CoZAR Tool and Help - Patientcare version

PATIENTCARE VERSION
Schedule: Completed by: Initials
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Ref: (a) The Joint Commission Accreditation Standards for Ambulatory Care, Environment of Care, 2016
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CoZAR system owner: Naval Health Clinic Patuxent River, Environment of Care Committee
CONSOLIDATED ZONE ASSESSMENT REPORT (CoZAR) ANNUAL TRACKER FOR DEPT:
Directions: The CoZAR may be completed anytime during each month. One purpose is to cross assign and involve several staff in a continual
department education and inspection system as they look around their departmental spaces, and talk with staff.
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Environment of CareInfection Control
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DirectorDept HeadTraining
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p.2 p.3 p.4 p.5
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2016
Page 1 tracks use, pages 2-9 are the CoZAR (Tool), and page 10 tracks deficiencies. The CoZAR (Help) is 6 pages.
p.6 p.7 p.8 p.9
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CY
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Due qtrly Due qtrlyDue
Submit CeZAR for BHCs and Directorates before the 5th monthly at
https://nhcpr-intra.nmed.ds.med.navy.mil/safe/CeZAR/Forms/AllItems.aspx
Reviewed by: Initial / Date
Patient Safety/Risk Mgmt
Due 5th monthly
NHCPR 5100 ( ) Page 1 of 10

# opportunities observed
/
# times 2 identifiers used
# Observed / # times
specimens are labeled in
front of patient
Fall Prevention Program
JUL AUG SEP OCT NOV DEC
Number
Reviewed: 0Goal 1: Improve the accuracy of patient identification
1. Verifies name & DOB with patient or family member when staff administers
meds and verifies 2 identifiers with records.
Direct
Observation
(Minimum: 5)
Month
JAN FEB MAR APR MAY JUN
JUL AUG SEP OCT NOV DEC
2. Verifies name & DOB with patient or family member when taking blood or
other specimens for clinical tests.
3. Verifies name & DOB with patient or family member when providing
treatments/testing (i.e. Radiology)
4. Containers used for blood and other specimens are labeled in the presence of
the patient (i.e. pap smears, bx containers)
Goal 7: Reduce the risk of health care-associated infections
Number
Compliant: 0
Month
JAN FEB MAR APR MAY JUN
Patient Safety (PS)
Goal 3: Improve the safety of using medications
5. Critical test results are reported to the ordering physician/provider or
designee within 60 minutes. (Lab)
# reviewed /
# of reports per policy
2. Medication list is reconciled via Ahlta and documented that reconciliation was
documented.
3. Medications are reconciled at each outpatient, including OTCs, herbal, and
other supplements via AHLTA.
1. Comply with current hand hygiene guidelines.
2. Measure procedure site infection rates for the first 30 days following
procedures.
Review 10
records
# records reviewed
/ # of records with proper
reconciliation
1. UP 1 Operative ite Marking completed by person performing the case and
consist of that person's initials.
2. UP 1 "Time-out" completed and documented.
# records reviewed
/
# of records with proper
reconciliation
4. Provide the patient (or family as needed) with written information on the medications
the patient should be taking. Explain the importance of managing medication information
to the patient at the end of the episode of care.
Review 10
records
6. Critical test results are reported to the ordering physician/provider or
designee within 60 minutes. (Radiology)
# critical tests reviewed
/ # instances where
report was given per
policy
1. Can staff identify how to report a fall/unsafe condition?
# records reviewed
/ # of records that
document current list of
meds.
Yes or No
# of procedures requiring site marking /
# of site markings done
# of procedures reviewed /
# time-outs documented
Review 5
records
1. Medications, containers, and solutions are labeled. This includes medications on sterile and
unsterile fields. (i.e. syringes, medicine cups, basins, or other containers)
Review 10
records
# opportunities observed /# times correct
PERFORMANCE MEASURES (POC Mr. Akbari at 301-342-3097)
UNIVERSAL PROTOCOL (UP) "Time-Out and Verification Process

