standards for hospitals - moh.gov.bw

Assessment Instrument Document

Date generated: 24/10/2014

These forms aredesigned to be used by both hospital personnel and external surveyors. The following

information must be providedafter each survey, before submitting the completed survey forms. 1.NAME OF HOSPITAL/CLINIC/FACILITY:________________________________________________

2.BASELINE/INTERNAL SURVEY INFORMATION:

Title and name of person who completed thisdocument: _________________________________________

Post and position held: ____________________________________________________________________

Date of survey: __________________________________________________________________________

3.EXTERNAL SURVEYINFORMATION:

Name of external surveyor: _________________________________________________________________

Date of external survey: ___________________________________________________________________

N.B. Hospital staff are please to use BLACK ink atall times. Theexternal surveyors are requested touseRED inkat all times. Please circle the ratedcompliance withthe criterion, e.g. NA (Not applicable), NC (Non-compliant), PC(Partially compliant), C (Compliant). Thedefaultcategory affected is designatedon the form foreach criterion as follows:1. patient and staff safety 2. legality 3. patient care 4. efficiency 5. structure 6. basic management 7. basic process 8. evaluation The seriousnessof the default is designated ontheform for each criterionas follows:1. mild 2. moderate 3. serious 4. veryserious

BOTSWANA NATIONAL HEALTH QUALITYSTANDARDS FOR HOSPITALS

14.Obstetric and Maternity Care

GUIDE TO COMPLETION OF FORM

Documents Checked

Surveyor: ..............................

Surveyor: ..............................

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14.1 Coordination of Patient Care14.1.1 Standard

During all phases of care, there are qualified individuals responsible for the patient'scare.

Standard Intent: The individuals who bear overall responsibility for the patient's care or for aparticular phase of care are identified in the patient's record or in a manner that is madeknown to the personnel.

Criterion CommentsRecommendations

Criterion 14.1.1.1

Critical: ¨Catg: Basic Management +Efficiency

Compliance

NA NC PC C

Default Severity for NC or PC = 4Very Serious

The individuals responsiblefor the patient’s care aredesignated.

Criterion 14.1.1.2

Critical: ¨Catg: Basic Management + Legality

Compliance

NA NC PC C


The individuals responsiblefor the patient’s care arequalified.

Criterion 14.1.1.3


Compliance

NA NC PC C


The individuals responsiblefor the patient’s care areidentified and made known tothe patient and other staff.

Criterion 14.1.1.4


Compliance

NA NC PC C


The requirements ofantenatal, labour andpostnatal wards andnurseries are individuallyincluded in the staffingrequirements.






Criterion 14.1.1.5


Compliance

NA NC PC C


A registered midwife and/ormedical practitioner is presentat every birth.

Criterion 14.1.1.6


Compliance

NA NC PC C


Specialists are available forconsultation.

Criterion 14.1.1.7


Compliance

NA NC PC C


At least one person isavailable at all times who isqualified (medical practitioneror advanced midwife) in themanagement of maternal andneonatal emergencies.






14.1.2 StandardThe delivery of services is integrated and coordinated amongst care providers.

Standard Intent: The coordination of patient care depends on the exchange of informationbetween the members of the multidisciplinary/interdisciplinary team. This can be throughverbal, written or electronic means as determined by organisational policies. The policiesshould indicate the appropriate means of communication. Clinical leaders should usetechniques to better integrate and coordinate care for their patients (for example, team-delivered care, multi-departmental patient care rounds, combined care planning forums,integrated patient records, case managers). The process for working together will be simpleand informal when the patient's needs are not complex. The patient, family and others are included in the decision process when appropriate. Thepatient's record contains a history of all care provided by themultidisciplinary/interdisciplinary team, and is made available to all relevant caregivers whoare authorised to have access to its content.


Criterion 14.1.2.1

Critical: ¨Catg: Basic Process + Patient Care

Compliance

NA NC PC C


The patient’s clinical recordsare completed according toguidelines determined by theorganisation.

Criterion 14.1.2.2


Compliance

NA NC PC C


The patient’s records are upto date to ensure the transferof the latest informationbetween care providers.

Criterion 14.1.2.3


Compliance

NA NC PC C

Default Severity for NC or PC = 3Serious

Information exchangedincludes a summary of thecare provided.






Criterion 14.1.2.4


Compliance

NA NC PC C


Information exchangedincludes the patient’sprogress.

Criterion 14.1.2.5


Compliance

NA NC PC C


The author can be identifiedfor each patient record entry.

Criterion 14.1.2.6


Compliance

NA NC PC C


The date of each patientrecord entry can be identified.

Criterion 14.1.2.7


Compliance

NA NC PC C


The time of each patientrecord entry can be identified.






14.2 Facilities and Equipment14.2.1 Standard

Adequate resources are available for the provision of safe care to patients in theward.

