STANDARDS FOR HOSPITALS - Gov

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

17.Theatre and Anaesthetic Services

GUIDE TO COMPLETION OF FORM

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17.1 Coordination of Patient Care17.1.1 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 17.1.1.1

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 17.1.1.2

Critical: ¨Catg: Basic Management + Legality

Compliance

NA NC PC C


The individuals responsiblefor the patient's care arequalified.

Criterion 17.1.1.3


Compliance

NA NC PC C


The individuals responsiblefor the patient's care areidentified and made known tothe patient and otherpersonnel.






17.1.2 StandardThe operating theatre and anaesthetic services are managed and staffed to providea safe and effective service.

Standard Intent: Theatre management personnel work with organisation leaders to ensureadequate and suitable management processes and staffing of the theatre, anaestheticservice and recovery room. The qualifications of those persons who administer anaesthesia in the hospital aredocumented in accordance with current professional society standards. There may not be aformally constituted committee, but the function must be performed at some level, forexample, in the private sector there are clinical forums where medical practitioners meetwith management. These forums include representatives of the theatre nursing staff. Privileges assigned to individuals may not be documented, but the organisation placesrestrictions on who may administer anaesthetics. In the private sector, privileging is impliedby the fact that anaesthetists are allowed to provide services in an organisation only oncetheir credentials have been checked. The patient has the right not to be subjected to prolonged anaesthesia for the surgeon'sconvenience.


Criterion 17.1.2.1


Compliance

NA NC PC C

Default Severity for NC or PC = 3Serious

There is a Theatre Users'Committee or equivalent,which meets regularly andconsists of representatives of,for example, the surgicalstaff, the anaesthetic staff,the nursing staff andorganisational management.

Criterion 17.1.2.2


Compliance

NA NC PC C


A senior professional who issuitably qualified andexperienced is in charge ofthe theatre and the recoveryarea.

Criterion 17.1.2.3


Compliance

NA NC PC C


Operating theatre rostersensure that registered nurseswith suitable qualificationsand experience are presentduring all shifts for theatreduties, anaestheticassistance and for recoveryroom duties.






Criterion 17.1.2.4

Critical: þCatg: Basic Management +Efficiency

Compliance

NA NC PC C


Anaesthesia is administeredonly by a qualifiedanaesthesiologist or qualifiednurse anaesthetist.

Criterion 17.1.2.5


Compliance

NA NC PC C


Trainee anaesthetists areunder the supervision oftrained anaesthesiologists.

Criterion 17.1.2.6


Compliance

NA NC PC C


The person administeringanaesthesia is directlyresponsible for only oneanaesthetic at a time.

Criterion 17.1.2.7


Compliance

NA NC PC C


Anaesthesia is commencedand terminated only in thepresence of a member of thestaff whose sole duty it is toassist the personadministering anaesthesiauntil such time as the latterindicates that assistance is nolonger required.

Criterion 17.1.2.8


Compliance

NA NC PC C


The surgeon performing theprocedure(s) is availablebefore the anaesthetistcommences administering theanaesthetic.






Criterion 17.1.2.9


Compliance

NA NC PC C


There is at least one suitablytrained and experiencedanaesthetic nurse peroperating theatre.

Criterion 17.1.2.10


Compliance

NA NC PC C


Nursing personnel who aretrained in recovery room careare available until the patienthas fully recovered.






17.2 Facilities, Equipment, Supplies and Medication17.2.1 Standard

Facilities for safe surgical and anaesthetic care are provided and maintained.

Standard Intent: The design of the operating theatre provides space for the reception,anaesthesia, surgery, recovery and observation of patients. There are areas for the disposal and collection of used equipment and health waste,including contaminated waste and sharps. Safe and adequate storage space forpharmaceutical and surgical supplies is available, including separate lockable cupboardsfor schedule 1 (Habit Forming Drugs) substances and other scheduled medicines and forinflammables, according to country-specific regulations. Theatre personnel are provided with office facilities or a day station, a restroom,washrooms, toilets, changing facilities and a separate space for their personal clothing andtheatre clothing. There are facilities for scrubbing-up procedures in each theatre, with hot and cold runningwater and elbow-operated taps. There is an anaesthetist's chair, an operating table withTrendelenburg position control, at least one lateral padded straight arm support and aninfusion pole. Equipment for patients awaiting surgery includes blood pressure monitoringequipment, vacuum points with ancillary fittings and oxygen points with flowmeters and allancillary fittings. Space and facilities are available for setting up surgical trays and forautoclaving instruments.