28. Receptacles designated for shredding PHI/PAI/PPI are properly monitored and regularly
emptied? Check trash/waste receptacles for improper disposal of documents?
27. Documents/etc. with Protected Health Information (PHI), Privacy Act information (PAI) or Personal
Private Information (PPI) are properly stored, protected, and/or disposed?
0
OCT NOV DEC JUL AUG
# No Total: 0
25. Monthly AED Operator's Checklist is completed?
26. Staff know the policy and process of proper handling and disposal of documents/media with
PHI/PAI/PPI information and how to report violations? (contact Privacy Officer)
HIPAA (POC: Ms. Foster)
# COTS Total:
24. The phone number to call for all medical emergencies is known? Answer: 911 for all codes.
22. High alert medications are readily identified by staff?
23. The code for cardiac emergency is known? Answer: Code Blue.
Resuscitation (POC: Dr Culp)
#COTS Total: # No Total:0 0
0 # No Total:
17. If temperature out of range, was action documented on the form (does staff know process to
follow when refer temperatures are out of range)?
Yes is default answer. # Assessed. "N/A" 1st time. Corrected On The Spot (COTS). If not able to COTS, No - Note action on page 10.
N/A
Risk Management (RM)
18. Are medications within their expiration date?
Medications (POC: LT Martin)
# COTS Total: 0
19. Multiple-dose vials are dated with date entered and 28 day expiration date (or expiration per
manufacturer's recommendations)?
20. Single dose vials are destroyed after single use, after one hour of opening or one hour after seal
puncture?
21. Sound Alike Look Alike Medications are readily identified by staff?
Month Month
JAN FEB MAR APR MAY JUN JAN FEB MAR APR MAY JUN
JUL AUG SEP
16. Immunization refrigerators temperatures are logged TWICE every day?
SEP OCT DECNOV
# Assess-
ed
PERFORMANCE MEASURES

38. Expiration dates are checked monthly on all containers of hand soap and waterless hand
hygiene products. Expired items are removed and replaced with items ready for use.
32. Infection control training is conducted annual on SWANK Health
33. Staff know that the Infection Control Manual is accessible on the NHCPR Intranet and can
demonstrate how to use it. F:0000 ALLINFECTION CONTROL MANUAL
46. Observation of clinical workspaces shows them to be free of all food and drink items.
47. Space below sinks free of patient care items. (Examples of exceptions: Properly labeled cleaning
supplies, unused sharp’s containers, plastic bags)
40. Separate refrigerators used to store biological specimens, medications, and food.
41. Biohazardous waste or infectious waste is segregated correctly. In Red bag trash, and sharp
containers.
42. Soiled utility room maintained in clean, organized manner.
43. Dirty linen is handled appropriately and closed containers used.
44. Patient care equipment cleaned and decontaminated correctly.
45. Cardboard shipping boxes removed from sterile/clean storage and patient care spaces.
39. Medication, specimens, and food are appropriately handled to avoid cross contamination.
34. Personal protective equipment is readily available and staff can explain when to use it.
35. Staff employ correct hand hygiene measures. Hands washed before and after patient contact.
Dispensers are not above or adjacent to electrical items, 48 inches high and separate.
36. Clean/sterile patient care supplies are stored appropriately (floor clearance: 8-10" sterile, >3"
clean. 18" from ceiling, liquids below solids, separated from dirty, prefer sterile above clean, expirable
items together, FIFO).
37. Expiration dates are checked monthly on sterile/non-sterile patient care supplies. Expired items
are removed and replaced with items ready for use.
# COTS Total: 0 # No Total: 0
30. The unit/area presents a clean appearance (without dust or debris) paying particular attention to
equipment, patient furniture, exam tables, chairs, etc.
31. In areas where toys are made available in the department, these items are cleaned DAILY and
whenever necessary using an approved hospital grade cleaner/disinfectant.
MAY JUN
JUL
N/A
Month Month
JAN FEB MAR APR JAN FEB MAR APR MAY JUN
AUG SEP
General-Direct Observation (see)
OCT NOV DEC JUL AUG SEP OCT NOV DEC
Infection Control (IC) / Department IC Representative
# Assess-
ed

Respiratory Etiquette / Other # COTS Total: 0 # No Total: 0
51. Dirty linen carts are covered and bags not left in corridors unattended.
56. Waste receptacle and alcohol based hand sanitizer are present and maintained in waiting area by use
of patients/visitors. Patients are provided a mask when they present signs or symptoms of a cold or flu.
N/A
AUG SEP OCT
53. Recapping is by scoop or one hand method. (passive technique)
54. Sharps containers are changed when ¾ full or have foul odor, then disposed of properly.
55. Sharps containers in patient care areas are wall mounted or if on floor, secured and out of reach of
children. Optimal distance for standing is 52 to 56 inches high and 11 to 19 inches reach.
Sharps # COTS Total: 0 # No Total: 0
52. SAFETY DEVICE is immediately activated with one hand after use.
Rolling Stock # COTS Total: 0 # No Total: 0
48. Bottles of irrigating solution such as sterile water or saline are one time use only.
49. Low level disinfectant (CaviWipes XL Wipe, 2 minute wait time) is used to clean patient transport
devices, countertops and surfaces - when?
50. Clean linen carts are covered, have solid bottom shelves and protected from dirt/dust.
Month Month
JAN FEB MAR APR MAY JUN JAN FEB MAR APR MAY JUN
JUL NOV DEC JUL AUG SEP OCT NOV DEC
Infection Control (IC) / Department IC Representative
# Assess-
ed
Infection Control Comments:

Environment of Care (EC) Zone Assessment Report: Patient Care Departments
74. Lead Apron and Collar devices are hung on should hangers and not laid over items. Examined
before each use for holes, rips and tears - include shoulder straps. If defective, turn into DRMO.
73. Operator's Manual available in department or on Sharepoint?
71. Patient injury because of medical equipment malfunctions are reported using a PSR?
72. PM sticker and ECN# are on equipment / DATE NOT Overdue?
69. Full acceptance procedures known before using medical equipment?
70. Broken or malfunction medical equipment / Defective Equipment Tag and procedure known?
DEC
N/A JAN FEB MAR APR MAY JUN JAN JUNMAR APR MAY
Month Month
JUL AUG SEP OCT NOV DEC JUL AUG
FEB
SEP OCT NOV
68. Unlock toilet or room where a patient can lock themselves in? (Try coin to unlock. Know where to
find keys to all rooms)
67. ESAMS: Is staff email and supervisor (safety rep.) accurate? Is date of birth entered?
66. ESAMS: Are staff transferred to deactivated so ESAMS roster is accurate?
65. Emergency call system at patient toilet is tested & functions? Total # ____
64. ESAMS: Have all staff been added and completed initial log-in at this command?
62. Pediatric toys and treats are non-chokable; will not hurt eye or puncture skin?
63. Chairs with wheels prohibited for patient use?
61. Patient waiting area - chairs, connectors, and furniture in good, safe condition?
59. Alarm sounds differ and recognized by staff? Test an alarm and reset per local procedures.
58. Emergency Electrical Power. Outlets are labled "emergency power" or identified in red? Staff
know equipment, outlets and areas on emergency power when the generator is activated?
60. Patient lift devices and methods known by staff?
57. Safety needle device is used immediately after withdrawal using one hand method? Needles,
syringes and sharps are controlled to prevent unauthorized access?
Additional items not addressed on pages 6 (to customize for your people, spaces and processes) # COTS Total: 0 # No Total: 0
Medical Equipment # COTS Total: 0 # No Total: 0
Safety # COTS Total: 0 # No Total: 0
# Assess-
ed

87. Safety Data Sheet and, symptoms of exposure and first aid readily found by staff?
96. Code Red Drill during inspection. Staff able to locate Fire Station Bill, call Code Red, and verbalize
emergency exits and muster location? RACE (Rescue, Alarm, Contain, Evacuate)
94. Fire Extinguisher inspected Monthly - unobstructed, seal not broken and tag initialed?
95. Sprinkler heads have an 18-inch clearance in entire room? (exception in helps)
92. Corridors are unobstructed. Temporary items not left over 30 minutes?
93. Doors fully open and close, without sticking? When pulled closed - it must latch.
90. Medical Gas Shutoff - Location and procedures known?
91. PASS procedures known for fire extinguisher use? (Pull pin, Aim nozzle, Squeeze handle, Sweep
nozzle). Locate department fire extinguishers and tell what type they are?
88. Emergency eyewash/showers are tested weekly and a log maintained with signature and date
tested? Staff are trained on location and use eyewash/showers? Not blocked?
89. Medical Gas Cylinders are secured, empty and full are labeled and seperated? Caps on?
85. Hazardous Material Authorized Use List (HMAUL) was last updated no more than 12 months
ago and is used as the table of content for the Safety Data Sheet (SDS) Binder?
86. Hazardous Material containers are labeled clearly with manufacturer's label? Flammables and
corrosives are properly stored. Hazardous waste properly stored and disposed of?
83. Asbestos and lead materials in the building is in good condition - not damaged?
84. Code Orange procedures for hazardous material spill cleanup is known?
# No Total:
81. Storage/Supplies are maintained to prevent creating a safety hazard? (not stacked too high or
unstable, not stored in front of fire doors, fire extinguishers, fire exits or electrical panels)
82. Personal Protective Equipment is available, in good condition & staff explain when to use?
79. Monthly Safety Talk is read by 100% of staff?
80. Slip, trip and fall hazards are promptly repaired or removed? (floors maintained in a dry condition
and clear of trip hazards? (e.g. electrical cords, telephone wires, computer cables)
78. Ergonomic - Back Injury Prevention methods known? No related discomfort or pain?
77. Indoor Air Quality is comfortable; with no toxic, unhealthy or unpleasant exposures?
OCT NOV DEC
JUN
JUL AUG SEP
Environment of Care (EC) Zone Assessment Report: Patient Care & ALL Departments
N/A JAN FEB MAR APR MAY JUN JAN FEB MAR APR MAY
75. Annual safety goal for 2016? Increase Enterprise Safety Analysis Management System (ESAMS)
training compliance from 50% to 90%.
Month Month
OCT NOV DEC JUL AUG SEP
76. Safety Bulletin Board location and identify at least one item? (Unsafe Condition Report - OPNAV
5100/11, Civil Service and MLC employee mishap information, DD Form 2272, etc.)
# COTS Total: 0 # No Total: 0Fire Safety
Hazardous Material and Waste
Safety and Security # COTS Total: # No Total:0 0
0 0# COTS Total:
# Assess-
ed

