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Environmental Rounds Tour Form and Questionnaire Sample
Sample Hospital
Leading Practices Library
Organizations submit practices to The Joint Commission that they have found to be “leading practices,” with permission to share them with other organizations. The Joint Commission makes these “leading practices” available to organizations that may wish to examine their applicability to their particular circumstances. Please understand that The Joint Commission can make no representations as to the results that any organization can expect from their use or adaptation of a “leading practice” to their particular circumstances.
12/15/2010
SAMPLE HOSPITAL
ENVIRONMENTAL TOURS FORM
Floor/Department & Manager: _________________________________ Date: ________________
Electrical
Housekeeping 02.01 Area not clean
02.02 Chute room doors are propped open
02.03 Microwave needs to be cleaned
02.04 Housekeeping carts need repair
02.05 Area not orderly
02.06 Refrigerator needs to be cleaned
02.07 Improper storage on housekeeping cart
02.08 Improper storage of chemicals
02.09 Improper storage in janitors’ closet
02.10 Keys left in janitors closet
02.11 Dirty items
02.12 Items not clean 02.13 Ice machine needs to be cleaned 02.14 Refrigerator/freezer needs to be defrosted
01.01 Patient care equipment inspection tag outdated
01.02 Non-patient care equipment inspection tag is outdated
01.03 Electrical boxes missing or damaged
01.04 Extension cords used as permanent wiring
01.05 Equipment located poorly
01.06 Cords located near a water source
01.07 Exposed wires
01.08 Power cords need to be rerouted away from sink, water or chemicals
01.09 Broken equipment not properly tagged or labeled 01.10 Critical equipment not plugged into red outlets
Fire Hazards 03.01 Fire exits obstructed
03.02 Fire extinguisher inspection tag outdated
03.03 Pull stations obstructed
03.04 Obstructed stairwells
03.05 Electrical boxes obstructed
03.06 Storage within 18 inches of the ceiling
03.07 Combustibles near a heat source
03.08 Aisles and passage ways obstructed
03.09 Fire extinguishers obstructed, missing or mounted too high
03.10 Doors propped, wedged, taped or tied open
03.11 Items located in front of/on top of flammable cabinet
03.12 Excessive amounts of combustibles stored
03.13 Heat producing equipment located poorly
03.14 Exit signs missing/obstructed
03.15 Escutcheon plate missing
03.16 Inadequate storage of items on the floor
03.17 Fire alarm detection impaired
03.18 Exit sign not functioning properly
03.19 Items stored on convector unit
03.20 Items stored in fire hose cabinet
03.21 Fire extinguisher obstructed
03.22 Decorations not meeting applicable standards
03.23 Obstruction of fire/smoke door
03.24 Space heater found
03.25 Candles found
03.26 Fire doors not closing properly
03.27 Paint covering door rating tag
03.28 Glazing in door damaged
03.29 Holes found in door/door frame
Engineering /Maintenance Controls
General Safety 05.01 Compressed gas cylinders unidentified and/or
improperly stored
05.02 Equipment not properly functioning/guarded
05.03 Unsafe storage of items
05.04 Smoking related materials found
05.05 Large section of unmarked glass present
05.06 Improper storage under the sink
05.07 Personal items stored improperly
05.08 Chemicals not labeled
05.09 Chemicals stored on the floor
05.10 Open chemicals without dates 05.11 Items stored on top of omni cell 05.12 Department does not have up-to-date chemical
inventory
05.13 Non-approved items found
Trips and Falls 06.01 Cords present tripping hazards
06.02 Supplies/equipment stored improperly
04.01 Sharps container not hung properly
04.02 Overfull sharps container
04.03 Med rooms/cabinets not locked
04.04 Exhaust hood needs cleaning
04.05 Sink/Counter top damage
04.06 Wall damage/painting needed
04.07 Door mesh not bolted to floor or ceiling
04.08 Items not properly installed
04.09 Floor covering in unsafe condition
04.10 Ceiling tiles missing or need repair
04.11 Holes in walls, floor or ceiling
04.12 Doors in need of repair
04.13 Flammable cabinet needs repair
04.14 Shelves/bracketing needs repair 04.15 Alcohol handwash dispensers not installed 04.16 Broken/cracked windows 04.17 Items need to be replaced 04.18 Lighting not functional/needs to be repaired or
replaced
Personal Protective Equipment 07.01 PPE missing/improperly used or stored
07.02 “PPE Located Here” signs are missing
