This document is a checklist used to assess standards and measurable elements for inpatient care at a healthcare facility. It covers areas like scope of service, patient safety goals, assessment of patients, patient and family education, and patient and family rights. For each standard, staff are asked questions to determine if the element is met, not met, not applicable, or not tested. Remarks can also be included. The goal is to evaluate areas like patient identification, communication, safety of medications, infection control, fall risk reduction, documentation, consent processes, privacy and more.
oint Commission International Accreditation Standards for Hospitals, 6th Edition, provides the basis for accreditation of hospitals throughout the world. Joint Commission International (JCI) standards define the performance expectations, structures, and functions that must be in place for a hospital to be accredited by JCI. The standards are divided into two main sections: 1) patient-centered care and 2) health care organization management.
There are several main dimensions most frequently used to measure hospitals performance via clinical efficiency ( Clinical quality , evidence -based practices , health improvement and outcomes for individual and patients)
oint Commission International Accreditation Standards for Hospitals, 6th Edition, provides the basis for accreditation of hospitals throughout the world. Joint Commission International (JCI) standards define the performance expectations, structures, and functions that must be in place for a hospital to be accredited by JCI. The standards are divided into two main sections: 1) patient-centered care and 2) health care organization management.
There are several main dimensions most frequently used to measure hospitals performance via clinical efficiency ( Clinical quality , evidence -based practices , health improvement and outcomes for individual and patients)
Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health.
NABH 5th edition hospital std april 2020anjalatchi
A. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations.
The presentation describes in brief the patients need, expectations and how to develop the patient care and feedback system to obtain maximum patient satisfaction.
Access, Assessment and Continuity of Care (AAC) NABHDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 1 Access, Assessment and Continuity of Care (AAC). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
A Key Performance Indicator (KPI) is a measurable value that demonstrates how effectively a company is achieving key business objectives. Organizations use key performance indicators at multiple levels to evaluate their success at reaching targets
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Joint Commission International 6th Edition standards interpretation FAQ'sJoven Botin Bilbao
Joint Commission International (JCI) works to improve patient safety and quality of health care in the international community by offering education, publications, advisory services, and international accreditation and certification.
Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health.
NABH 5th edition hospital std april 2020anjalatchi
A. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations.
The presentation describes in brief the patients need, expectations and how to develop the patient care and feedback system to obtain maximum patient satisfaction.
Access, Assessment and Continuity of Care (AAC) NABHDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 1 Access, Assessment and Continuity of Care (AAC). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
A Key Performance Indicator (KPI) is a measurable value that demonstrates how effectively a company is achieving key business objectives. Organizations use key performance indicators at multiple levels to evaluate their success at reaching targets
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Joint Commission International 6th Edition standards interpretation FAQ'sJoven Botin Bilbao
Joint Commission International (JCI) works to improve patient safety and quality of health care in the international community by offering education, publications, advisory services, and international accreditation and certification.
DevOps unquestionably is one of the most transformational movements to happen to IT and is helping IT deliver to ideas to market faster. But where does one start? What should we focus on first. This infographic explores what are the critical success factors for ensure success with DevOps. A related eBook is available for download at http://info.scriptrock.com/prerequisites-for-devops-success.
Determinants of Supply Chain Performance of Indian Manufacturing OrganizationsWaqas Tariq
This paper aims at proposing various determinants of supply chain performance of Indian manufacturing organizations. The determinants are summarized based on extensive literature review of empirical research articles on supply chain management (SCM) and performance measurement approaches. This study is a part of a larger research project exploring SC related practices. A critical analysis is carried out so as to identify research gaps in context of performance measurement of supply chains, as well as to propose directions for future research. A conceptual model is also proposed. Critical investigation of selected articles led to an idea that there can be significant effect of selected variables on SC Performance. It is to be seen that how various parameters, taken from the literature review, affect SC performance and ultimately contributing to its competitiveness. The various parameters like supplier-buyer relations, external supply chain, environmental factors, human metrics, information sharing and performance measurement approaches are taken in a single study in the context of Indian manufacturing organizations. Based on a pilot study with sample size of 100, empirical tests resulted in reduction of items. Based on the obtained results, the organizations can enhance the SCM performance by improving the current practices/strategies through focusing on the determinants that significantly influence SCM performance. Further research can be carried out by using data of various supply chains of other sectors and industries of India to generalize the research.