Standard Intent: In order to provide safe patient care, each unit requires adequate resources. The physical facilities required include adequate office accommodation for staff; sluicerooms which are hygienically clean at all times; treatment and dressing rooms; andadequate storage space for clean linen. Cleaning equipment is safely stored in a room orcupboard used for this purpose only. There are adequate toilet and bathing facilities for thenumber of patients in the ward, as determined by national legislation. Each delivery room has at least:a) one cardio-tocograph machineb) an infant warming and resuscitation cartc) an incubator with adjustable temperature and separate oxygen supplyd) a foetal monitora) equipment for inhalation analgesia. There is a temperature-controlled nursery and it has:• suitable bassinettes• photo-therapy lights• a panel for viewing babies• a designated area for preparing infant feeds• a refrigerator for milk feeds only• facilities allocated for washing utensils used when preparing infant feeds. There is adequate lighting and ventilation. Nurse call systems are available at bedsides and in bathrooms and toilets and areconnected to the emergency power supply. Where there is no piped oxygen and vacuum supply, there are mobile oxygen cylinders andvacuum pumps. All necessary fittings for oxygen and suction are in place and workingsatisfactorily. Each ward is provided with a socket outlet that is connected to the emergencypower supply. A resuscitation trolley is available at the point of need within one minute. In addition, there isaccess to a defibrillator or automated external defibrillator (AED) within three minutes of anypatient collapsing. Resuscitation equipment includes at least:• a defibrillator with adult paddles/pads (and infant paddles/pads where applicable)• an ECG monitor• a CPR board (if required)• suction apparatus (electrical or alternative) plus a range of soft and hard suctioncatheters• a bag-mask manual ventilator• a range of endotracheal tubes and two laryngoscopes with a range of straight andcurved blades, spare batteries, spare globes where applicable• an introducer/stylet for endotracheal intubation• a syringe to inflate the ETT cuff• oropharyngeal tubes• equipment to perform an emergency cricothyroidotomy (needle and surgical)• appropriate facilities for intravenous therapy and drug administration (includingpaediatric sizes)• drugs for cardiac arrest, coma, seizures and states of shock (including paediatric doseswhere applicable)• plasma expanders.







Criterion 14.2.1.1

Critical: ¨Catg: Basic Management +Physical Struct

Compliance

NA NC PC C


Patient and staffaccommodation andequipment is adequate tomeet patient care needs.

Criterion 14.2.1.2


Compliance

NA NC PC C


Oxygen and vacuum suppliesmeet the needs of patients forcare.

Criterion 14.2.1.3

Critical: ¨Catg: Basic Process + Efficiency

Compliance

NA NC PC C


There is evidence thatequipment is maintained inaccordance with the policiesof the organisation.

Criterion 14.2.1.4

Critical: þCatg: Basic Management +Physical Struct

Compliance

NA NC PC C


Resuscitation equipment isavailable in accordance withthe policies of theorganisation.

Criterion 14.2.1.5


Compliance

NA NC PC C


Where there are no pipedoxygen installations, there isa documented procedure forensuring that cylinderpressures (i.e. contents) aremonitored according toorganisational policy whilepatients are receiving oxygen.






Criterion 14.2.1.6

Critical: ¨Catg: Basic Management + PatientCare

Compliance

NA NC PC C


Each patient has access to anurse call system at all times.

Criterion 14.2.1.7


Compliance

NA NC PC C


Electricity and water isavailable in accordance withthe policies of theorganisation.

14.2.2 StandardSpecific resources are available for the provision of safe care to patients in theobstetric and maternity unit/ward.

Standard Intent: Professional guidelines for obstetric/maternity care services recommend thepersonnel and resources required to manage the service safely. The personnel in the wardare in possession of these guidelines and ensure that the recommendations areimplemented. These guidelines provide norms for staffing an obstetric/maternity care unitand also for the services and facilities required.


Criterion 14.2.2.1


Compliance

NA NC PC C


Current guidelines for theprovision ofobstetric/maternity careservices and facilities arefollowed.

Criterion 14.2.2.2


Compliance

NA NC PC C


Staffing of the servicecomplies with acceptedstaffing norms forobstetric/maternity careservices.






Criterion 14.2.2.3


Compliance

NA NC PC C


Available medical equipmentcomplies with acceptednorms for obstetric/maternitycare services.

Criterion 14.2.2.4


Compliance

NA NC PC C


Where resuscitation,intensive care, life support orobstetric/maternity monitoringequipment is used that doesnot have built-in batterybackup units, there is anuninterruptible power supply(UPS) that complies withrelevant requirements and isregularly serviced and tested.

Criterion 14.2.2.5


Compliance

NA NC PC C


There is a dedicated area forthe preparation of infantfeeds.






14.3 Clinical Practice Guidelines14.3.1 Standard

Clinical practice guidelines are used to guide patient care and reduce unwantedvariation.

Standard Intent: Clinical practice guidelines provide a means for improving quality and theyassist practitioners and patients in making clinical decisions. Guidelines are found in theliterature under many names, including practice parameters, practice guidelines, patientcare protocols, standards of practice and/or care pathways. Regardless of the source, thescientific basis of guidelines should be reviewed and approved by organisational leadersand clinical practitioners before implementation. Consideration should be given toproviding guidelines for high risk, high volume and high cost conditions as these will formthe basis for structured clinical audits. This ensures that they meet the criteria established by the leaders and are adapted to thecommunity, patient needs and organisational resources. Once implemented, guidelines arereviewed on a regular basis to ensure their continued relevance.


Criterion 14.3.1.1


Compliance

NA NC PC C


Clinical practice guidelinesrelevant to the patients andservices of the organisationare available to guide patientcare processes.