07.03 Proper isolation techniques not being performed 07.04 Glove holder (s) empty 07.05 Gloves stored on top of sharps container 07.06 Glove box needs to be replaced 07.07 Additional glove boxes needed
Infection Control 08.01 Improper storage in refrigerator
08.02 Refrigerator logs not up-to-date and/or inadequately logged
08.03 Inadequate temp. for refrigerator
08.04 Associate food/drink in patient care areas
08.05 Food in refrigerator is not dated (patient only)
08.06 Unsecured meds
08.07 Dirty linen stored improperly
08.08 Clean linen stored improperly
08.09 Patient care items stored on the floor
08.10 Improper storage of food
08.11 Inadequate separation of clean and soiled supplies
08.12 Med prep/food not dated
08.13 Med prep equipment not clean and/or broken
08.14 Evidence of standing water
08.15 Multi-dose medication found with no date
08.16 Isolation stations/carts not adequately stocked
08.17 Improper storage of items
08.18 Mattress cover torn/damaged
08.19 Expired meds/materials
08.20 Uncontrolled sharps/needles
08.21 Toys not properly cleaned
08.22 Pre-drawn syringes found
08.23 Temperature log out of range
08.24 Presence of mold found
08.25 Meds of discharged patient found
08.26 Improper soaking/cleaning of instruments
08.27 Improper documentation
08.28 Autoclave-internal/external indicators
Hand Hygiene 08.40 Hand Hygiene procedures not properly performed
08.41 Paper towels not stored properly
08.42 Proper soap missing at sink
08.43 Alcohol gel/soap dispensers are empty
08.44 Non hospital approved lotion found
Regulated Waste 09.01 Biohazardous waste improperly disposed
09.02 Red bag being used for regular trash
09.03 Improper use of a biohazard bag
09.04 Biohazard waste container broken/needs repaired 09.05 Red bag waste improperly stored 09.06 Sharps container needs to be installed 09.07 Red bags stored on floor 09.08 No lids on red bag trash 09.09 Unstable sharps containers 09.10 Trash can need to be replaced 09.11 Sharps container full
Signs and Labels
10.01 Labels used improperly/missing/coming loose
10.02 Secondary containers not properly labeled
10.03 Proper safety signs missing
10.04 Flammable cabinet not properly labeled
10.05 Room sign/numbers missing
10.06 Evacuation routes posted incorrectly/missing 10.07 No stickers on refrigerator
10.08 “Wash your Hands” signs not posted in staff washroom
Associate Education 11.01 Staff- No knowledge of MSDS (how to obtain)
11.02 Staff- No knowledge of the locations of emergency exits routes, pull stations, fire extinguishers in the area
11.03 Staff- No knowledge of procedures for an associate injury, needle stick or blood or body fluid exposure
11.04 Staff- No knowledge of proper reporting for SMDA
11.05 Staff- No knowledge of where to reference Infection
Control policies and procedures
11.06 Staff- No knowledge of where to reference safety policies and procedures
11.07 Staff- No knowledge of how to label a piece of broken equipment
11.08 Staff- No knowledge of internal or external disasters
11.09 Staff- No knowledge of controls used to protect workers from needle stick injuries
11.10 Staff- No knowledge of how to look up the history of a piece of medical equipment to identify next date of scheduled maintenance
11.11 EOC Manual is not centrally located and/or accessible
11.12 Staff are not following safe practice/procedures
Construction
12.01 Exits obstructed or not inspected daily
12.02 Temporary construction areas not smoke tight & not built of non-combustible material
12.03 Additional fire fighting equipment not available
12.04 Storage has not been reduced
12.05 Training in alternate fire safety not performed
12.06 Safety orientation for contractors not performed
12.07 Wires not capped/exposed/dangerously located
12.08 “No smoking” signs posted
Flammables
Public Safety
14.01 Associates not wearing ACMC issued ID Badge
14.02 Keys found in doors
14.03 Items/areas not secured
Clinical Areas 15.01 Medication carts not properly working
15.02 Emergency medications not secured
15.03 Code carts not properly logged
15.04 Narcotics not controlled at all times
15.05 Patient information not secured
15.06 MARs not in the Medix
13.01 Flammables not labeled/labeled incorrectly
13.02 Flammables stored improperly
13.03 More than one days supply in secondary container
13.04 Refrigerators with flammables not labeled
13.05 Open cans stored under fume hoods >30 days
13.06 Labs have propane burning equipment
13.07 Chemicals not separated by hazard type
13.08 Appropriate spill kits not present
13.09 Eyewash station missing/needs to be replaced
13.10 Fume hoods have not been tested for face velocity within 12 months
