Shco Entry Level Self Assessment Toolkit

8/20/2019 Shco Entry Level Self Assessment Toolkit

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Self Assessment Toolkit

Compliance to the requirement: 10

Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying out of total samples selected)

Non-compliance to the requirement: 0

Not pplicable: N

!"aluation Criteria

# $"erall score of minimum 50% in each chapter

(Name & ddress of the 'C$)

$rganisation is required to pro"ide self assessment report in the format 'elf ssessment *ool+it gi"en belo, ll the entries are to be properly filledup .egarding scoring follo,ing criteria ,ould be applicable

•$"erall score of minimum 50% in all standards


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SELF ASSESSMENT TOOLKIT

Elements

AAC.1: The organization efines an is!la"s the ser#i$es that it $an !ro#ie.

a *he ser"ices being pro"ided are clearly defined

b *he defined ser"ices are prominently displayed

c *he rele"ant staffs are oriented to these ser"ices

*he organi/ation determines ,ho can perform the assessments

*he initial assessment for in-patients is documented ,ithin hours or earlier

%o$&mentation

'(es) No*

Im!lementation

'(es) No*

E#ien$e'$ross referen$e to

o$&ments)man&als et$.*

S$ores

'+) ,) 1+*

Cha!ter 1: ACCESS- ASSESSMENT AN% CONTINIT( OFCA/E 'AAC*

AAC.0: The organization has a o$&mente registration- amission antransfer !ro$ess.

a Process addresses registering and admitting out-patients3 in-patients andemergency patients

b Process addresses mechanism for transfer or referral of patients ,ho do notmatch the organi/ational resources

AAC. 2atients $are for 3" the organization &nergo an esta3lishe initialassessment.

a *he organi/ation defines the content of the assessments for in-patients andemergency patients

b

c

AAC.4 2atient $are is $ontin&o&s an all !atients $are for 3" theorganization &nergo a reg&lar reassessment.


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ll patients are reassessed at appropriate inter"als

'taff in"ol"ed in direct clinical care document reassessments

4maging ser"ices comply ,ith legal and other requirements

AAC.5 Organization has a efine is$harge !ro$ess.

a uring all phases of care3 there is a qualified indi"idual identified as responsiblefor the patient6s care ,ho coordinates the care in all the settings ,ithin theorgani/ation

b

c

d Patients are reassessed to determine their response to treatment and to planfurther treatment or discharge

AAC., La3orator" ser#i$es are !ro#ie as !er the s$o!e of the hos!ital6sser#i$es an la3orator" safet" re7&irements.

a 'cope of the laboratory ser"ices are commensurate to the ser"ices pro"ided bythe organi/ation

b Procedures guide collection3 identification3 handling3 safe transportation3processing and disposal of specimens

c 7aboratory results are a"ailable ,ithin a defined time frame and critical results are

intimated immediately to the concerned personnel

d 7aboratory personnel are trained in safe practices and are pro"ided ,ithappropriate safety equipment8 de"ices

AAC.8 Imaging ser#i$es are !ro#ie as !er the s$o!e of the hos!ital6sser#i$es an esta3lishe raiation safet" !rogramme.

a

b 'cope of the imaging ser"ices are commensurate to the ser"ices pro"ided by theorgani/ation

c 4maging results are a"ailable ,ithin a defined time frame and critical results are

intimated immediately to the concerned personneld 4maging personnel are trained in safe practices and are pro"ided ,ith appropriate

safety equipment8 de"ices

a Process addresses discharge of all patients including 9edico-legal cases andpatients lea"ing against medical ad"ice


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4n case of death the summary of the case also includes the cause of death

Cha!ter 0: CA/E OF 2ATIENTS 'CO2*

CO2.1: Care of !atients is g&ie 3" a$$e!te norms an !ra$ti$e.

a *he care and treatment orders are signed and dated by the concerned doctor

b Clinical Practice uidelines are adopted to guide patient care ,here"er possible

a

b

c

a *he transfusion ser"ices are go"erned by the applicable la,s and regulations

b discharge summary is gi"en to all the patients lea"ing the organi/ation(including patients lea"ing against medical ad"ice)

c ischarge summary contains the reasons for admission3 significant findings3in"estigation results3 diagnosis3 procedure performed (if any)3 treatment gi"en andthe patient6s condition at the time of discharge

d ischarge summary contains follo, up ad"ice3 medication and other instructionsin an understandable manner

e ischarge summary incorporates instructions about ,hen and ho, to obtainurgent care

f

CO2.0: Emergen$" ser#i$es in$l&ing am3&lan$e are g&ie 3" o$&mente!ro$e&res an a!!li$a3le la9s an reg&lations.

ocumented procedures address care of patients arri"ing in the emergencyincluding handling of medico-legal cases

'taff should be ,ell "ersed in the care of emergency patients in consonance ,iththe scope of the ser"ices of hospital

dmission or discharge to home or transfer to another organi/ation is alsodocumented

CO2.: %o$&mente !ro$e&res efine rational &se of 3loo an 3loo!ro&$ts.