Nursing audit assists in:
1. Evaluating Nursing care given,
2. Achieving deserved and feasible quality of nursing care,
3. Stimulating better nursing records maintenance,
4. Focuses on patient care provided and not on care provider,
5. Contributes to research in nursing.
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This presentation explains the concept of patient safety, healthcare quality and how these can be embedded into surgical care to ensure excellent patient outcomes.
These slides were presented to the Surgery Interest Group of Africa (SIGAF) in April 2023 by Vivian Akwuaka.
Test bank for Physical Examination and Health Assessment 8th Edition by Carol...nursing premium
A Test bank is a ready-made electronic Q&A testing resource that is tailored to the contents of an individual textbook. Feedback is often provided on answers given by students, containing page references to the book.
Test bank for Physical Examination and Health Assessment 8th Edition by Carol...nursing premium
A Test bank is a ready-made electronic Q&A testing resource that is tailored to the contents of an individual textbook. Feedback is often provided on answers given by students, containing page references to the book.
Test Bank For Canadian Physical Examination and Health Assessment 3rd Edition...nursing premium
A Test bank is a ready-made electronic Q&A testing resource that is tailored to the contents of an individual textbook. Feedback is often provided on answers given by students, containing page references to the book.
Formalization and automated computation of diabetes quality indicators with C...Kathrin Dentler
Clinical quality indicators are often used to measure the quality of healthcare services and can be classified into structure-related, process-related and outcome-related indicators. The objective of this study is to investigate whether the electronic medical record (EMR) data in Chinese hospitals can be used for the automated computation of di- abetes quality indicators, especially the process-related indicators. The clinical quality indicators formalization (CLIF) tool and SNOMED CT terminology were adopted to formalize some selected diabetes indicators into executable queries and patient data were collected from the EMR of a Chinese diabetes specialty hospital. The formalized indicators were run on the patient data to test the feasibility of the automated computation of formalized indicators. In this study, all of the 38 indicators can be for- malized and 32 of them can be computed based on the EMR data. The results indicated that Chinese EMRs can be used for the computation of most diabetes indicators, including some process-related indicators, and it also can be improved to better support the computation of more indicators.
Test bank for clinical procedures for medical assistants 10th edition by bone...robinsonayot
Test bank for clinical procedures for medical assistants 10th edition by bonewit west.pdf
Test bank for clinical procedures for medical assistants 10th edition by bonewit west.pdf
In India, Young Graduates Struggle by Dr. Mahboob Khan to Get Jobs.pdfHealthcare consultant
In the world’s most populous country, tens of thousands of graduates and postgraduates, many with professional degrees, such as engineering, spend years studying at the tutoring centers that have mushroomed in Indian cities, hoping to qualify for a highly sought-after government job. The chances are slim. Less than one-half of 1% of the more than 1 million who take the exam each year pass.
The middle class in India is growing unexpectedly, however they're still dealing with demanding situations in accessing excellent and low-priced healthcare. This is because of a number of of factors, such as inefficient healthcare gadget, high price of healthcare, and lack of know-how.
Chat GPT for Doctors -Revolutionizing Healthcare Communication by Dr.Mahboob.pdfHealthcare consultant
Learn how Chat GPT for doctors can revolutionize healthcare communication by improving efficiency and accuracy of patient-provider interaction.
In recent years, there has been a growing interest in the potential of artificial intelligence (AI) to transform healthcare. One area that has received particular attention is communication between patients and healthcare providers. The emergence of chatbots powered by AI has provided a new tool for improving the efficiency and effectiveness of healthcare communication. One of the most promising applications of AI-powered chatbots is Chat GPT for doctors.
As an expert in hospital management and administration i have written this book -Hospital Management is a new theory in management faculty. Earlier a senior doctor used to perform the role of a hospital manager. However, nowadays everything demands a specialist. Almost all the things related to hospital have changed. Many categories concerning medical sciences and hospital have altered totally. There are various types of hospitals today, including ordinary hospitals, specialty hospitals and super specialty hospitals. The categories are regarding to the types of facilities they offer to the people.