13.11 Velocity of fume hoods is not >100 linear feet per minute
13.12 Holders or mitts for handling hot items not present
13.13 CO2 extinguishers not present
13.14 No spill plates used to catch chemicals
13.15 Broken glass containers full/not present
Environmental Sensitive Areas
16.01 Safety rails need covering
16.02 Objects can be used as weapons
16.03 Breakaway hardware needed
16.04 Plastic draw on curtains need to be removed
16.05 Non-glass partitions needed
16.06 Vents need to be covered
16.07 Hinges present hazard
16.08 Engineering controls needed
16.09 Tamper-proof screws needed
16.10 Electrical outlets need to be covered
16.11 Sharps edges present
16.12 Other
Other/Miscellaneous
17.01
Notes/Follow-Up:
* = Performance Monitors
1
SAMPLE HOSPITAL
ENVIRONMENT OF CARE ROUNDS
SURVEY QUESTIONNAIRE
Department___________________________________ Location – Building: ___________ Floor: ____ Room(s): _________________
Survey Conducted on: ___/___/___ Time : _________ By: ______________________________________________________________
Print name & signature
Department Head _______________________________________ Department Manager________________________________________
Print name & signature
Notes attached to SURVEY QUESTIONNARIE [ ] Yes [ ] No
Survey Questionnarie Routing Original: Safety Officer
Copy: Department Head [ ] Department Manager [ ] Administration [ ]
Page 1 of 3
SAFETY MANAGEMENT
No. Statement Method Used to Survey Yes No NA Comments
*1. Staff have received instruction Leadership verification [ ] [ ] [ ] ______________
on Department Specific Safety Plan
2. Department Specific Safety Policy reviewed every Obtain Policy & review [ ] [ ] [ ] ______________
3 years
* 3. Document completion of Department specific Leadership verification [ ] [ ] [ ] ______________
Safety Education for all associates, I.e. Review of your
Department’s Fire Response and Evacuation Procedure.
4. Staff knows process to report patient safety events Random staff interview [ ] [ ] [ ] ______________
& associate injury events
*5. Staff can describe their role in the event of an Random staff interview [ ] [ ] [ ] ______________
equipment failure E.g., (placement of Defective Tag on equipment/take out of service/report)
*6 One or more Staff has completed Crisis Response Training Leadership verification [ ] [ ] [ ] ______________
SMOKING
7. Staff knows how to report evidence of smoking violations. Random visual inspection [ ] [ ] [ ] ______________
SECURITY
8. Patient valuables are secure Random visual inspection [ ] [ ] [ ] ______________
9. Staff valuables are secure Random visual inspection [ ] [ ] [ ] _____________
*10. Offices are kept locked when not occupied to deter Theft Random visual inspection [ ] [ ] [ ] ______________
*11. Cables to lock down lap tops and computers in use in Random visual inspection [ ] [ ] [ ] ______________
common areas to deter Theft
*12. Staff can describe the procedure for response & Random staff interview [ ] [ ] [ ] ______________
reporting Code Pink incident e.g., infant or child abduction.
*13. Staff displaying ID badge at all times Random visual inspection [ ] [ ] [ ] ______________
*14. Staff can describe their Units procedure for response & Random staff interview [ ] [ ] [ ] ______________
reporting Security incident e.g., Code Grey = thefts, work place violence
HAZARDOUS MATERIALS & WASTE
*15. Staff can describe their role in the event of a Random staff interview [ ] [ ] [ ] ______________
Hazardous material spill or release
16. Only those hazardous chemicals listed on the Random visual inspection [ ] [ ] [ ] ______________
Department’s Chemical Inventory is present
17. Sharps/Syringes properly stored. Random visual inspection [ ] [ ] [ ] ______________
SAMPLE HOSPITAL
SURVEY QUESTIONNAIRE
* = Performance Monitors 2
Page 2 of 3
HAZARDOUS MATERIALS & WASTE MANAGEMENT (continued)
No. Statement Method Used to Survey Yes No NA Comments
*18. Staff can identify precautions to follow Random staff interview [ ] [ ] [ ] ______________ when working with hazardous materials.
E.g. Use appropriate personal protective equipment.
*19. Staff demonstrate the ability to access Random visual inspection [ ] [ ] [ ] ______________
MSDS via 3E Company’s MSDS FAX on
DEMAND SERVICE, or 3E Company’s ONLINE SERVICE
20. Hazardous materials including waste is Random visual inspection [ ] [ ] [ ] _______________ appropriately labeled and segregated
21. Compressed gas cylinders are properly Random visual inspection [ ] [ ] [ ] _______________
stored & secured.