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b

c Procedure addresses documenting and reporting of t ransfusion reactions

a Care of patient is in consonance ,ith the documented procedures

b dequate staff and equipment are a"ailable

a *he organi/ation defines the scope of obstetric ser"ices

b

c *he organi/ation has the facilities to ta+e care of neonates

a *he organi/ation defines the scope of its paediatric ser"ices

b Pro"isions are made for special care of children by competent staff

c

d

e

CO2.5: %o$&mente !ro$e&res g&ie the aministration of anaesthesia.

4nformed consent is obtained for donation and transfusion of blood and bloodproducts

CO2.4: %o$&mente !ro$e&res g&ie the $are of !atients as !er the s$o!eof ser#i$es !ro#ie 3" hos!ital in Intensi#e $are an high e!enen$" &nits.

CO2.,: %o$&mente !ro$e&res g&ie the $are of o3stetri$al !atients as !erthe s$o!e of ser#i$es !ro#ie 3" hos!ital.

$bstetric patient6s care includes regular ante-natal chec+-ups3 maternal nutritionand post-natal care

CO2.8: %o$&mente !ro$e&res g&ie the $are of !aeiatri$ !atients as !erthe s$o!e of ser#i$es.

Patient assessment includes detailed nutritional gro,th and immuni/ation

assessment

Procedure addresses identification and security measures to pre"ent child8neonate abduction and abuse

*he children6s family members are educated about nutrition3 immuni/ation andsafe parenting


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a *here is a documented policy and procedure for the administration of anaesthesia

b

c

d n immediate preoperati"e re-e"aluation is documented

e

f

g !ach patient6s post-anaesthesia status is monitored and documented

a

b n informed consent is obtained by a surgeon prior to the procedure

c

d

e

f

Cha!ter : MANAEMENT OF ME%ICATION 'MOM*

ll patients for anaesthesia ha"e a pre-anaesthesia assessment by aqualified8trained indi"idual

*he pre-anaesthesia assessment results in formulation of an anaesthesia plan

,hich is documented

4nformed consent for administration of anaesthesia is obtained by theanaesthetist

naesthesia monitoring includes regular and periodic recording of heart rate3cardiac rhythm3 respiratory rate3 blood pressure3 o;ygen saturation3 air,ay

CO2.;: %o$&mente !ro$e&re g&ies the $are of !atients &nergoing

s&rgi$al !ro$e&res.'urgical patients ha"e a preoperati"e assessment and a pro"isional diagnosisdocumented prior to surgery

ocumented procedure addresses the pre"ention of ad"erse e"ents li+e ,rongsite3 ,rong patient and ,rong surgery


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a

b *hese comply ,ith the applicable la,s and regulations

c 'ound ali+e and loo+ ali+e medications are stored separately

d =eyond e;piry date medications are not stored8used

e

MOM.0: %o$&mente !ro$e&re g&ies the !res$ri!tion of mei$ations.

a *he organi/ation determines ,ho can ,rite orders

b $rders are ,ritten in a uniform location in the medical records

c 9edication orders are clear3 legible3 dated and signed

d

MOM.: 2oli$ies an !ro$e&res g&ie the safe is!ensing of mei$ations.

a

b igh ris+ medication orders are "erified prior to dispensing

MOM.4: There are efine !ro$e&res for mei$ation aministration

a 9edications are administered by trained personnel

b

c Prepared medication is labelled prior to preparation of a second drug

ocumented procedure shall incorporate purchase3 storage3 prescription anddispensation of medications

ocumented procedures address procurement and usage of implantableprosthesis

*he organi/ation defines a list of high ris+ medication & process to prescribethem

9edications are chec+ed prior to dispensing including e;piry date to ensure thatthey are fit for use

igh ris+ medication orders are "erified prior to administration3 medication orderincluding patient3 dosage3 route and timing are "erified


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d 9edication administration is documented

e

MOM.,: A#erse r&g e#ents are monitore.