Steve Jobs logged off too soon. He was a serial innovator whose illness cost the world a bright talent who was also a great company leader. I hope that the music from the hymns of praise sung to him in his waning days is playing on his iPod as he ascends into the firmament of the greatest American business leaders. If there were a Nobel prize for business, surely he would have won it. He did what he set out to do and more. He saw the potential for computing power for the masses, useful and accessible to everyone. In a phrase that drove the early Apple, he created bicycles for the mind.
“He is a charismatic leader who inspires people to follow him. A strategic thinker who can master the details. A tireless worker with incredible focus and problem-solving skills. He is well-liked by his employees but is also able
to make and execute unpopular decisions. Above all, he is an exceptional communicator who can convey a vision to any audience, from Wall Street to
the most junior employee.”
Some of the lower vibrations, as you can see on the chart are anger, grief, shame, fear. Some of the higher vibrations are love, joy, appreciation and excitement.
Going to higher vibrations means more energy ,lower vibration is easily achieved and is default in everyone of us and is easily aggravated by gravity.
thats why anger, grief,shame and fear are more common than love ,joy appreciation and excitement.
Hospitals profitability can be increased by boosting patient satisfaction, reducing readmissions and understanding revenue cycle performance.
In this period of healthcare reform, numerous organizations continue to change their business practices so they can obtain more hospital profitability while also delivering quality care. Healthcare expenditures are expected to reach $4.4 trillion by 2022, and this high level of spending activity has hospitals currently under a lot of pressure to reduce costs.
Development of the digital economy started way before COVID-19. The exact date of the beginning may be defined in different ways, depending on different definitions of “digital economy.” The popularly understood “digital economy” phenomenon began when T-Mall was set up in 2003 and when Alipay came online in 2004. While the digital technology brings about the fourth industrial revolution, just like the steam engine, electrical machines, and computers, respectively.
Strategy is not complex. But it is hard. It’s hard because it forces people and organizations to make
specific choices about their future—something that doesn’t happen in most companies. Dr .Mahboob
Khan
Couch potatoes as they are called are the ones who stick on to their sofas just watching the idiot box that has caused many such unwarranted developments in health.
Probably a long vacation could be a precipitating factor for inactivity while the unexpected strife in the country’s developments has brought with it some unexpected holidays. This is the time when children tend to relax but when they cross the line the human body becomes mentally and physically inactive.
While Metaverse is evolving, it holds new potential in healthcare that combines the technologies like Artificial Intelligence, Virtual Reality, Augmented Reality, Internet of Medical Devices, Web 3.0, intelligent cloud, edge and quantum computing along with robotics to provide new directions to healthcare.
Robotic Process Automation in Healthcare-An Urgency! By.Dr.Mahboob KhanHealthcare consultant
More and more industries are adopting RPA because RPA exceeds adopters’ expectations not only when it comes to the rapid rate of ROI(Return on Investment) increase, but also when it comes to facilitating compliance (92%), improved quality and accuracy (90%), or improved productivity (86%).
As per a study conducted by McKinsey, the healthcare sector had a 36% technical potential for automation. It also stated robotic process automation as one of the emerging technologies that will reshape healthcare and create between $350 billion and $410 billion in annual value by 2025.
Apply This to Your Life
We know this is boring, but you know you need to do it!
Clear an hour in your schedule somewhere in the next week, and set your filing system up!
Many inventions originated in wealthy countries and these were responsible to produce global public goods and medical goods.In which everyone got benefitted even developing and poor countries too.This transfer of knowledge is now compromised by the extension of intellectual property rights and held by high-income countries.
Precision medicine will drive new standards of care in post COVID -19 world. In simplest terms precision medicine is the right test for the right patient and at the right time. A physician must choose from an array of complicated tests that are appropriate for a diagnosis and creation of a treatment plan for their patient in a timely manner.
Ways That Quantum Technology Could transform Health Care. By.Dr.Mahboob KhanHealthcare consultant
You probably don’t grasp the finer points of how quantum mechanics works, but scientists are using its tricky rules to make medicine faster, less painful, and more personalized.
How is COVID-19 Reshaping the role of Institutional strategy? By.Dr.Mahboob KhanHealthcare consultant
While workers around the globe are keeping essential services running, it is imperative for business leaders, particularly senior strategy executives, to reflect on the lasting implications of COVID-19 and what they can do to best position their people, their businesses, and society to recover and thrive in the long term. Five key shifts can help chief strategy officers (CSOs) successfully guide their organizations through the pandemic.
