Hope -On site Assessment Check List

 

LABORATORY        

                                   

·        Are PPE properly used while collecting blood samples?                        

·        Are samples identified properly?                           

·        Are the samples transported in a safe manner?                         

·        Is disposal of specimen done in a safe manner?                           

·        Is there any defined turnaround time for a test?                             

· Are laboratory personnel using appropriate safety equipment/ devices?                                

                                   

RADIOLOGY            

           

·        Are imaging personnel using appropriate safety equipment/ devices?                        

·        Is there any defined turnaround time for a test?

                                   

EMERGENCY           

                       

·        Are services being provided as per laid down Norms?                          

                                   

HDA               

           

· Is patient care is given as per the HCO’s documented procedure?                                 

·        Are staff in High dependency Areas adequate?                          

·       Do high dependency areas have adequate equipment (monitors, suction equipment, oxygen cylinders/central oxygen supply)?                         

                                   

OG     

                       

·        Does the hospital has measures to prevent child/ neonate abduction and abuse?

·        Is NICU present in the Obstetrics ward?                           

                                   

OT      

                       

·        Is pre-anesthesia assessment done by a qualified/trained anesthetist?                 

·        Is there a documented anesthesia plan following pre-anesthesia assessment?   

·        Is there immediate preoperative re-evaluation  done?                            

·        Is anesthesia monitoring done?                          

·        Is post anesthesia monitoring is done?                              

·        Is WHO Patient Safety Check List used to identify the right patient?                            

·        Is they are using the documented procedure as in their manual                             

·        Is OT Zoning done as Un-sterile, Semi-sterile, Sterile?                         

·        Is there monitoring of infection control practices?                                   

·        Are narcotic drugs used?                           

·       Is there a record of usage, administration and disposal of narcotic drugs?                 

·        Does the OT wash-up area have a no-touch hand wash facility?                        

                                   

WARD/PHARMACY            

           

·        Are there expired drugs in any patient care area?                                  

·        Is there any pharmacy/Stores present?                           

·        Are there any expired drugs in the pharmacy?                                  

·        Is the medication expiry date checked before dispensing?                               

·        Is there a list of emergency medications?                        

·        Is there a list of high-risk medications?                             

·        Are high-risk medications verified before dispensing?                            

·        Does the labeling of the drug have a name, UHID, dose, date strength when more than one drug is loaded before administration?                                

·   Is medication order checked for name, dosages, route, and timings before administration?

·        Is medication administration documented?                                  

·        Is fridge temperature record present?                              

                                   

PATIENT AND STAFF        

                       

·        Is privacy maintained during procedures?                                   

·        Are patients protected from physical abuse & neglect?                         

·        Is patient’s information confidential?                                 

·        Is patients consent taken before carrying out any procedure?                         

·        Is patient aware of how to voice a complaint?                             

· Does hospital inform patients about the expected cost of treatment?                                

·        Does patients have access to their clinical records?                                

·        Is patient aware of the plan of care, preventive aspects, possible complications, medications, the expected results, and cost as applicable?                        

                                   

 

WARD/EMERGENCY          

                       

·      Does hospital maintain cleanliness and general hygiene of areas/surfaces, furniture, fixtures and items used in inpatient care?                        

·        Does hospital adhere to standard precautions in all areas?                              

·        Does the hospital provide adequate gloves, masks, soaps, and disinfectants, and are they used correctly?                              

·     Are admissions or discharge to home or transfer to another organization is documented in emergency unit?                              

·        Are there adequate staff present in ICU ?                        

                                   

HRM  

                       

·     Are staff health related issues/problems taken care by the hospital?                           

·        Are staffs' personal files maintained?                                

·        Are occupational health hazards taken care of?                         

·        Does training occur when job responsibility changes?                           

·        Are past medical records of doctors retrievable?                        

·        In case of grievances, is any action taken to redress the same?                                 

·        Is staff aware of the disciplinary procedure?                          

·  Is staff able to demonstrate and take actions to report and eliminate/minimize risks?                                   

                                   

MRD  

                       

·        Does medical record have copy of death certificate?                             

·    Is the documented procedure for maintaining confidentiality, security and the integrity of information adhered?                             

·        Is any information disclosed without a patient authorization?                               

·        Is destruction of medical records as per HCO procedure?                                

·        Is fire extinguisher present?                                   

                                   

HOUSE KEEPING    

                       

·        Does staff know the procedure of cleaning non-infected patient's room?                   

·     Does staff know the procedure of cleaning infected patient's room ?                          

·        Does staff know the procedure of cleaning blood spill ?                        

·        Is the waste collected, segregated, transported and disposed as per the Biomedical Waste regulations ?                         

·        Does staff know the procedure of cleaning or washing the blood stained linen?                               

                                   

STERILISATION AREA

                                   

·    Are equipment cleaning, disinfection and sterilization practices adhered?                  

·    Are indicators used to monitor the effectiveness of the sterilization process?                          

·        Do the sterilized drums and trays have a date of expiry?                          

                                   

MANAGEMENT

                                   

·        Are requisite fee for BMW, related documents & reports submitted to competent authorities on stipulated date?                               