Criterion 14.3.1.2

Critical: ¨Catg: Evaluation + Patient Care

Compliance

NA NC PC C


The implementation ofguidelines is monitored aspart of a structured clinicalaudit.

Criterion 14.3.1.3

Critical: ¨Catg: Evaluation + Efficiency

Compliance

NA NC PC C


Guidelines are reviewed andadapted on a regular basis.






14.4 Assessment of Patients14.4.1 Standard

All patients cared for by the organisation have their health needs identified throughan established assessment process.

Standard Intent: When a patient enters a ward, the specific information required and theprocedures for obtaining and documenting it depend on the patient's needs and on thesetting in which care is being provided. The organisation defines in writing the scope and content of assessments to be performedby each clinical discipline within its scope of practice and applicable laws and regulations. These findings are used throughout the care process to evaluate patient progress andprovide information regarding the need for re-assessment. It is essential that assessmentsare well documented and can be easily retrieved from the patient's record. The health organisation determines the time frame for completing assessments. This mayvary in the different settings within the organisation. When an assessment is partially orentirely completed outside the organisation, the findings are verified on admission to theorganisation.


Criterion 14.4.1.1


Compliance

NA NC PC C


The organisation implementspolicies and procedures forassessing patients onadmission and during on-going care.

Criterion 14.4.1.2

Critical: ¨Catg: Basic Process + Legality

Compliance

NA NC PC C


Only those individualspermitted by applicable lawsand regulations or byregistration perform theassessments.

Criterion 14.4.1.3


Compliance

NA NC PC C


The scope and content ofassessment by eachdiscipline is defined.






Criterion 14.4.1.4


Compliance

NA NC PC C


Policies and proceduresensure that assessments areperformed within appropriatetime frames and that they areadequately documented inthe patient’s records.

14.4.2 StandardEach patient has an initial assessment that complies with current policies,procedures and guidelines.

Standard Intent: The initial assessment of a patient is critical for the identification of the needsof the patient and initiation of the care process. A patient's social, cultural and family statusare important factors that can influence their response to illness and care. Families can beof considerable help in these areas of assessment and in understanding the patient's wishesand preferences. Economic factors are assessed as part of the social assessment,particularly when the patient and his/her family will be responsible for the cost of all or aportion of the care. A functional and nutritional assessment allows for the patient to be referred for specialistcare if necessary. Certain patients may require a modified assessment, e.g. very young patients, the frail orelderly, those terminally ill or in pain, patients suspected of drug and/or alcohol dependenceand victims of abuse and neglect. The assessment process is modified in accordance withnational guidelines and protocols. The outcome from the patient's initial assessment resultsin an understanding of the patient's medical and nursing needs so that care and treatmentcan begin. Planning for discharge is initiated during the initial assessment process. When the medicalassessment was conducted outside the organisation, a legible copy of the findings is placedin the patient's record. Any significant changes in the patient's condition since thisassessment are recorded.


Criterion 14.4.2.1


Compliance

NA NC PC C


Each patient admitted has aninitial assessment that meetsorganisational policy.






Criterion 14.4.2.2


Compliance

NA NC PC C


The initial assessmentincludes health history.

Criterion 14.4.2.3


Compliance

NA NC PC C


The initial assessmentincludes physicalexamination.

Criterion 14.4.2.4


Compliance

NA NC PC C


The initial assessmentincludes functionalexamination, whereapplicable.

Criterion 14.4.2.5


Compliance

NA NC PC C

Default Severity for NC or PC = 2Moderate

The initial assessmentincludes social and economicassessment, whereapplicable.

Criterion 14.4.2.6


Compliance

NA NC PC C


The initial assessmentincludes psychologicalassessment, whereapplicable.






Criterion 14.4.2.7


Compliance

NA NC PC C


The initial assessmentincludes cultural assessment,where applicable.

Criterion 14.4.2.8


Compliance

NA NC PC C


The initial assessmentincludes antenatal history.

Criterion 14.4.2.9


Compliance

NA NC PC C


The initial assessmentincludes maternal and foetalexamination.

Criterion 14.4.2.10


Compliance

NA NC PC C


The initial assessment resultsin an initial diagnosis.

Criterion 14.4.2.11


Compliance

NA NC PC C


The initial assessment resultsin the identification of thepatient’s medical, nursing orother health needs.






14.4.3 StandardHealth professionals responsible for patient care collaborate to analyse andintegrate assessment information.

Standard Intent: A patient benefits most when the personnel responsible for the patient worktogether to analyse the assessment findings and to combine this information into acomprehensive picture of his or her condition. From this collaboration the patient's needsare identified, the order of their importance is established and care decisions are made.


Criterion 14.4.3.1


Compliance

NA NC PC C


Assessment findings aredocumented in the patient’srecord and are readilyavailable to those responsiblefor the patient’s care.

Criterion 14.4.3.2


Compliance

NA NC PC C


Patient assessment data andinformation are analysed andintegrated by thoseresponsible for the patient’scare.

Criterion 14.4.3.3


Compliance

NA NC PC C


Patient needs are prioritisedon the basis of assessmentresults.

Criterion 14.4.3.4


Compliance

NA NC PC C


The patient and/or the familyparticipate in the decisionsregarding the priority needs tobe met.






