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JCI Internal Audit Checklist N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) SN STANDARDS/MEASURABLE ELEMENTS Y A A1 a b c d e f g h i j k A2 a b A3 a b c d SCOPE OF SERVICE AFTER ENTERING THE WARD Tell me about your ward Staff should able to share the following:  No of beds in the word/cubicle  Are your wards usually full?/What the occupancy rate?  Nurse to patient ratio in the ward  How many units are you responsible for?  Type of patients  Common conditions of patients in the wards  Average age of patients  Average length of safety Staff doing the coordination is able to articulate  No of working shifts for nurses  No of staff at each shifts in the wards  The difference between Nurses and HCA  How patients are being assigned to the consultant  specific core competency for for professional staff to practice in this ward  What you if the patients does not speak English?  How the appointments are obtained /given AFTER RECEIVING PATIENT'S CASE NOTES Could you tell me more about this patients ? Staff should be able to share the following  Patient's diagnosis  Time patient was seen  How he was seen  course of treatment  Reasons for transfer/discharge, if any Is the patient on any clinical pathway? DOCUMENTATION - COMPLETENESS AND LEGIBILITY (MCI) Legibility of patients clinical records is evidenced  Every clinical record entry Identifies the data and name of person who made the entry in the records  Inpatients entries must also include time of entry Doctors use the SOAP format in writing case notes Order forms and checklist are adequately filled in (e.g Radiology laboratory) MET? N N.A REMARKS N.T PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN STANDARDS/MEASURABLE ELEMENTS f g Standardizes symbols/abbreviations are used No parts of the clerking sheet should be left blank "N.A" should be written in those sections not deemed to be clinically relevant B INTRNATIONAL PATIENT SAFETY GOALS(IPSG) B1 a Identify patients correctly (IPSG1) How you identify patients How you identify unknown /unconscious /uncommunicative patients (e.g comalose)? When you use patient's identifiers? b c B2 a b B3 a b c d e f g h i j k l N.A-Not Applicable Improve Effective Communication (IPSG2) Verbal and Telephone orders -"Read Back" What is the procedure of taking down verbal/telephonic order for the doctor or receiving &reporting critical test results? b How you a verbal handover of your patients when you go for a break ? What you inform the nurse Safety of High alert medications (HAM)(IPSG3) Are there any high concentrated electrolyte her? Where should they be kept? why are the concentrated electrolytes kept in ICUs? For places that can store concentrated electrolytes, they are not stored in matrix drawer or omnicell shelves What HAM you have in the clinic? where is the list of High Alert Medication? Can high alert alert medications be stored with other drugs? Where are HAM placed/ stored &how you ensure the safety of HAM? refrigerated drugs are  Kept under lock and key  Fridges should be located in secure areas allowing only medical/nursing staff access Drugs are not under lock and key in ED resuscitation rooms and during surgery or procedure How you know how long you can keep the medications? Do you have discard dates for medications and disinfectants once they are opened? What are the examples of measures used to improve the safety of high alert medications when you serve PRN (pro re nata or "as needed") medication N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) SN STANDARDS/MEASURABLE ELEMENTS Y B4 a b c d e f B5 a b c d e f Ensure Correct site/Procedure/Patient surgery (IPSG4) When you Tme-out Do you document the completed time-out procedure?Where is it? What you check before conducting the procedure? How is site making done? How you involved patients during site making? when doyou site making? Reduce risk of Healthcare Associated Infections(HAI)(IPSG5) When you practice hand hygiene Staff practice correct hand washing and hand disinfection techniques when we hand wash and not handrub hand hygiene items are available /Alcohl handrub at cubicles are reasonably used What kind of training is there for staff on infection control practices? What you teach patient regarding infection control? g Reduce risk of patient Harm Reducing from Falls(Exclude ICU &HDs) (IPSG6) How you determine the Score for falls risk? When is the initial fails risk assessment for all patients? When and how often you conduct the fall risk reassessment for all patients? What interventions you those patients who are at