Criterion 17.2.1.1

Critical: ¨Catg: Basic Management +Physical Struct

Compliance

NA NC PC C


The design of the operatingtheatre complex providesspace for the reception,anaesthesia, surgery,recovery and observation ofpatients.

Criterion 17.2.1.2


Compliance

NA NC PC C


There is direct access to theoperating theatres from thereceiving, scrubbing-up andrecovery areas.






Criterion 17.2.1.3


Compliance

NA NC PC C


The accommodation forpatients awaiting surgery issuitably equipped.

Criterion 17.2.1.4


Compliance

NA NC PC C


There is safe and adequatestorage space forpharmaceutical and surgicalsupplies.

Criterion 17.2.1.5


Compliance

NA NC PC C


Access to the theatre suites iscontrolled.

Criterion 17.2.1.6


Compliance

NA NC PC C


There is access tosterilisation and disinfectionfacilities.

Criterion 17.2.1.7


Compliance

NA NC PC C


There is a system forcontrolling the environmentaltemperature and humidity thatensures safe limits foranaesthetised patients(temperature between 22 and25 degrees Celcius andrelative humidity between40% and 70%).






Criterion 17.2.1.8

Critical: þCatg: Basic Management +Physical Struct

Compliance

NA NC PC C


Where resuscitation,intensive care, life support orcritical monitoring equipmentwithout built-in battery backupunits is used, there is anuninterruptible power supply(UPS) which complies withrelevant requirements and isregularly serviced and tested.

Criterion 17.2.1.9


Compliance

NA NC PC C


There is either an UPS or abattery backup system for thetheatre lamp which isregularly tested, with suchtests being fully documented.

Criterion 17.2.1.10


Compliance

NA NC PC C


The theatre has a lockablerefrigerator for medications,the temperature of which ismeasured and recorded daily.






17.2.2 StandardAnaesthetic equipment, supplies and medications used comply with therecommendations of anaesthetic professional organisations or alternateauthoritative sources.

Standard Intent: Anaesthetic risks are significantly reduced when appropriate and well-functioning equipment is used to administer anaesthesia and monitor the patient. Adequatesupplies and medications are also available for planned use and emergency situations.Each organisation understands the required or recommended equipment, supplies andmedications needed to provide anaesthetic services to its patient population.Recommendations on equipment, supplies and medications can come from a governmentagency, national or international anaesthetic professional organisations or otherauthoritative sources. There is an equipment maintenance programme.


Criterion 17.2.2.1


Compliance

NA NC PC C


The recommendations ofanaesthetic professionalorganisations or alternateauthoritative sources guidethe provision and use ofanaesthetic mixturecomponents.

Criterion 17.2.2.2


Compliance

NA NC PC C


The recommendations ofanaesthetic professionalorganisations or alternateauthoritative sources guidethe provision and use ofbreathing circuits.

Criterion 17.2.2.3


Compliance

NA NC PC C


The recommendations ofanaesthetic professionalorganisations or alternateauthoritative sources guidethe use of scavengingequipment for removingvapours and anaestheticgases.






Criterion 17.2.2.4


Compliance

NA NC PC C


The recommendations ofanaesthetic professionalorganisations or alternateauthoritative sources guidethe provision and use ofmonitoring equipment.

Criterion 17.2.2.5


Compliance

NA NC PC C


The recommendations ofanaesthetic professionalorganisations or alternateauthoritative sources guidethe provision and use ofancillary equipment.

Criterion 17.2.2.6

Critical: ¨Catg: Basic Management + PatientCare

Compliance

NA NC PC C


Recommended medicationsare used.

Criterion 17.2.2.7


Compliance

NA NC PC C


A medication trolley isavailable for the exclusiveuse of the anaesthesiologistin each theatre.

Criterion 17.2.2.8


Compliance

NA NC PC C


A tracheotomy tray isavailable.






Criterion 17.2.2.9


Compliance

NA NC PC C


Theatre personnel ensurethat all equipment is includedin the organisation’sequipment replacement andmaintenance programme.

17.2.3 StandardEmergency and protective equipment are provided in the operating theatre.

Standard Intent: Theatre staff must prepare for any emergencies through the provision ofemergency and protective equipment.


Criterion 17.2.3.1


Compliance

NA NC PC C


Emergency resuscitationequipment is available andfunctional.

Criterion 17.2.3.2

Critical: ¨Catg: Basic Process + Efficiency

Compliance

NA NC PC C


Emergency resuscitationequipment shows evidence ofregular checking.

Criterion 17.2.3.3


Compliance

NA NC PC C


There is a mechanism forsummoning assistance in anemergency.






Criterion 17.2.3.4


Compliance

NA NC PC C


There is appropriate shieldingand protective clothing in thepresence of biohazards(including lasers) orradiographic equipment.