Retaining Healthcare Quality During COVID-19 and Future of Care Delivery. By....Healthcare consultant
With the onset of COVID-19, healthcare delivery organizations around the world were collectively faced with one primary challenge: How to effectively deliver quality healthcare to all patients, regardless of the entry point into the system, while protecting the well-being of non-COVID-19 patients and the healthcare workforce.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
1. JCI Internal Audit Checklist N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
A SCOPE OF SERVICE
PASS/FAIL/N.A
(Circle one for this section)
A1 AFTER ENTERING THE WARD
Tell me about your ward
Staff should able to share the following:
a No. of beds in the word/cubicle
Are your wards usually full?/What the occupancy rate?
b Nurse to patient ratio in the ward
How many units are you responsible for?
c Type of patients
Common conditions of patients in the wards
Average age of patients
d Average length of safety
Staff doing the coordination is able to articulate
e No. of working shifts for nurses
f No. of staff at each shifts in the wards
g The difference between Nurses and HCA
h How patients are being assigned to the consultant
i
specific core competency for for professional staff to
practice in this ward
j What do you do if the patients does not speak English?
k How the appointments are obtained /given
A2 AFTER RECEIVING PATIENT'S CASE NOTES
a 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
b Is the patient on any clinical pathway?
A3
DOCUMENTATION - COMPLETENESS AND LEGIBILITY
(MCI)
a Legibility of patients clinical records is evidenced
b
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
c Doctors use the SOAP format in writing case notes
d
Order forms and checklist are adequately filled in (e.g.
Radiology laboratory)
2. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
f Standardizes symbols/abbreviations are used
g
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 Identify patients correctly (IPSG1)
PASS/FAIL/N.A
(Circle one for this section)
a How do you identify patients
b
How do you identify unknown /unconscious
/uncommunicative patients (e.g. comalose)?
c When do you use 2 patient's identifiers?
B2 Improve Effective Communication (IPSG2)
PASS/FAIL/N.A
(Circle one for this section)
Verbal and Telephone orders -"Read Back"
a
What is the procedure of taking down verbal/telephonic
order for the doctor or receiving &reporting critical test
results?
b
b How do you do a verbal handover of your patients when
you go for a break ? What do you inform the nurse.
B3 Safety of High alert medications (HAM)(IPSG3)
PASS/FAIL/N.A
(Circle one for this section)
a
Are there any high concentrated electrolyte her? Where
should they be kept?
b why are the concentrated electrolytes kept in ICUs?
c
For places that can store concentrated electrolytes, they
are not stored in matrix drawer or omnicell shelves
d What HAM do you have in the clinic?
e where is the list of High Alert Medication?
f
Can high alert alert medications be stored with other
drugs?
g
Where are HAM placed/ stored &how do you ensure the
safety of HAM?
h refrigerated drugs are
Kept under lock and key
Fridges should be located in secure areas allowing only
medical/nursing staff access.
i
Drugs are not under lock and key in ED resuscitation rooms
and during surgery or procedure
j How do you know how long you can keep the medications?
Do you have discard dates for medications and
disinfectants once they are opened?
k
What are the examples of measures used to improve the
safety of high alert medications
l
when do you serve PRN (pro re nata or "as needed")
medication
3. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
B4 Ensure Correct site/Procedure/Patient surgery (IPSG4)
PASS/FAIL/N.A
(Circle one for this section)
a When do you Tme-out
b
Do you document the completed time-out
procedure?Where is it?
c What do you check before conducting the procedure?
d How is site making done?
e How do you involved patients during site making?
f when doyou do site making?
B5 Reduce risk of Healthcare Associated Infections(HAI)(IPSG5)
PASS/FAIL/N.A
(Circle one for this section)
a When do you practice hand hygiene
b
Staff practice correct hand washing and hand disinfection
techniques
c when do we hand wash and not handrub
d
hand hygiene items are available /Alcohl handrub at
cubicles are reasonably used
e
What kind of training is there for staff on infection control
practices?
f What do you teach patient regarding infection control?