fail risk? How we know which patients here are at fall risk? How you educate patients & families on falls prevention ? What happens when a patient falls? How you report falls? C ASSESSMENT OF PATIENTS (AOP) C1 a b Initial Assessment (AOP1.2) What are the main factors in the Initial Assessment? How long the doctor and nurses need to complete the initial medical and nursing assessment of a patient? C2 a Re-assessments(AOP2) How often you re -assess patient B6 a b c d e f MET? N N.A REMARKS N.T PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) SN STANDARDS/MEASURABLE ELEMENTS Y C3 a b c Nutritional screening(AOP1.6) Do you nutritional screening ? What you when patient has nutritional risk? who can refer patient to the dietician? How fast would the dietician see the patient? For Speech Therapist ,Prosthelist & Ortholist Podiatrist, Medical Social Worker ,Occupational Therapist and Psychologist: Physiotherapist: Respiratory Therapist: Acupuncturist: Case Manager: C4 a Pain Assessment(AOP1.7) Do you screen for pain the initial assessment? How you assess for pain /What you measure? b Pain score is documented What happens to the patient when significant pain is c identified by screening criteria? d(i) How often you assess/re-assess for pain? If pain score is ≥ 6, interventions and evaluation post pain d(ii) interventions are documented C5 a Discharge planning (AOP1.11) What's the time frame for discharge planning D a b PATIENTS &FAMILY EDUCATION(PFE) What are assessed and documented in the patient record? who initiates patient education What have you been communicating to the patient about education? PFE form is adequately filled up c d E E1 a b c PATIENTS &FAMILY RIGHTS(PFR) Consent Taking /Information Consent(PFR6) What is the process for obtaining consent Is the patient capable of give consent? Who you obtain consent from if patient is incapable of giving consent? What are some of the procedure and treatments that require informed consent? Is the re a list of them? MET? N N.A REMARKS N.T PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) SN STANDARDS/MEASURABLE ELEMENTS d e Do you use family members as interpreters for consent? No medical abbreviations and symbols are used For parts of the consent form that are not relevant, that particular portion should be marked "not applicable"/"N.A" No alterations made in the consent form Y f g E2 a b c E3 a b c d e f g E4 a b c d E5 a b c d Patient's Charter What relevant and available information you have to inform patients/family? When the patients come to the ward, are they given the patient's charter? What if they want to read? What you if the patient who does not understand English asks fo the patient's charter? Patient Privacy and confidentiality (PFR1) How you ensure patients personal belongings are protected? How are patients protected from physical assault? How you ensure patients privacy and confidentiality ? Privacy is povided to patients during the care and treatment(Observation) What is the process when patient or family request for a second opinion? Where can the patients carry out religious service or worship? what if patient or family request for spirutual support? Care of high Risk Patients/ High risk Services(COP.3) What is the timeframe to prepare patient's care plan? The patient's plan of care is documented in the medical record and masurable goals are indicated , when appropriate What are the High risk groups? What you when depressed patients become suicidal? Do Not Resuscitate Orders (DNR) (PER2.3) & Eternal of Care at the End of Life (PFR 2.5) How is a DNR order made? Can the on cal doctor (register and above ) make the DNR and EOC orders? How often to you review the DNR and EOC order? If Patient (on DNR &EOC ) is not able to communicate , how you assist the family with decision on end of life case? How you know if a patient has an AMD? MET? N N.A REMARKS N.T PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN STANDARDS/MEASURABLE ELEMENTS e If you are faced with unresolved ethical dilemmas, what you do? E6 a b c Use of Restraints(COP3.7) Who can initiate restraint use for a patient? How often you need to monitor patients on restraints? How long is each restraint order limited to? F ACCESS OF CARE AND CONTINUTY OF CARE (ACC) F1 Patient Transfer/Referral(ACC 3,4) Staff are able to articulate: Patient transfer to ICU/ Specialized services is according to criteria, and jointly agreed/ approved by primary team and ICU doctor When and how referrals for services(e.g AHS) are made Who accompany patients during transfer when a patient is transferred to another healthcare