14.5 Patient Care14.5.1 Standard

The care provided to each patient is planned and written in the patient’s record.

Standard Intent: A single integrated plan is preferable to a separate care plan recorded by eachhealth professional. Collaborative care and treatment team meetings or similar patient discussions are recorded. Individuals qualified to do so order diagnostic and other procedures. These orders must beeasily accessible if they are to be acted on in a timely manner. Locating orders on acommon sheet or in a uniform location in patient records facilitates the correctunderstanding and carrying out of orders. The organisation decides:• which orders must be written rather than verbal• who is permitted to write orders• where orders are to be located in the patient's records. The method used must respect the confidentiality of patient care information.


Criterion 14.5.1.1


Compliance

NA NC PC C


The planned care is providedand noted in the patient’srecord.

Criterion 14.5.1.2


Compliance

NA NC PC C


All procedures and diagnostictests ordered and performedare written into the patient’srecord.

Criterion 14.5.1.3


Compliance

NA NC PC C


The results of procedures anddiagnostic tests performedare available in the patient’srecord.






Criterion 14.5.1.4


Compliance

NA NC PC C


Re-assessments aredocumented in the patient'srecord.

Criterion 14.5.1.5

Critical: þCatg: Basic Process + Patient Care

Compliance

NA NC PC C


The maternal and foetalconditions and the progressof labour are recorded on apartogram in every labour.

Criterion 14.5.1.6


Compliance

NA NC PC C


The patient’s plan of care ismodified when the patient’sneeds change.






14.5.2 StandardPolicies and procedures guide the care of high-risk patients and the provision ofhigh-risk services.

Standard Intent: Some patients are considered "high-risk" because of their age, condition or thecritical nature of their needs. Children are commonly in this group as they may not speak forthemselves, understand the care process or participate in decisions regarding their care.Similarly, the frightened, confused or comatose patient is unable to understand the careprocess when care needs to be provided efficiently and rapidly. Policies and procedures are important. They help the personnel understand these patientsand services and respond in a thorough, competent and uniform manner. The clinical andmanagerial leaders take responsibility for identifying the patients and services consideredhigh-risk, using a collaborative process to develop policies and procedures and training staffin their implementation. The special facilities and safety measures required by children need to be specified.It is particularly important that the policies or procedures indicate:• how planning will occur• the documentation required for the care team to work effectively• special consent considerations• monitoring requirements• special qualifications or skills of the personnel involved in the care process• the resuscitation equipment available and how to use it, including equipment forchildren. Clinical guidelines should be incorporated in the process because there are several criteriarequiring guidelines to be used. Monitoring provides the information needed to ensure thatthe policies and procedures are adequately implemented and followed for all relevantpatients and services. Policies and procedures should focus on high-risk patients and procedures, e.g.a) the care of emergency patientsb) methods of deliveryc) management of meconium stained liquord) Apgar scoring and evaluatione) performing of episiotomiesf) the handling, use and administration of blood and blood productsg) the management of contaminated blood supplies (expired, opened or damagedcontainer) h) the care of patients with communicable diseasesi) the care of immuno-suppressed patientsj) the use of restraint and the care of patients in restraintk) the care of young, dependent childrenl) the security of newborn babies.


Criterion 14.5.2.1


Compliance

NA NC PC C


Policies and procedures foridentified high-risk patientsand procedures, whichinclude at least items a) to l)in the intent statement above,are implemented.






Criterion 14.5.2.2


Compliance

NA NC PC C


The personnel are trainedand use the policies andprocedures to guide care.

14.5.3 StandardRisks, benefits, potential complications and care options are discussed with thepatient and his or her family or with those who make decisions for the patient.

Standard Intent: This section deals with the process of obtaining informed consent from thepatient and does NOT refer to providing health education in general, which is dealt with inStandard 14.8. Patients and their families or decision-makers receive adequate information to participate incare decisions. Patients and families are informed as to what tests, procedures andtreatments require consent and how they can give consent. For example, consent may begiven verbally by signing a consent form or through some other mechanism. Patients andfamilies understand who may give consent in addition to the patient. Designated personnel are trained to inform patients and to obtain and document patientconsent, e.g. a doctor for a surgical procedure or a nurse for HIV testing. These staffmembers clearly explain any proposed treatments or procedures to the patient and, whenappropriate, the family. Informed consent includes:• an explanation of the risks and benefits of the planned procedure• identification of potential complications• consideration of the surgical and non-surgical options available to treat the patient. In addition, when blood or blood products may be needed, information on the risks andalternatives is discussed. The organisation lists all those procedures that require written, informed consent. Leadersdocument the processes for obtaining informed consent. The consent process alwaysconcludes with the patient signing the consent form, or the documentation of the patient'sverbal consent in the patient's record by the individual who provided the information forconsent. Documentation includes the statement that the patient acknowledges fullunderstanding of the information. The patient's surgeon or other qualified individual providesthe necessary information and the name of this person appears on the consent form.


Criterion 14.5.3.1


Compliance

NA NC PC C


There is a documentedprocess for obtaininginformed consent.






Criterion 14.5.3.2


Compliance

NA NC PC C


Patients are informed abouttheir condition and theproposed treatment.