B6
Reduce risk of patient Harm Reducing from Falls(Exclude
ICU &HDs) (IPSG6)
PASS/FAIL/N.A
(Circle one for this section)
a How do you determine the Score for falls risk?
b When is the initial fails risk assessment for all patients?
c
When and how often do you do conduct the fall risk
reassessment for all patients?
d
What interventions do you do those patients who are at fail
risk?
e How do we know which patients here are at fall risk?
f
How do you educate patients & families on falls prevention
?
g
What happens when a patient falls? How do you report
falls?
C ASSESSMENT OF PATIENTS (AOP)
C1 Initial Assessment (AOP1.2)
PASS/FAIL/N.A
(Circle one for this section)
a What are the main factors in the Initial Assessment?
b
How long do the doctor and nurses need to complete the
initial medical and nursing assessment of a patient?
C2 Re-assessments(AOP2)
PASS/FAIL/N.A
(Circle one for this section)
a How often do you re -assess patient
4. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
C3 Nutritional screening(AOP1.6)
PASS/FAIL/N.A
(Circle one for this section)
a Do you do nutritional screening ?
What do you do when patient has nutritional risk?
b who can refer patient to the dietician?
c 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 Pain Assessment(AOP1.7)
PASS/FAIL/N.A
(Circle one for this section)
a Do you screen for pain the initial assessment?
How do you assess for pain /What do you measure?
b Pain score is documented
c
What happens to the patient when significant pain is
identified by screening criteria?
d(i) How often do you assess/re-assess for pain?
d(ii)
If pain score is ≥ 6, interventions and evaluation post pain
interventions are documented.
C5 Discharge planning (AOP1.11)
PASS/FAIL/N.A
(Circle one for this section)
a What's the time frame for discharge planning
D PATIENTS &FAMILY EDUCATION(PFE)
PASS/FAIL/N.A
(Circle one for this section)
a What are assessed and documented in the patient record?
b who initiates patient education
c
What have you been communicating to the patient about
education?
d PFE form is adequately filled up
E PATIENTS &FAMILY RIGHTS(PFR)
PASS/FAIL/N.A
(Circle one for this section)
E1 Consent Taking /Information Consent(PFR6)
a What is the process for obtaining consent
b Is the patient capable of give consent?
Who do you obtain consent from if patient is incapable of
giving consent?
c
What are some of the procedure and treatments that require
informed consent? Is the re a list of them?
5. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
d Do you use family members as interpreters for consent?
e No medical abbreviations and symbols are used.
f
For parts of the consent form that are not relevant, that
particular portion should be marked "not applicable"/"N.A"
g No alterations made in the consent form.
E2 Patient's Charter
PASS/FAIL/N.A
(Circle one for this section)
a
What relevant and available information do you have to
inform patients/family?
b
When the patients come to the ward, are they given the
patient's charter? What if they want to read?
c
What do you do if the patient who does not understand
English asks fo the patient's charter?
E3 Patient Privacy and confidentiality (PFR1)
PASS/FAIL/N.A
(Circle one for this section)
a
How do you ensure patients personal belongings are
protected?
b How are patients protected from physical assault?
c How do you ensure patients privacy and confidentiality ?
d
Privacy is povided to patients during the care and
treatment(Observation)
e
What is the process when patient or family request for a
second opinion?
f
Where can the patients carry out religious service or
worship?
g what if patient or family request for spirutual support?
E4 Care of high Risk Patients/ High risk Services(COP.3)
PASS/FAIL/N.A
(Circle one for this section)
a What is the timeframe to prepare patient's care plan?
b
The patient's plan of care is documented in the medical
record and masurable goals are indicated , when
appropriate.
c What are the High risk groups?
d What do you do when depressed patients become suicidal?
E5
Do Not Resuscitate Orders (DNR) (PER2.3) & Eternal of Care
at the End of Life (PFR 2.5)
PASS/FAIL/N.A
(Circle one for this section)
a How is a DNR order made?
Can the on cal doctor (register and above ) make the DNR
and EOC orders?
b How often to you review the DNR and EOC order?
c
If Patient (on DNR &EOC ) is not able to communicate , how
do you assist the family with decision on end of life case?
d How do you know if a patient has an AMD?
6. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
e If you are faced with unresolved ethical dilemmas, what do you do?