a d"erse drug e"ents are defined and monitored

b d"erse drug e"ents are documented and reported ,ithin a specified time frame

Cha!ter 4: 2ATIENT /I


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b Patients are taught in a language and format that they can understand

Cha!ter ,:


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d

e

Cha!ter 8: CONTINOS @ALIT( IM2/OEMENT 'C@I*

a

b

c

a

b *hese indicators shall be monitored

Cha!ter 5: /ES2ONSI=ILITIES OF MANAEMENT '/OM*

/OM.1: The res!onsi3ilities of the management are efine.

a *he organi/ation has a documented organogram

b *he organi/at ion is registered ,ith appropriate authorit ies as applicable

c

.equisite fees3 documents and reports are submitted to competent authorities onstipulated dates

ppropriate personal protecti"e measures are used by all categories of staffhandling bio-medical ,aste

[email protected]: There is a str&$t&re 7&alit" im!ro#ement an $ontin&o&s monitoring!rogramme in the organization.

*here is a designated indi"idual for coordinating and implementing the qualityimpro"ement programme

*he quality impro"ement programme is a continuous process and updated atleast once in a year

ospital 9anagement ma+es a"ailable adequate resources required for qualityimpro"ement programme

[email protected]: The organization ientifies ke" ini$ators to monitor the str&$t&res-!ro$esses an o&t$omes 9hi$h are &se as tools for $ontin&al im!ro#ement.

$rgani/ation shall identify the appropriate +ey performance indicators in bothclinical and managerial areas

*he organi/ation has a designated indi"idual(s) to o"ersee the hospital ,idesafety programme


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/OM.0: The organization is manage 3" the leaers in an ethi$al manner.

a *he management ma+es public the mission statement of the organi/ation

b *he leaders8management guide the organi/ation to function in an ethical manner

c *he organi/ation discloses its o,nership

d *he organi/ations billing process is accurate and ethical

Cha!ter ;: FACILIT( MANAEMENT AN% SAFET( 'FMS*

a

b 9aintenance staff is contactable round the cloc+ for emergency repairs

c

d >acility inspection rounds to ensure safety are conducted periodically

e *here is a safety education programme for rele"ant staff

a *he organi/ation plans for equipment in accordance ,ith its ser"ices

b

FMS.1: The organizationBs en#ironment an fa$ilities o!erate to ens&re safet"of !atients- their families- staff an #isitors.

4nternal and !;ternal 'ignage6s shall be displayed in a language understood bythe patients8 families and communities

*he hospital has a system to identify the potential safety and security ris+sincluding ha/ardous materials

FMS.0: The organization has a !rogram for $lini$al an s&!!ort ser#i$ee7&i!ment management.

*here is a documented operational and maintenance (pre"enti"e and brea+do,n)plan

FMS.: The organization has !ro#isions for safe 9ater- ele$tri$it"- mei$algas an #a$&&m s"stems.


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a Potable ,ater and electricity are a"ailable round the cloc+

b l ternate sources are pro"ided for in case of failure and tested regularly

c *here is a maintenance plan for medical gas and "acuum systems

a

b

c 'taff is trained for their role in case of such emergencies

d 9oc+ drills are held at least t,ice in a year

Cha!ter :


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c ctions are ta+en to redress the grie"ance


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a *he record pro"ides an up-to-date and chronological account of patient care

b

c

d

e

f Care pro"iders ha"e access to current and past medical record

a

b

a

b *he retention process pro"ides e;pected confidentiality and security

c

*he medical record contains information regarding reasons for admission3diagnosis and plan of care

$perati"e and other procedures performed are incorporated in the medical

record*he medical record contains a copy of the discharge note duly signed byappropriate and qualified personnel

4n case of death3 the medical records contain a copy of the death certificateindicating the cause3 date and time of death

IMS.: %o$&mente !oli$ies an !ro$e&res are in !la$e for maintaining$onfientialit"- integrit" an se$&rit" of re$ors- ata an information.

ocumented procedures e;ist for maintaining confidentiality3 security and integrityof information

Pri"ileged health information is used for the purposes identified or as required byla, and not disclosed ,ithout the patients authorisation

IMS.4: %o$&mente !ro$e&res eDist for retention time of re$ors- ata aninformation.

ocumented procedures are in place on retaining the patient6s clinical records3data and information

*he destruction of medical records3 data and information is in accordance ,ith the

laid do,n procedure

Documents

Shco Entry Level Self Assessment Toolkit