Criterion 14.5.3.3


Compliance

NA NC PC C


Patients know the identity ofthe medical practitioner orother professional practitionerresponsible for their care.

Criterion 14.5.3.4


Compliance

NA NC PC C


The information provided isrecorded with the record ofthe patient having providedwritten or verbal consent.






14.5.4 StandardPre- and post-operative assessments are documented.

Standard Intent: The pre-operative anaesthetic assessment determines whether the patient is agood candidate for the planned surgery and may significantly influence the pre- and intra-operative management. The clinical assessment and results of investigations must beavailable to the doctor performing the assessment. In an emergency, the initial medicalassessment may be limited to the patient's apparent needs and condition. Appropriate re-assessments are essential to modify and guide effective treatment. A patient's post-surgical care is related to the findings and the surgical procedure. Thesurgical report is available within a time frame needed to provide post-surgical care to thepatient. Post-operative monitoring is appropriate to the patient's condition and the procedureperformed. Results of monitoring influence intra- and post-operative decisions such asreturn to surgery, transfer to another level of care and the need for further investigations ordischarge.


Criterion 14.5.4.1


Compliance

NA NC PC C


The patient’s initial medicalassessment is documentedbefore anaesthesia.

Criterion 14.5.4.2


Compliance

NA NC PC C


The patient’s pre-operativediagnosis is recorded beforeanaesthesia.

Criterion 14.5.4.3


Compliance

NA NC PC C


A post-operative diagnosis isdocumented.






Criterion 14.5.4.4


Compliance

NA NC PC C


The name of the surgeon andthe names of other personnelas required by law aredocumented.

Criterion 14.5.4.5


Compliance

NA NC PC C


The patient’s physiologicalstatus is monitored during theimmediate post-surgeryperiod.

14.5.5 StandardThe organisation implements processes to support the patient in managing pain.

Standard Intent: While pain may be a part of the patient experience, unrelieved pain hasadverse physical and psychological effects. The patient's right to appropriate assessmentand management of pain is respected and supported. The organisation has processes to:• identify patients with pain during initial assessment and re-assessment• communicate with and provide education for patients and families about painmanagement in the context of their personal, cultural and religious beliefs• educate health service providers in pain assessment and management.


Criterion 14.5.5.1


Compliance

NA NC PC C


The assessment processmakes provision for patientsin pain to be identified.

Criterion 14.5.5.2


Compliance

NA NC PC C


Patients in pain receive careaccording to painmanagement guidelines.






Criterion 14.5.5.3


Compliance

NA NC PC C


Patients and families areeducated about pain and painmanagement.

Criterion 14.5.5.4


Compliance

NA NC PC C


The organisation hasprocesses to educate healthprofessionals in assessingand managing pain.

14.5.6 StandardThe organisation develops processes to manage end-of-life care.

Standard Intent: Dying patients have unique needs for respectful, compassionate care. Concern for the patient's comfort and dignity guides all aspects of care during the finalstages of life. To accomplish this, all personnel are made aware of the unique needs ofpatients at the end of life. These needs include treatment of primary and secondarysymptoms, pain management, responding to the concerns of the patient and their family andinvolving them in care decisions. End-of-life care provided by the organisation includes:a) providing appropriate treatment for any symptoms according to the wishes of the patient and familyb) sensitively addressing issues such as autopsy and organ donationc) involving the patient and family in all aspects of cared) responding to the psychological, emotional, spiritual and cultural concerns of the patientand family.


Criterion 14.5.6.1


Compliance

NA NC PC C


Policies and proceduresregarding end-of-life care, atleast including elements a) tod) in the intent statement, areimplemented.






Criterion 14.5.6.2


Compliance

NA NC PC C


The patient and thefamily/guardian are involvedin care decisions.

Criterion 14.5.6.3


Compliance

NA NC PC C


Pain and primary orsecondary symptoms aremanaged.

Criterion 14.5.6.4


Compliance

NA NC PC C


Interventions address patientand family religious andcultural concerns.






14.6 Medication14.6.1 Standard

Medication use in the organisation complies with applicable laws and regulations.

Standard Intent: Medication management is not only the responsibility of the pharmaceuticalservice but also of managers and clinical care providers. Medical, nursing, pharmacy andadministrative personnel participate in a collaborative process to develop and monitorpolicies and procedures.Each organisation has a responsibility to identify those individuals with the requisiteknowledge and experience, and who are permitted by law, registration or regulations toprescribe or order medications. In emergency situations, the organisation identifies anyadditional individuals permitted to prescribe or order medications. Requirements fordocumentation of medications ordered or prescribed and for using verbal medication ordersare defined in policy.


Criterion 14.6.1.1


Compliance

NA NC PC C


Policies and procedures thatguide the safe prescribing,ordering and administration ofmedications areimplemented.

Criterion 14.6.1.2


Compliance

NA NC PC C


The use of verbal/telephonicmedication orders isdocumented.

Criterion 14.6.1.3


Compliance

NA NC PC C


Only those permitted by theorganisation and by relevantlaw and regulation prescribemedication.

Criterion 14.6.1.4


Compliance

NA NC PC C


Medications, including herbaland over-the-countermedications, brought into theorganisation by the patient orthe family are known to themedical practitioner and arenoted in the patient’s record.