E6 Use of Restraints(COP3.7)
PASS/FAIL/N.A
(Circle one for this section
a Who can initiate restraint use for a patient?
b How often do you need to monitor patients on restraints?
c How long is each restraint order limited to?
F ACCESS OF CARE AND CONTINUTY OF CARE (ACC)
F1 Patient Transfer/Referral(ACC 3,4)
PASS/FAIL/N.A
(Circle one for this section
Staff are able to articulate:
a
Patient transfer to ICU/ Specialized services is according to criteria,
and jointly agreed/ approved by primary team and ICU doctor
b When and how referrals for services(e.g. AHS) are made
c Who accompany patients during transfer
d
when a patient is transferred to another healthcare organization,
What relevant documents are required to handover to the staff of
the receiving institution?
F2 Patient Discharge and Follow Up (ACC 4)
PASS/FAIL/N.A
(Circle one for this section
a
Staff able to articulate process & requirements for patient going on
home leave.
b
Staff/ Care Manager aware of the community healthcare providers/
organizations that patients can be discharged or referred to.
c
When do you have to complete the Hospital Inpatient Discharge
summery (EOSS)?
d Upon discharge , what documents will the patient take?
e
Who is allowed to give approval to patients who request for
discharge against medical advice (AMA)?
f
For an approved AMA, what do you need to give the patient/ legally
acceptable surrogate at the point of discharge?
G ANAESTHESIA AND SURGICAL CARE (ASC)
G1 Sedation (Moderate and Deep sedation) (ASC 3)
PASS/FAIL/N.A
(Circle one for this section
a What do you have to do before administering sedation?
b What minimum monitoring is provided when performing sedation?
How often do you monitor patient when performing sedation?
c
What is the criteria for assessing the readiness for discharge to
ward from sedation monitoring?
d
How do you know if the doctor has been to perform moderate
sedation?
7. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
G2 Anaesthesia (ASC4,5,6)
PASS/FAIL/N.A
(Circle one for this section)
a Pre-anaesthesia assessment performed
b Anaesthesia care is planned and documented
c
Patient is reassessed prior to induction of anaesthesia by the
anaesthesiology team?
d When do you monitor patient's physiological status?
e What tol do 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 do you do when the PACU is full after surgery?
G3 Surgery (ASC 7)
PASS/FAIL/N.A
(Circle one for this section)
a Before surgery, what assessment is needed?
b Patient is re-evaluated before surgery . Date and time documented.
c
Documentation of the following are completed in the surgical
reports and brief operative notes:
d
Written surgical reports is completed and available before patient
leaves PACU
H EMERGENCY RESUSCITATION
H1 Emergency Medications (MMU3.2)
PASS/FAIL/N.A
(Circle one for this section)
a Where can I find emergency medications?
b
Emergency Medications are stored , maintained and protected from
loss o theft
c
Emergency medications are available, monitored , and replaced
after use.
d How do 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)
PASS/FAIL/N.A
(Circle one for this section)
a
Check that emergency trolley is locked &checking is documented
daily.
b who checks the E-trolley
How often do you check the items in the E-trolley?
What do you checked for?
c Are all the E-trolleys the same in the hospital?
d
Check defibrillator is complete with defibrillation pads(in sealed
package and are not expired)
e Staff able to demonstrate proficient testing of:
f Demonstrate fixing of a functioning laryngoscope.
8. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
H3 Emergency Resuscitation Activation (cop 3.2)
PASS/FAIL/N.A
(Circle one for this section)
a Staff able to recognize and assess cardiac arrest to activate CPR
Staff know the steps/ who to call for Emergency Resuscitation
at:
b Clinical area (ward)
c Non-clinical area(public)
d What number to call during emergency resuscitation ?
I MEDICATION MANAGEMENT AND USE (MMU)
I1 Storage (MMU 3)
PASS/FAIL/N.A
(Circle one for this section)
a How are the medications stored?
b Medications are stored using First-in-first-out principle.
c How do you label look-alike and sound-alike medications?
d There is segregation of look-alike and sound-alike medications?
e
Controlled drugs are checked each shift and kept locked in
safe?
f
The type of quality of controlled drugs physically available
tallies with the number recorded in the CD Book?
g Staff able to show log on drug wastage
h Staff able to show specimen signature for controlled drugs?
i Drug fridge temperature maintained at 2°C-8°C.