Criterion 17.2.3.5


Compliance

NA NC PC C


Emergency and resuscitationequipment and supplies haveclearly defined instructions foruse.

Criterion 17.2.3.6

Critical: ¨Catg: Basic Process + Pat & StaffSafety

Compliance

NA NC PC C


Hazard or warning noticesare displayed.

17.2.4 StandardRecovery room facilities and equipment are available to provide safe and effectivecare.

Standard Intent: The number of beds/trolley spaces in the recovery room provides sufficientspace for at least one patient from each operating theatre that it services and is sufficient forpeak loads. The provision, use and maintenance of recovery room equipment comply withthe guidelines for practice of the professional society.


Criterion 17.2.4.1


Compliance

NA NC PC C


The recovery area forms partof the operating suite.






Criterion 17.2.4.2


Compliance

NA NC PC C


There is an adequate numberof recovery beds for thepatients from the operatingtheatre.

Criterion 17.2.4.3


Compliance

NA NC PC C


There is adequate lighting.

Criterion 17.2.4.4


Compliance

NA NC PC C


The provision, use andmaintenance of recoveryroom equipment comply withthe guidelines for practice ofthe relevant professionalsociety.






17.3 Clinical Practice Guidelines17.3.1 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 to providingguidelines for high risk, high volume and high cost conditions as these will form the basis forstructured 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 17.3.1.1

Critical: ¨Catg: Basic Process + Patient Care

Compliance

NA NC PC C


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

Criterion 17.3.1.2

Critical: ¨Catg: Evaluation + Patient Care

Compliance

NA NC PC C


The implementation ofguidelines is monitored aspart of a structured clinicalaudit.

Criterion 17.3.1.3

Critical: ¨Catg: Evaluation + Efficiency

Compliance

NA NC PC C


Guidelines are reviewed andadapted on a regular basis.






17.4 Policies and Procedures17.4.1 Standard

Policies and procedures relating to the activities in the operating theatre aredeveloped and implemented.

Standard Intent: Policies and procedures are necessary to guide the administration of theoperating theatre and anaesthetic services to ensure the smooth operation of those servicesand to ensure that the personnel act swiftly and in a coordinated manner in an emergency.Those policies and procedures are made available to all theatre, recovery room andanaesthetic personnel and are known and implemented. Biohazards, which need to bemonitored and notified, include radiation, laser and electrical hazards. Policies andprocedures are available to ensure that informed consent is documented and the patient iscorrectly identified; they also make sure that the nature of surgery and the site are correctlydocumented. Processes during the surgery such as the use of instruments and countingprocedures are documented to ensure coordination and safety.


Criterion 17.4.1.1


Compliance

NA NC PC C


Written policies andprocedures that guide theactivities of the theatre andanaesthetic services areimplemented.

Criterion 17.4.1.2


Compliance

NA NC PC C


Policies and procedures thatrelate to the duties of thetheatre and recovery roomnurses are implemented.

Criterion 17.4.1.3

Critical: þCatg: Basic Management + PatientCare

Compliance

NA NC PC C


Policies and procedures thatrelate to the preparation ofpatients for surgery areimplemented.






Criterion 17.4.1.4


Compliance

NA NC PC C


Policies and procedures thatrelate to theatre cleaning areimplemented.

Criterion 17.4.1.5


Compliance

NA NC PC C


Policies and procedures thatrelate to the notification ofbiohazards are implemented.

Criterion 17.4.1.6


Compliance

NA NC PC C


Policies and procedures thatrelate to medicationsidentified for special controlby law or organisationalpolicy are implemented.

Criterion 17.4.1.7


Compliance

NA NC PC C


Policies and procedures thatrelate to patient positioningare implemented.






17.4.2 StandardPolicies and procedures are developed relating to the preparation of patients forsurgery.

Standard Intent: Policies and procedures are available to ensure that informed consent isdocumented and the patient is correctly identified; they also make sure that the nature ofsurgery and the site are correctly documented. Processes during the surgery such as theuse of instruments and counting procedures are documented to ensure coordination andsafety.


Criterion 17.4.2.1


Compliance

NA NC PC C


Policies and proceduresrelating to the scheduling ofpatients for listed andemergency surgicalprocedures are implemented.

Criterion 17.4.2.2


Compliance

NA NC PC C


Policies and proceduresrelating to the patientidentification areimplemented.

Criterion 17.4.2.3

Critical: þCatg: Basic Management + PatientCare

Compliance

NA NC PC C


Policies and proceduresrelating to the verification ofthe nature and site of theoperation are implemented.