EMERGENCY PREPAREDNESS
*22. Staff can describe their role in the event Random staff interview [ ] [ ] [ ] ________________ of a Mass Casualty. (Code Triage)
*23. Staff knows the location of the Random staff interview [ ] [ ] [ ] ________________ Environment of Care manual and that it contains Department
Specific Safety information including Emergency operations
response procedures and response to Utilities failure.
*24. Staff can describe decontamination Random staff interview [ ] [ ] [ ] ________________
procedures they should follow if contaminated.
*25. All associates can identify the designated phone Random staff interview [ ] [ ] [ ] ________________
extension to call to report any Hospital emergency I.e. FIRE - SECURITY – MEDICAL
FIRE PREVENTION MANAGEMENT
26. Staff know Fire response procedures (RACE) Random staff interview [ ] [ ] [ ] ________________
*27. Staffs know the 3 Steps of Evacuation. Random staff interview [ ] [ ] [ ] ________________
28. Storage minimum 18” from sprinkler head Random visual inspection [ ] [ ] [ ] ________________
29. Staff can locate Medical Gas shut off valve Random staff interview [ ] [ ] [ ] ________________
*30. In the event of a Fire, if deemed necessary, Random staff interview [ ] [ ] [ ] ________________
Nursing staff can identify staff person on Unit
responsible for shut-off of the Oxygen
31. Hazardous Areas are maintained with self- Random visual inspection [ ] [ ] [ ] ________________
closing door & positive latching E.g., Soiled/Clean Utility Rooms, Laboratories
32. Fire extinguisher inspection tags are current Random visual inspection [ ] [ ] [ ] ________________
33. Staff can identify need to clear hallways of Random visual inspection [ ] [ ] [ ] ________________ equipment as second step to Unit Fire Response.
(After closing doors)
34. Fire & smoke doors, emergency “Stairs Exit” Random visual inspection [ ] [ ] [ ] ________________
doors are not blocked or wedged open
35. All fire protection equipment has clear access Random visual inspection [ ] [ ] [ ] ________________
E.g., fire hose/portable fire extinguisher cabinets
36. Fire & smoke doors, emergency “Stairs Exit” Random visual inspection [ ] [ ] [ ] ________________
doors close automatically & latch
*37. Emergency Exit egress corridors is unobstructed Random visual inspection [ ] [ ] [ ] ________________
38. Emergency “Stairs”, “Exit” signs are illuminated Random visual inspection [ ] [ ] [ ] ________________
39. Extension cords are not used Random visual inspection [ ] [ ] [ ] ________________
SAMPLE HOSPITAL
SURVEY QUESTIONNAIRE
* = Performance Monitors 3
FIRE PREVENTION MANAGEMENT continued
40. Portable heating devices are not used Random visual inspection [ ] [ ] [ ] _______________
In patient care areas
Page 3 of 3
MEDICAL EQUIPMENT MANAGEMENT
No. Statement Method Used to Survey Yes No NA Comments
*41. Patient caregivers can hear and or provided with a Random staff interview [ ] [ ] [ ] ________________
System that otherwise alerts them in the event of a Medical Equipment Alarm activation within their
Nursing Unit or other Clinical Care Area
*42. Clinical staff demonstrate the ability to Random visual inspection [ ] [ ] [ ] ________________
access Patient care equipment inventory
& PM inspection record information via Advocate On Line. I.e. Cardiac Monitor, Ventilator
UTILITIES MANAGEMENT
*43. Department Leadership is educating and Leadership verification [ ] [ ] [ ] ________________ documenting on an annual basis their Associate’s
competency on the appropriate interventions
(Preparations to Make to Minimize Each Potential Problem)
and response (Assessment of the situation & Action required)
during a utility interruption. I.e. Loss of Electricity, Oxygen, or Water
44. Staffs know location(s) of Red outlets Random staff interview [ ] [ ] [ ] ________________
servicing life support equipment located within their work area.
SURVEY TEAM NOTES
To be completed by the Survey Team & Department representative at the closing of the Validation
Recommendations
Associate Emergency Handbook or other document designed for quick reference to emergency procedures.
Displayed in the department Yes No NA
[ ] [ ] [ ]
Comments _______________________________________
CODE RED (Department Specific Fire Plan Information) is current Yes No NA
[ ] [ ] [ ]
Comments _______________________________________
CODE RED (Department Specific Fire Plan) is Yes No NA
displayed in the department. [ ] [ ] [ ]
Comments__________________________________________________________________________________________
___________________________________________________________________________________________________