organization, What relevant documents are required to handover to the staff of the receiving institution? a b c d F2 f Patient Discharge and Follow Up (ACC 4) Staff able to articulate process & requirements for patient going on home leave Staff/ Care Manager aware of the community healthcare providers/ organizations that patients can be discharged or referred to When you have to complete the Hospital Inpatient Discharge summery (EOSS)? Upon discharge , what documents will the patient take? Who is allowed to give approval to patients who request for discharge against medical advice (AMA)? For an approved AMA, what you need to give the patient/ legally acceptable surrogate at the point of discharge? G ANAESTHESIA AND SURGICAL CARE (ASC) a b c d e G1 Sedation (Moderate and Deep sedation) (ASC 3) a What you have to before administering sedation? b What minimum monitoring is provided when performing sedation? How often you monitor patient when performing sedation? What is the criteria for assessing the readiness for discharge to c ward from sedation monitoring? How you know if the doctor has been to perform moderate d sedation? N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS PASS/FAIL/N.A (Circle one for this section PASS/FAIL/N.A (Circle one for this section PASS/FAIL/N.A (Circle one for this section PASS/FAIL/N.A (Circle one for this section JCI Internal Audit Checklist (For Inpatient Only) SN STANDARDS/MEASURABLE ELEMENTS G2 Anaesthesia (ASC4,5,6) a Pre-anaesthesia assessment performed b Anaesthesia care is planned and documented Patient is reassessed prior to induction of anaesthesia by the c anaesthesiology team? d When you monitor patient's physiological status? e What tol you use to monitor the physiological status? f What is the criteria for patient to be discharge from PACU? g How long does the patient need to stay in the PACU post operation? h What you when the PACU is full after surgery? G3 Surgery (ASC 7) a Before surgery, what assessment is needed? b Patient is re-evaluated before surgery Date and time documented Documentation of the following are completed in the surgical c reports and brief operative notes: Written surgical reports is completed and available before patient d leaves PACU H N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) EMERGENCY RESUSCITATION H1 Emergency Medications (MMU3.2) a Where can I find emergency medications? Emergency Medications are stored , maintained and protected from b loss o theft Emergency medications are available, monitored , and replaced c after use d How you replace the medications In the Emergency drug kit? e No expired items in the E-kit /E-trolley Staff should know who checks for the expiry dates H2 Equipments (FMS 8) Check that emergency trolley is locked &checking is documented a daily b who checks the E-trolley How often you check the items in the E-trolley? What you checked for? c Are all the E-trolleys the same in the hospital? Check defibrillator is complete with defibrillation pads(in sealed d package and are not expired) e Staff able to demonstrate proficient testing of: f Demonstrate fixing of a functioning laryngoscope PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN STANDARDS/MEASURABLE ELEMENTS H3 a b c d Emergency Resuscitation Activation (cop 3.2) Staff able to recognize and assess cardiac arrest to activate CPR Staff know the steps/ who to call for Emergency Resuscitation at: Clinical area (ward) Non-clinical area(public) What number to call during emergency resuscitation ? I MEDICATION MANAGEMENT AND USE (MMU) I1 a b c d Storage (MMU 3) How are the medications stored? Medications are stored using First-in-first-out principle How you label look-alike and sound-alike medications? There is segregation of look-alike and sound-alike medications? Controlled drugs are checked each shift and kept locked in safe? The type of quality of controlled drugs physically available tallies with the number recorded in the CD Book? Staff able to show log on drug wastage Staff able to show specimen signature for controlled drugs? Drug fridge temperature maintained at 2°C-8°C The medications fridge lights are working Staff interviewed can explain what he/she is supposed to when the alarm for the medication fridge goes off medications are properly and safely stored according to recommended storage conditions as specified by manufacturers What is the procedure for inpatients who bring their own medication and for of patients own medication There is a procedure to stored and control sample medications Cartons are stacked in a "criss- cross" manner to improve stability: will not