Criterion 17.4.2.4


Compliance

NA NC PC C


Policies and proceduresrelating to the verification ofthe last oral intake areimplemented.






Criterion 17.4.2.5


Compliance

NA NC PC C


Policies and proceduresrelating to the checking ofconsent documents areimplemented.

Criterion 17.4.2.6


Compliance

NA NC PC C


Policies and proceduresrelating to specifying theinstruments required forspecific operations areimplemented.

Criterion 17.4.2.7


Compliance

NA NC PC C


Policies and proceduresrelating to aseptic techniquesare implemented.

Criterion 17.4.2.8


Compliance

NA NC PC C


Policies and proceduresrelating to intra-operativerecording required areimplemented.

Criterion 17.4.2.9


Compliance

NA NC PC C


Policies and proceduresrelating to the recording oftissue(s) and specimen(s)collected are implemented.






Criterion 17.4.2.10


Compliance

NA NC PC C


Policies and proceduresrelating to the countingprocedures for swabs,instruments and needles, andprocedures to be adopted inthe event of incorrect counts,are implemented.

17.4.3 StandardPolicies and procedures are developed relating to the anaesthetic service.

Standard Intent: Guidelines of professional societies and associations are available andfollowed whenever anaesthesia is administered. Implementing these guidelines isparticularly important with regard to the qualifications, training and experience needed bypersonnel in the service. This includes the nurses who assist the anaesthetist and whomonitor the recovery of patients. Implementing these guidelines is also particularly importantwith regard to the provision, maintenance and use of medical equipment and drugs. Controlling bodies also develop guidelines and regulations relating to professional practice.


Criterion 17.4.3.1


Compliance

NA NC PC C


Policies and proceduresrelating to the requiredqualifications of persons whoadminister anaesthetics andof persons who assist theanaesthetist areimplemented.

Criterion 17.4.3.2


Compliance

NA NC PC C


Policies and proceduresrelating to the pre-operativeassessment and pre-medication are implemented.

Criterion 17.4.3.3


Compliance

NA NC PC C


Policies and proceduresrelating to the administrationof anaesthesia areimplemented.






Criterion 17.4.3.4


Compliance

NA NC PC C


Policies and proceduresrelating to assessing thefitness of patients to leave therecovery area areimplemented.

Criterion 17.4.3.5


Compliance

NA NC PC C


Policies and procedurescomply with currentguidelines of relevantprofessional bodies.

17.4.4 StandardPolicies and procedures guide the care of patients undergoing moderate and deepsedation.

Standard Intent: Sedation, in particular moderate and deep sedation, poses risks to patientsand thus needs to be provided using clear definitions, policies and procedures. The degreesof sedation occur on a continuum, and a patient may progress from one degree to anotherbased on the medications administered, route and dosages. Important considerationsinclude the patient's ability to maintain protective reflexes, an independent, continuouspatent airway, and to respond to physical stimulation or verbal commands. Sedation policies and procedures indicate:a) how planning will occur and will include the identification of differences between adultand paediatric populations, or other special considerationsb) documentation required for the care team to work and communicate effectivelyc) special content considerations, if appropriated) patient monitoring requirementse) special qualifications or skills of staff involved in sedation processesf) the availability and use of specialised equipment.


Criterion 17.4.4.1


Compliance

NA NC PC C


Policies and procedures thataddress at least elements a)to f) of the intent statementregarding the care of patientsundergoing moderate anddeep sedation areimplemented.






Criterion 17.4.4.2


Compliance

NA NC PC C


There is a pre-sedationassessment, according toorganisation policy, toevaluate risk andappropriateness of thesedation for the patient.

Criterion 17.4.4.3

Critical: þCatg: Basic Process + Patient Care

Compliance

NA NC PC C


A qualified individual monitorsthe patient during sedationand during the period ofrecovery from sedation anddocuments the monitoring.

Criterion 17.4.4.4


Compliance

NA NC PC C


Moderate and deep sedationare administered according toorganisation policy.






17.5 Anaesthetic Care17.5.1 Standard

A pre-anaesthetic assessment is conducted and recorded.