14.6.2 StandardMedications are safely administered.

Standard Intent: Only personnel who are suitably trained and experienced may administermedication to patients. The responsibility of these persons for medication administration isdocumented. The safe administration of medications requires a strict and comprehensiveprotocol. The patient, medical practitioner, nurse and other care providers work together to monitorpatients on medications. The purpose of monitoring is to evaluate the response tomedication, adjust the dosage or type of medication when needed and to evaluate thepatient for adverse effects. The organisation follows national regulations for the reporting of adverse effects.Doctors, nurses and pharmacists are expected to report reactions that are suspected to beadverse drug events, irrespective of whether the event is well recognised, potentially seriousor clinically "insignificant". There is a reporting process focused on the prevention of medication errors throughunderstanding the types of errors that occur. Improvements in medication processes andstaff training are used to prevent errors in the future. The pharmacy participates in such stafftraining.


Criterion 14.6.2.1


Compliance

NA NC PC C


Only those permitted by theorganisation and by relevantlaws and regulationsadminister medications.

Criterion 14.6.2.2

Critical: ¨Catg: Basic Process + Pat & StaffSafety

Compliance

NA NC PC C


There is evidence thatpatients are identified beforemedications areadministered.

Criterion 14.6.2.3


Compliance

NA NC PC C


Medications are checkedagainst the originalprescriptions andadministered as prescribed.






Criterion 14.6.2.4


Compliance

NA NC PC C


Health professionals monitormedication effects on patientscollaboratively.

Criterion 14.6.2.5


Compliance

NA NC PC C


Adverse Drug Reactions(ADR) are observed,recorded and reportedthrough a process and withina time frame defined by theorganisation.

Criterion 14.6.2.6


Compliance

NA NC PC C


Medication errors arereported through a processand within a time framedefined by the organisation.

Criterion 14.6.2.7


Compliance

NA NC PC C


The medications prescribedfor and administered to eachpatient are recorded.






14.6.3 StandardMedications are stored in a safe and clean environment.

Standard Intent: Patient care units store medications in a clean and safe environment thatcomplies with law, regulation and professional practice standards.


Criterion 14.6.3.1


Compliance

NA NC PC C


Medication is stored in alocked storage device orcabinet that is accessible onlyto authorised personnel.

Criterion 14.6.3.2


Compliance

NA NC PC C


Medications identified forspecial control (by law ororganisational policy) arestored in a cabinet ofsubstantial construction, forwhich only authorisedpersonnel have the keys.

Criterion 14.6.3.3

Critical: þCatg: Basic Process + Legality

Compliance

NA NC PC C


Medications identified forspecial control (by law ororganisational policy) areaccurately accounted for.

Criterion 14.6.3.4

Critical: þCatg: Basic Process + Pat & StaffSafety

Compliance

NA NC PC C


Medications are securely andlegibly labelled with relevantinformation as required bylaw and organisational policy.






Criterion 14.6.3.5


Compliance

NA NC PC C


Medications are stored in aclean environment.

Criterion 14.6.3.6


Compliance

NA NC PC C


Medication is stored inaccordance withmanufacturer’s instructionsrelating to temperature, lightand humidity.

Criterion 14.6.3.7


Compliance

NA NC PC C


A lockable refrigerator isavailable for thosemedications requiring storageat low temperatures.

Criterion 14.6.3.8


Compliance

NA NC PC C


The temperature of therefrigerator is monitored andrecorded.

Criterion 14.6.3.9


Compliance

NA NC PC C


Expiry dates are checked(including those ofemergency drugs) and drugsare replaced before expirydate.






14.7 Food and Nutrition Therapy14.7.1 Standard

Food and nutrition therapy appropriate for the patient and consistent with his or herclinical care is regularly available.

Standard Intent: A qualified caregiver orders appropriate food or other nutrients. The patientparticipates in planning and selecting foods and the patient's family may, when appropriate,participate in providing food. They are educated as to which foods are contraindicated,including information about any medications associated with food interactions. Whenpossible, patients are offered a variety of food choices consistent with their nutritional status. The nutritional status of the patients is monitored.


Criterion 14.7.1.1


Compliance

NA NC PC C


Food, appropriate to thepatient, is regularly available.

Criterion 14.7.1.2


Compliance

NA NC PC C


An order for food, based onthe patient’s nutritional statusand needs, is recorded in thepatient’s file.

Criterion 14.7.1.3


Compliance

NA NC PC C


When families provide food,they are educated about thepatient’s diet limitations.

Criterion 14.7.1.4


Compliance

NA NC PC C


Patients assessed as being atnutrition risk receive nutritiontherapy.






Criterion 14.7.1.5


Compliance

NA NC PC C


A collaborative process isused to plan, deliver andmonitor nutrition therapy.

Criterion 14.7.1.6


Compliance

NA NC PC C


Nutrition therapy provided,either oral or intravenous, iswritten in the patient’s record.

Criterion 14.7.1.7


Compliance

NA NC PC C


Response to nutrition therapyis monitored and recorded.






14.8 Patient and Family Education14.8.1 Standard

Education supports patient and family participation in care decisions andprocesses.