topple when pushed gently and staff are able to reach for the top carton without having to use a stepper There is no obstruction of firefighting equipment (e.g Sprinkler, fire hoses, fire extinguishers) In the medication storage area e f g h i j k l m n o I2 a b Ordering and Transcribing (MMU 4) Who or where can you look for where you have doubts/ clarification on the medications prescribed? Patients recorded contain a list of current medications taken prior to admission and this information is made available to the pharmacy and the patient's care providers N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN c d e f I3 a b c d e f I4 a b c STANDARDS/MEASURABLE ELEMENTS Preparing and Dispensing (MMU 5) Injection trolleys are: Clean and tidy Assigned area for drug dilution Aseptic techniques observed during dilution Medication cart is clean and tidy Stock medication is dated upon opening there are no expired medications/ tubes How you review medications prescriptions or orders for appropriateness? Staff is able to articulate how to dispense the medication for the omnicell during omnicell downtime h i I5 a Monitoring(MMU 7) What you when adverse side effects are observed? e f g N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS The doctor screens through all the patient's existing medications and documents in the clerking case notes, under "Present Medicines" The doctor reviews if the medicines are still required by the patient and enters the drugs the drugs to be continued in the eIMR These drugs should be indicated in brackets under the Remarks column "patient's existing medication" Initial medication orders are compared to the list of medications taken prior to admission , according to the organization’s established process There are special precautions or procedure for ordering drugs with look-alike and sound-alike names? Administering Medications ( MMU 6) what is process of administering medications to patients? Drug allergies are identified and indicated What are the rights of medication administration? medication prescribed and administered is written in the patient's record What you with the leftover cytotoxic drug and consumable used during administration of cytotoxic drugs? For multiple uses of the drug/mixture the following are recorded For medication prepared in a syringe or burette for continuous infusion, the following is labeled : Are patients able to self- administration of medication during their hospital stay? eIMR and eMARS are logged off when not in use d N.A-Not Applicable PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable SN STANDARDS/MEASURABLE ELEMENTS b c What happens when there is a medication error/near miss? there is a medication recall system in place J INJECTION CONTRO (PCI) J1 c Equipment (PCI 7.1) Staff have knowledge of: Who is supposed to clean equipments Devices which are reused in the hospital (None) The process for the collection , analysis and use of infection prevention and control data related to reused devices and materials J2 a b Laundry and linen Management (PCI 7.1, ME 3) soiled linen is appropriately disposed Linen carrier is properly covered J3 a b Waste Disposal (PCI 7.2) Name some examples of biohazard waste How you dispose biohazard materials? J4 a b c Sharps and needles (PCI 7.3) Sharp boxes is less than 2/3 filled What is the process of disposing the sharp box? Staff's knowledge of needle-stick injury protocol J5 Patients In Isolation (PCI 8) What you need to observe before entering an isolation room/ ward? Signage for isolation precaution are available and appropriate Personal protection Equipment (PPE) is available for use Staff educates patient's relatives to take precautions for patients in isolation room What happens when one bedded isolation rooms are unavailable? Patients with known/ suspected diseases are isolated appropriately a b a b c d e f J6 a b Personal Protective Equipment (PCI 9) Staff know which situations to use different levels of PPE Staff demonstrates correct techniques of pulling on and taking of PPE and known what to removal of PPE N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN STANDARDS/MEASURABLE ELEMENTS J7 a b MRSA(PCI 6) Cases of MRSA infection are documented and reported What precautions you have for MRSA patient? K FACILITY MANAGEMENT AND SAFETY (FMS) K1 a Safety and Security (FMS 4) All staff, visitors and venders are identified K2 a b c d e Hazardous Materials (FMS 5) How you handle a chemical spill? Show your Materials Safety Datasheet(MSDS) Give examples on the type of hazardous wastes How is general waste disposed? How you dispose