·        Do leaders/management guide the organization to function in an ethical manner ?  

·        Is any documented hospital mission present?                            

·       Are document for registration and admission of patient being maintained in OPD?   

·       Are document for registration and admission of patient being maintained in IPD?     

·        Are document for registration and admission of patient being maintained in Emergency?   

·        Is copy of basic Tariff List including bed charges, OT charges, ICU bed charges, packages, etc. present?                                

·        What is the parameter for patient identification?                          

·        Does the continous process of quality improvement programme and patient safety programme gets updated atleast once in a year?                            

·        cancer survivor meetings happening every 6 months to get the feedback to improve the quality of services                                 

                                   

MAINTENANCE AND BME

                       

·        Is Maintenance staff contactable round the clock for emergency repairs?                  

·  Does the hospital plan for equipment in accordance with its services?                                   

·        Is the documented operational and maintenance (preventive and breakdown) plan adhered?                              

                                   

MAINTENANCE AND FACILITY CHECKS                      

           

·        Are all the medical gas cylinders stored in racks or in chains?                          

·  Are fire/smoke detectors installed in patient care areas with fire-panel?                      

·        Are there fire extinguisher present in patient care areas?                                  

·        Is fire fighting equipment kept up-to-date?                                   

·        Does HCO have safe exit plan?                            

                                   

SAFETY MANAGEMENT   

                       

·        Are adequate safety devices available in the lab ?                                 

·        Are aprons and shields used for shielding of body parts of staff and patients?                      

·        Are TLD badges/dosimeters (as applicable) provided to each staff member in the radiation area?                        

·  Are there standardised colur coding of cylinders & medical gas pilelines?                  

·        Are there safe storage of medical gas cyclinders?                                 

                                   

AMBULANCE ACCESSIBILITY    

                       

·        Select the level of access available for the ambulance for patient drop off                  

·        Patient can be shifted on trolley directly from ambulance to emergency/ward bed    

·        Select the type of ownership of the ambulance                           

·        What is the total number of ambulance available?                                 

·        Is ambulance appropriately equiped ?                             

·        How many drivers for the ambulances are available?                            

·        ambulance is outsourced and there is MOU                                

·        How many doctors are available for the ambulances?                           

·        How many nurses are available for the ambulances?                            

                                   

           

UNIFORM SIGNAGE

                                   

·        Are scope of services present?                             

·        Are Patients’ rights & responsibility displayed?                            

·        Are there fire exit signage present?                                  

·        Are directional signages present?                         

·        Are departmental signages present?                                

                                   

DOCUMENTATION                         

                                   

·        Is document related to procedure(s) of collection, identification, handling, safe transportation, processing and disposal of specimens available and properly documented?

·        Is document showing process addresses discharge of all patients including Medico-legal cases and patients leaving against medical advice available and properly documented?          

·        Is document showing care of patients arriving in the emergency including handling of medico-legal cases available and properly documented?                                

·        Is document showing policies and procedures used to guide the rational use of blood and blood products available and properly documented?                           

·       Is document showing procedures to govern transfusion of blood and blood products available and properly documented?                                

·        Is document showing procedure for the administration of anaesthesia available and properly documented?                                   

·        Is document showing defined criteria to transfer the patient from the recovery area available and properly documented?                                

·        Is document showing procedure of prevention of adverse events like wrong site, wrong patient and wrong surgery available and properly documented?                             

·        Is document showing procedure for incorporating purchase, storage, prescription and dispensation of medications available and properly documented?                             

·        Is document showing procedure to address procurement and usage of implantable prostheses available and properly documented?                               

·        Is document showing policies and procedure exit for storage of medications available and properly documented?                                   

·        Is document showing policies and procedures to govern usage of radioactive drugs available and properly documented?                                

·        Is document showing Policies and procedures of safe storage, preparation, handling, distribution and disposal of radioactive drugs available and properly documented?     

·        Is Infection control manual showing periodic update and surveillance activities available and properly documented?                                   

·        Is document showing operational and maintenance (preventive and breakdown) plan for clinical and support service equipment available and properly documented?        

·        Is document showing a safe exit plan in case of fire and non-fire emergencies available and properly documented?                                   

·        Is document showing well-defined staff recruitment process available and properly documented?                        

·        Is document showing disciplinary and grievance handling procedure available and properly documented?                                   

·        Is document showing policies and procedures for maintaining confidentiality, integrity and security of records, data, and information available and properly documented?   

·        Is document showing procedures of exist for a retention time of medical records, data and information available and properly documented?                               

·        Is document showing define the process to whom the patient record can be released available and properly documented?                                

·        Is document showing procedure on the destruction of medical records available and properly documented?                                   

·        Photograph of signed document of Scope of Services                          

·        Photograph of the signed list of General Duty Medical Officers                               

·        Photograph of the signed list of Nurses                                  

·        Photograph of the signed list of Paramedical Staff: (OT, ECG, Radiology, PFT, Lab, Optometrist, EMG, Dialysis)                     

           

Photograph of the signed list of Administrative & Support Staff