FEB MAR APR MAY JUN
Month Month
NOV DECDEC JUL AUG SEP OCTJUL AUG SEP OCT NOV
N/A JAN FEB MAR APR MAY JUN JAN
Environment of Care Zone (EC) Assessment Report: Patient Care & ALL Departments
113. Are all exits signs fully iluminated? Are exit lights tested monthly for 30 seconds? 90 minutes
annually?
Environment of Care Comments.
112. Plumbing handles/fixtures operate appropriately? Not loose or leaking? Showers/ faucets
operate properly? Water temperature and pressure? Commodes flush properly?
110. Recycling options are used within their workspaces? (Blue bins for white paper, brown bins for dry
cell recycle batteries, and bins by soda machines for bottles and cans)
111. Heat maximum 20 ℃ in winter. Cool minimum 25 ℃ iin summer.
108. Environmental Goal for 2016? .
109. Energy Conservation - are lights and air / heat secured when nobody is present?
106. Smoking policy is enforced? No smoking allowed at grounds? No cigarrette butts found?
107. Environmental Policy - Are personnel aware of the CO's Environmental Policy Statement?
104. Electric Safety: extension cords/multiple outlets are not used for refrigerators, coffee pots,
mircowaves, space-food-water heaters? No damage, wear or tear? Dept. Self-Inspections.
105. Space heaters have written authorization from Facilities Managemente. Only oil cooled space
heaters are used in admin rooms?
102. Signage is accurate and facilitates patient traffic flow? Signage is on approved bulletin boards and
laminated in patient care spaces (not taped or thumb tacked to walls or doors)?
103. Staff food refrigerator clean? Refrigerator labeled with magnetic sign from Safety Office?
100. Inspect floor - is it intact, free from damage and no soiled carpet?
101. Good Housekeeping - orderliness, cleanliness, and no gear adrift? No clutter in storage areas?
Items marked for DRMO and processed promptly?
98. Inspect furniture - for safe and good condition? (no broke armrests, legs or components, no soiled
or torn fabric. If need replaced, order through Materials Management)
99. Inspect ceiling - lights are working and ceiling tiles are not broken, stained, or need replaced?
97. Inspect walls - decorations, cabinetry for finish quality, holes, permanent stains, damage. All in
good condition? Cables & wires are secure, covered & neatly organized-removed if unused?
Additional items not addressed on pages 7 & 8 (to customize for your people, spaces and processes) # COTS Total: 0 # No Total: 0
Environmental and Energy Conservation
Facilities: Submit DMLSS Work Request
# Assess-
ed

SEAT Comments:
Training
N/A
Month Month
JAN FEB MAR APR MAY JUN JAN FEB MAY JUN
JUL AUG SEP OCT NOV DEC JUL AUG SEP OCT NOV DEC
1. Do all staff members have a work-space specific competency completed, including annual updates
within their training jacket?
2. Do all staff members have a completed EOC orientation within 48 hours of check in to the work center
in their training jacket?
3. Do all staff members have a current, signed position description in their training jacket?
4. Do all staff members have a signed Privacy Act statement that does not contain their full SSN in their
training jacket?
29. Dept SOPs "say what they do and do what they say"
5. Are all clinical staff currently certified in BLS skills?
# Assess-
ed
PERFORMANCE MEASURES MAR APR

Note: Please add another page now.
31 Jun 2013Y
HM2 Sharp submitted DMLSS Work Request to repair on
16 Jun 2013.
99
EXAMPLE: Ceiling tile broken in corridor - 1/2 hole on
left corner. Outside of room 2C35. 15 Jun 2013
Completed Y/N - dateAction (DMLSS Work Request, Purchase Req., Trng.)
Deficiency (No) Tracker - Not able to Correct On The Spot (COTS)
Item Description, location, and date
NHCPR 5100 ( ) Page 10 of 10

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