cytotoxic wastes? K3 a Emergency Management (FMS 6) The following information is posted? Emergency instructions Emergency phone numbers Fire Emergency instructions Staff has participated in Emergency Preparedness Exercise (at least per year) N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A b K4 a b c d e f g h i j K5 a Fire Safety (FMS 7) Staff is able to articulate procedures related to: Fire safety R.A.C.E relating to fire Location of Fire Extinguishers P.A.S.S relating to fire Location of Fire hose reel P.O.R.T.S relating hose reel Contact number for fire safety reporting center Clear passage way for all fire exits Fire exit doors closed completely Location of fire assembly area Staff has participated in fire drills (at least per yr) Medical Equipment (FMS 8) Preventive Maintenance of equipment is updated & documented PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN b c STANDARDS/MEASURABLE ELEMENTS N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS Oxygen cylinders are stored properly in holder in a designated area Point of Care Testing Equipment: -Urine lab-stick-not expired -Hypo -count machine  show Quality records  expiry date time frame K6 a Utility Systems(FMS 9) Show you uninterruptable power supply(UPS) K7 a b c d e f g h i Utility Room-Clean (FMS 11.2) Items are labeled and placed in correct containers Stock items are arranged in first in first out order No carton boxes on floor /All items are elevated from the floor No contaminated or dirty items in utility room No patient care items under the sink CSSD items are stored in a clean and dry area Check integrity of items Pat- slide on the wall Utility room door is kept closed K8 a b Utility Room-Dirty (Sluice Room) (FMS 11.2) Room door is kept closed Separation of clean and dirty items K9 a b c d Food and Pantry (COP 4.1) Food stored in the fridge are labeled with name date and time Floor is clean and not littered No food related items placed under the sink Area clean: infection control measures implemented L a STAFF QUALIFICATIONS AND EDUCATION (SQE) Department Staffing plan Staff schedule/roster in place PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN b c d e f g h I j k M a b c d e f STANDARDS/MEASURABLE ELEMENTS N.A-Not Applicable N.T- Not Tested Assessed (Tick as appropriate) MET? Y N N.A N.T REMARKS In the event of an emergency, what would your staffing response plan be? Plan is in place for unexpected staff shortage Job description are current and available for all staff How you ensure competency for your staff? Does Nursing or Pharmacist competency training? What groups staffs are BCLS certified? How does your Hospital carry out Privileging? Do all departments have a list of specific privileges for senior consultants / aside from common privileges? All newly appointed , promoted and transferred staff ( including contract workers, students, volunteers, temp staff) have attended department induction program All newly appointed staff have attended the hospital orientation program and can articulate what they have learnt during their orientation Each staff can articulate heor he or she is continuously (i.e knowledge, skills, competencies) All staff wear name tags or identification badges What quality improvement activities are you involved in? QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS) What are your quality data and measures / quality improvement projects? Are there any new /modified clinical pathways developed in the last 12 months? What is a serious reportable event? What is medication error? What is a near miss? What are steps to take in the event of a serious reportable event / near miss? PASS/FAIL/N.A (Circle one for this section) JCI Internal Audit Checklist (For Inpatient Only) SN N.A-Not Applicable STANDARDS/MEASURABLE ELEMENTS Y Other Comments: Prepared by Dr.Mahboob Khan Phd Healthcare Quality Consultant Copy right reserved c 2015 N.T- Not Tested Assessed (Tick as appropriate) MET? REMARKS N N.A N.T ... sections not deemed to be clinically relevant B INTRNATIONAL PATIENT SAFETY GOALS(IPSG) B1 a Identify patients correctly (IPSG1) How you identify patients How you identify unknown /unconscious /uncommunicative... lab-stick-not expired -Hypo -count machine  show Quality records  expiry date time frame K6 a Utility Systems(FMS 9) Show you uninterruptable power supply(UPS) K7 a b c d e f g h i Utility Room-Clean... What quality improvement activities are you involved in? QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS) What are your quality data and measures / quality improvement projects? Are there any new /modified