Standard Intent: Learning occurs when attention is paid to the methods used to educatepatients and families. The organisation selects appropriate educational methods and peopleto provide the education. Staff collaboration helps to ensure that the information patientsand families receive is comprehensive, consistent and as effective as possible. Education isfocused on the specific knowledge and skills that the patient and his or her family will needto participate and make decisions on how to continue with care at home. Variables likeeducational literacy, beliefs and limitations are taken into account. Each organisation decides on the placement and format for educational assessment,planning and delivery of information in the patient's record. Education is provided to supportcare decisions of patients and families. In addition, when a patient or family directlyparticipates in providing care, for example changing dressings, feeding and administration,they need to be educated. It is sometimes important that patients and families are made aware of any financialimplications associated with care choices, such as choosing to remain an inpatient ratherthan being an outpatient. Education in areas that carry high risk to patients is routinelyprovided by the organisation, for instance instruction in the safe and effective use ofmedications and medical equipment. Community organisations that support health promotion and disease prevention educationare identified and, when possible, on-going relationships are established.


Criterion 14.8.1.1


Compliance

NA NC PC C


Patients and families indicatethat they have been informedabout their diagnosis.

Criterion 14.8.1.2


Compliance

NA NC PC C


Patients indicate that theyhave been informed about themanagement of theircondition.






Criterion 14.8.1.3


Compliance

NA NC PC C


Patients are educated abouttheir diagnosis, relevant highhealth risks, e.g. safe use ofmedication and medicalequipment, medicine andfood interaction, diet and foodinteractions, defaulting onmedication use, etc.

Criterion 14.8.1.4


Compliance

NA NC PC C


Patients and families indicatethat they have been informedabout any financialimplications of care decisions.

14.9 Continuity of Care14.9.1 Standard

The organisation designs and carries out processes to provide continuity of patientcare services within the organisation and coordination among health professionals.

Standard Intent: As patients move through a health organisation from admission to discharge ortransfer, several departments and services and many different health service providers maybe involved in providing care. Without coordination and effective transfer of information andresponsibilities, errors of omission and commission may occur, exposing the patient toavoidable risks.


Criterion 14.9.1.1


Compliance

NA NC PC C


Policies and procedures thatguide the movement ofpatients within theorganisation areimplemented.

Criterion 14.9.1.2


Compliance

NA NC PC C


Individuals responsible for thepatient’s care and itscoordination are identified forall phases.






Criterion 14.9.1.3


Compliance

NA NC PC C


Continuity and coordinationare evident throughout allphases of patient care.

Criterion 14.9.1.4


Compliance

NA NC PC C


The record of the patientaccompanies the patientwhen transferred within theorganisation.

14.9.2 StandardThere is a process known to staff to appropriately refer patients for specialisedconsultation/investigation at other health facilities.

Standard Intent: In some cases, medical practitioners refer patients for a secondaryconsultation to confirm an opinion, to request more extensive diagnostic evaluations thanmay be available locally or to have patients receive specialised treatment that the referringorganisation may be unable to provide. The organisation must clearly describe the referralprocess, especially where patients are sent to another facility for specialist consultation orspecial investigations and then return to the original facility.


Criterion 14.9.2.1


Compliance

NA NC PC C


Policies and procedures thatguide the movement ofpatients for referral to anotherorganisation areimplemented.

Criterion 14.9.2.2


Compliance

NA NC PC C


A copy of the referral note isavailable in the patientrecord.






Criterion 14.9.2.3


Compliance

NA NC PC C


Follow-up care, based on thefindings ofinvestigations/consultationsperformed outside theorganisation are noted in thepatient record.

14.9.3 StandardThere is a process to appropriately transfer patients to another organisation to meettheir continuing needs.

Standard Intent: Transfer may be for specialised consultation at another health facility (thepatient returns to the referring facility after the consultation) and/or treatment or urgentservices, or for less intensive services such as sub-acute care or long-term rehabilitation. To ensure continuity of care, adequate information must accompany the patient. Transfermay be an uncomplicated process with the patient alert and talking, or may involvecontinuous nursing or medical supervision. The process for transferring the patient mustconsider transportation needs. The qualifications of the individual accompanying the patientmust be appropriate.


Criterion 14.9.3.1


Compliance

NA NC PC C


There is a documentedprocess for transferringpatients to otherorganisations.

Criterion 14.9.3.2


Compliance

NA NC PC C


The transferring organisationdetermines that the receivingorganisation can meet thepatient’s continuing careneeds and establishesarrangements to ensurecontinuity.

Criterion 14.9.3.3


Compliance

NA NC PC C


The process for transferringthe patient considerstransportation needs.






Criterion 14.9.3.4


Compliance

NA NC PC C


The process determines thatpatients are accompaniedand monitored by anappropriately qualified personduring transfer.

Criterion 14.9.3.5


Compliance

NA NC PC C


When a patient is transferredto another organisation, thereceiving organisation isgiven a written summary ofthe patient’s clinical conditionand the interventionsprovided by the referringorganisation.

Criterion 14.9.3.6


Compliance

NA NC PC C


A copy of the transfersummary is available in thepatient record.

Criterion 14.9.3.7


Compliance

NA NC PC C


The health organisationagreeing to receive thepatient is noted in thepatient’s record.