The medications fridge lights are working
j
Staff interviewed can explain what he/she is supposed to do
when the alarm for the medication fridge goes off.
k
medications are properly and safely stored according to
recommended storage conditions as specified by
manufacturers
l
What is the procedure for inpatients who bring their own
medication and for of patients own medication
m There is a procedure to stored and control sample medications.
n
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.
o
There is no obstruction of firefighting equipment (e.g. Sprinkler,
fire hoses, fire extinguishers) In the medication storage area.
I2 Ordering and Transcribing (MMU 4)
PASS/FAIL/N.A
(Circle one for this section)
a
Who or where can you look for where you have doubts/
clarification on the medications prescribed?
b
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.
9. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
c
The doctor screens through all the patient's existing medications
and documents in the clerking case notes, under "Present
Medicines".
d
The doctor reviews if the medicines are still required by the
patient and enters the drugs the drugs to be continued in the e-
IMR. These drugs should be indicated in brackets under the
Remarks column "patient's existing medication"
e
Initial medication orders are compared to the list of medications
taken prior to admission , according to the organization’s
established process.
f
There are special precautions or procedure for ordering drugs
with look-alike and sound-alike names?
I3 Preparing and Dispensing (MMU 5)
PASS/FAIL/N.A
(Circle one for this section)
a Injection trolleys are:
Clean and tidy
Assigned area for drug dilution
Aseptic techniques observed during dilution
b Medication cart is clean and tidy
c Stock medication is dated upon opening.
d there are no expired medications/ tubes.
e
How do you review medications prescriptions or orders for
appropriateness?
f
Staff is able to articulate how to dispense the medication for the
omnicell during omnicell downtime
I4 Administering Medications ( MMU 6)
PASS/FAIL/N.A
(Circle one for this section)
a what is process of administering medications to patients?
b Drug allergies are identified and indicated
c What are the 5 rights of medication administration?
d
medication prescribed and administered is written in the
patient's record.
e
What do you do with the leftover cytotoxic drug and
consumable used during administration of cytotoxic drugs?
f For multiple uses of the drug/mixture the following are recorded
g
For medication prepared in a syringe or burette for continuous
infusion, the following is labeled :
h
Are patients able to do self- administration of medication during
their hospital stay?
i eIMR and eMARS are logged off when not in use.
I5 Monitoring(MMU 7)
PASS/FAIL/N.A
(Circle one for this section)
a What do you do when adverse side effects are observed?
10. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
b What happens when there is a medication error/near miss?
c there is a medication recall system in place
J INJECTION CONTRO (PCI)
J1 Equipment (PCI 7.1)
PASS/FAIL/N.A
(Circle one for this section)
Staff have knowledge of:
a Who is supposed to clean equipments
b Devices which are reused in the hospital (None)
c
The process for the collection , analysis and use of infection
prevention and control data related to reused devices and
materials
J2 Laundry and linen Management (PCI 7.1, ME 3)
PASS/FAIL/N.A
(Circle one for this section)
a soiled linen is appropriately disposed
b Linen carrier is properly covered
J3 Waste Disposal (PCI 7.2)
PASS/FAIL/N.A
(Circle one for this section)
a Name some examples of biohazard waste
b How do you dispose biohazard materials?
J4 Sharps and needles (PCI 7.3)
PASS/FAIL/N.A
(Circle one for this section)
a Sharp boxes is less than 2/3 filled
b What is the process of disposing the sharp box?
c Staff's knowledge of needle-stick injury protocol
J5 Patients In Isolation (PCI 8)
PASS/FAIL/N.A
(Circle one for this section)
a
What do you need to observe before entering an isolation room/
ward?
b Signage for isolation precaution are available and appropriate
c Personal protection Equipment (PPE) is available for use
d
Staff educates patient's relatives to take precautions for patients
in isolation room
e
What happens when one bedded isolation rooms are
unavailable?
f
Patients with known/ suspected diseases are isolated
appropriately
J6 Personal Protective Equipment (PCI 9)
PASS/FAIL/N.A
(Circle one for this section)
a Staff know which situations to use different levels of PPE
b
Staff demonstrates correct techniques of pulling on and taking
of PPE and known what to do removal of PPE
11. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
J7 MRSA(PCI 6)
PASS/FAIL/N.A
(Circle one for this section)
a Cases of MRSA infection are documented and reported
b What precautions do you have for MRSA patient?
