station, etc.) (Observation)

  Met

  Not Met

  N/A

• PFR.3 Privacy of patients is maintained throughout the care process. (Observation)

  Met

  Not Met

  N/A

• PFR.4 The hospital protects patient belongings. (Observation)

  Met

  Not Met

  N/A

• PFR.17 Hospital leaders develop and adopt ethical standards in dealing with patients and their supporters and sponsors. (Staff knowledge on ethical dilemma workflow in KFMC) (Staff Interview)

  Met

  Not Met

  N/A

MANAGEMENT OF INFORMATION (1 standard and 1 sub-standard)

• MOI.9 The hospital maintains sufficient provisions that ensure the operation of the information system during scheduled or unscheduled(unexpected) downtime

  Met

  Not Met

  N/A

• MOI 9.1 There are procedures and forms to be used during scheduled or unscheduled downtime (Staff Interview)

  Met

  Not Met

  N/A