14.9.4 StandardThere is an organised process to appropriately discharge patients.

Standard Intent: The organisation begins to plan for the patient's continuing needs as early inthe care process as possible. Instructions for discharge and follow-up visits must be clearand provided in writing. The discharge summary is one of the most important documents to ensure continuity of careand facilitate correct management at subsequent visits. Information provided by theorganisation may include when to resume daily activities, preventive practices relevant tothe patient's condition and, when appropriate, information on coping with disease ordisability.The summary contains at least:a) the reason for admissionb) the diagnosis of main and significant illnessesc) the results of investigations that will influence further managementd) all procedures performede) the patient's condition at dischargef) discharge medicationsg) follow-up arrangements.


Criterion 14.9.4.1


Compliance

NA NC PC C


There is a documentedprocess to appropriatelydischarge patients.

Criterion 14.9.4.2


Compliance

NA NC PC C


The organisation works withthe family, health practitionersand agencies outside theorganisation to ensure timelyand appropriate discharge.

Criterion 14.9.4.3


Compliance

NA NC PC C


Patients and, as appropriate,their families are givenunderstandable follow-upinstructions and this is notedin the patient’s record.






Criterion 14.9.4.4


Compliance

NA NC PC C


A discharge summary, whichincludes at least items a) to g)in the intent statement, iswritten by the medicalpractitioner when eachpatient is discharged.

Criterion 14.9.4.5


Compliance

NA NC PC C


Each record contains a copyof the discharge summary.






14.10 Quality Improvement14.10.1 Standard

A formalised proactive quality improvement approach is maintained in the service.

Standard Intent: This refers to the implementation of organisational quality improvementprocesses (Service Element 8). It is the responsibility of management of the organisation to ensure that standards are setthroughout the organisation. Within each department or service, it is the responsibility ofmanagers to ensure that standards are set for the particular department. This requirescoordination with the organisation's central/management/coordinating quality improvementstructures or systems. Departmental managers use available data and information toidentify priority areas for quality monitoring and improvement.Quality monitoring could include:a) patient assessmentb) mortality and morbidity ratesc) surgical procedures carried outd) the use of antibiotics and other medications and medication errorse) the use of anaesthesiaf) the use of blood and blood productsg) patient and family expectations and satisfaction. The following will be evaluated:• problems identified in this service for which quality improvement activities were initiated• the processes put in place to resolve the problems• the identification of indicators to measure improvement• the tool(s) used to evaluate these indicators• the monitoring of these indicators and corrective steps taken when goals were notachieved• graphed and/or tabled results, as appropriate.


Criterion 14.10.1.1


Compliance

NA NC PC C


There are formalised qualityimprovement processes forthe service that have beendeveloped and agreed uponby the personnel of theservice.

Criterion 14.10.1.2


Compliance

NA NC PC C


Indicators of performance areidentified to evaluate thequality of treatment andpatient care.






Criterion 14.10.1.3


Compliance

NA NC PC C


The quality improvementcycle includes the monitoringand evaluation of thestandards set and theremedial action implemented.

Criterion 14.10.1.4


Compliance

NA NC PC C


A documentation auditsystem is in place.

14.11 Patient Rights14.11.1 Standard

The department/service implements processes that support patient and family rightsduring care.

Standard Intent: This refers to the implementation of organisational policies on patient andfamily rights (Service Element 5). Compliance will be verified during observation of patientcare processes, patient record audits and patient interviews.


Criterion 14.11.1.1


Compliance

NA NC PC C


There are processes thatsupport patient and familyrights during care.

Criterion 14.11.1.2


Compliance

NA NC PC C


Measures are taken to protectthe patient’s privacy, personand possessions.






Criterion 14.11.1.3


Compliance

NA NC PC C


The personnel respect therights of patients and familiesto treatment and to refusetreatment.

14.12 Prevention and Control of Infection14.12.1 Standard

The department/service implements infection prevention and control processes.

Standard Intent: This refers to the implementation of organisational processes for infectionprevention and control (Service Element 9).


Criterion 14.12.1.1


Compliance

NA NC PC C


The department identifies theprocedures and processesassociated with the risk ofinfection and implementsstrategies to reduce risk.

Criterion 14.12.1.2


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of respiratory tractinfections.

Criterion 14.12.1.3


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of urinary tractinfections.






Criterion 14.12.1.4


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of infection throughintravascular invasivedevices.

Criterion 14.12.1.5


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of infection throughsurgical wounds.

14.13 Risk Management14.13.1 Standard

The department/service implements risk management processes.

Standard Intent: This refers to the implementation of organisational risk managementprocesses. (Service Element 7).


Criterion 14.13.1.1


Compliance

NA NC PC C


The department conducts on-going monitoring of risksthrough documentedassessments as part oforganisational riskmanagement processes.

Criterion 14.13.1.2


Compliance

NA NC PC C


A system for monitoringincidents/nearmisses/sentinel/adverseevents is available andincludes the documentation ofinterventions and responsesto recorded incidents.






Criterion 14.13.1.3


Compliance

NA NC PC C


Security measures are inplace and are implemented toensure the safety of patients,personnel and visitors.

Criterion 14.13.1.4


Compliance

NA NC PC C


Fire safety measures areimplemented.

Criterion 14.13.1.5


Compliance

NA NC PC C


The organisation’s policy onhandling, storing anddisposing of health waste isimplemented.