K FACILITY MANAGEMENT AND SAFETY (FMS)
K1 Safety and Security (FMS 4)
PASS/FAIL/N.A
(Circle one for this section)
a All staff, visitors and venders are identified
K2 Hazardous Materials (FMS 5)
PASS/FAIL/N.A
(Circle one for this section)
a How do you handle a chemical spill?
b Show your Materials Safety Datasheet(MSDS)
c Give examples on the type of hazardous wastes.
d How is general waste disposed?
e How do you dispose cytotoxic wastes?
K3 Emergency Management (FMS 6)
PASS/FAIL/N.A
a The following information is posted?
Emergency instructions
Emergency phone numbers
Fire Emergency instructions
b
Staff has participated in Emergency Preparedness Exercise
(at least 1 per year)
K4 Fire Safety (FMS 7)
PASS/FAIL/N.A
(Circle one for this section)
Staff is able to articulate procedures related to:
a Fire safety R.A.C.E. relating to fire
b Location of Fire Extinguishers
c P.A.S.S. relating to fire
d Location of Fire hose reel
e P.O.R.T.S. relating hose reel
f Contact number for fire safety reporting center
g Clear passage way for all fire exits
h Fire exit doors closed completely
i Location of fire assembly area
j Staff has participated in fire drills (at least 1 per yr)
K5 Medical Equipment (FMS 8)
PASS/FAIL/N.A
(Circle one for this section)
a
Preventive Maintenance of equipment is updated &
documented
12. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
b
Oxygen cylinders are stored properly in holder in a
designated area
c Point of Care Testing Equipment:
-Urine lab-stick-not expired
-Hypo -count machine
show Quality records
expiry date time frame
K6 Utility Systems(FMS 9)
PASS/FAIL/N.A
(Circle one for this section)
a Show you uninterruptable power supply(UPS)
K7 Utility Room-Clean (FMS 11.2)
PASS/FAIL/N.A
(Circle one for this section)
a Items are labeled and placed in correct containers
b Stock items are arranged in first in first out order
c
No carton boxes on floor /All items are elevated from the
floor
d No contaminated or dirty items in utility room
e No patient care items under the sink
f CSSD items are stored in a clean and dry area
g Check integrity of items
h Pat- slide hung on the wall
i Utility room door is kept closed
K8 Utility Room-Dirty (Sluice Room) (FMS 11.2)
PASS/FAIL/N.A
(Circle one for this section)
a Room door is kept closed
b Separation of clean and dirty items
K9 Food and Pantry (COP 4.1)
PASS/FAIL/N.A
(Circle one for this section)
a
Food stored in the fridge are labeled with name date and
time
b Floor is clean and not littered
c No food related items placed under the sink
d Area clean: infection control measures implemented
L STAFF QUALIFICATIONS AND EDUCATION (SQE)
PASS/FAIL/N.A
(Circle one for this section)
a Department Staffing plan Staff schedule/roster in place
13. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
b
In the event of an emergency, what would your staffing
response plan be?
c Plan is in place for unexpected staff shortage
d Job description are current and available for all staff
e How do you ensure competency for your staff?
Does Nursing or Pharmacist do competency training?
f What groups staffs are BCLS certified?
g How does your Hospital carry out Privileging?
Do all departments have a list of specific privileges for
senior consultants / aside from common privileges?
h
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.
I
Each staff can articulate heor he or she is continuously (i.e.
knowledge, skills, competencies)
j All staff wear name tags or identification badges
k What quality improvement activities are you involved in?
M QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS)
PASS/FAIL/N.A
(Circle one for this section)
a
What are your quality data and measures / quality
improvement projects?
b
Are there any new /modified clinical pathways developed
in the last 12 months?
c What is a serious reportable event?
d What is medication error?
e What is a near miss?
f
What are steps to take in the event of a serious reportable
event / near miss?
14. JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
Other Comments:
Prepared by Dr.Mahboob Khan Phd
Healthcare Quality Consultant
Copy right reserved c 2015