Standard Intent: Because anaesthesia carries a high level of risk, its administration is carefullyplanned. The patient's pre-anaesthetic assessment is the basis for that plan and for the useof post-operative analgesia. The pre-anaesthetic assessment provides information neededto:• select the type of anaesthesia to be administered and plan anaesthetic care• identify any drug sensitivities• safely administer the appropriate anaesthetic, and• interpret the findings of patient monitoring. An anaesthesiologist or other qualified individual conducts the pre-anaesthetic assessment. Anaesthetic care is carefully planned and documented in the anaesthetic record. The planconsiders information from other patient assessments and identifies the anaesthetic to beused, the method of administration, other medications and fluids, monitoring procedures andanticipated post-anaesthetic care. The anaesthetic planning process includes education of the patient and his or her family ordecision-maker regarding the risks, potential complications and options related to theplanned anaesthesia and post-operative analgesia. This discussion occurs as part of theprocess of obtaining consent for anaesthesia. The anaesthesiologist or the qualifiedindividual who will administer the anaesthetic provides this education.


Criterion 17.5.1.1


Compliance

NA NC PC C


Patients have an anaestheticassessment performed beforethe administration ofanaesthesia.

Criterion 17.5.1.2


Compliance

NA NC PC C


The medical assessment ofsurgical patients isdocumented before the startof the anaesthesia.

Criterion 17.5.1.3


Compliance

NA NC PC C


The patient, family anddecision-makers areeducated regarding the risks,potential complications of andoptions related to theanaesthesia.






Criterion 17.5.1.4


Compliance

NA NC PC C


The anaesthesiologist orother qualified individualprovides that education.

17.5.2 StandardEach patient's physiological status is monitored and recorded during anaesthesiaand surgery.

Standard Intent: The anaesthetist monitors and records the physiological status of the patientduring anaesthesia and enters the drugs and intravenous fluids used, and the anaesthetic,in the patient's anaesthetic record. The anaesthetist has access to the patient care notes and is familiarised with the findings ofthe medical examination. It is important that each health professional has access to therecords of other care providers, in accordance with organisational policy. All the criteria related to this standard will be assessed by undertaking an audit of randomlyselected records of patients who have undergone surgical procedures. If copies of the intra-operative records are not available in the patient records, it must beestablished if they are kept elsewhere, e.g. by the anaesthetists. Wherever the records are kept, documented evidence will be sought and the criteria markedaccording to findings.


Criterion 17.5.2.1


Compliance

NA NC PC C


The patient's physiologicalstatus is continuouslymonitored during theanaesthesia and surgery.

Criterion 17.5.2.2


Compliance

NA NC PC C


The results of suchmonitoring are entered intothe patient’s record.






Criterion 17.5.2.3


Compliance

NA NC PC C


The anaesthetic used isentered into the patient'sanaesthetic record.

17.5.3 StandardThere is a system to monitor and document each patient’s post-anaesthetic statusand to discharge the patient from the recovery area according to acceptedguidelines.

Standard Intent: Physiological monitoring provides reliable information about the patient's statusduring the administration of anaesthesia and the recovery period. Monitoring methodsdepend on the patient's pre-anaesthetic status, anaesthetic choice and the complexity of thesurgical or other procedures performed during anaesthesia. In all cases, however, themonitoring process is continuous and the results are entered into the patient's record. Monitoring during anaesthesia provides the basis for monitoring during the post-anaestheticrecovery period. The ongoing, systematic collection and analysis of data on the patient'sstatus in recovery may support decisions about moving the patient to other settings and lessintensive services. Only a suitably qualified and experienced registered nurse or adesignated member of the medical staff may carry out monitoring in the recovery area.Recording of monitoring data provides the documentation to support discharge decisions. Patients are discharged from the post-anaesthesia recovery area in the following ways:a) The patient is discharged by a fully qualified anaesthetist or other individual authorisedby the individual(s) responsible for managing the anaesthetic serviceb) The patient is discharged by a nurse or similarly qualified individual in accordance withpost-anaesthesia criteria developed by the organisation's leaders and the discharge isdocumented in the patient's recordc) The patient is discharged to a unit which has been designated as appropriate for post-anaesthesia or post-sedation care of selected patients, such as an intensive care unit. The time of arrival in and discharge from the recovery area are recorded. Signatures ofthose who hand over and those who receive the patient are recorded.


Criterion 17.5.3.1


Compliance

NA NC PC C


The anaesthetist isresponsible for supervisingthe recovery period.






Criterion 17.5.3.2


Compliance

NA NC PC C


Monitoring is appropriate tothe patient's condition duringthe post-anaesthetic recoveryperiod.

Criterion 17.5.3.3


Compliance

NA NC PC C


The qualifications andexperience of staff memberswho may monitor patients aredocumented.

Criterion 17.5.3.4


Compliance

NA NC PC C


Monitoring findings areentered into the patient'srecord.

Criterion 17.5.3.5


Compliance

NA NC PC C


Established criteria are usedto make decisions todischarge patients from therecovery room.

Criterion 17.5.3.6


Compliance

NA NC PC C


The individual responsible fordischarging the patientaccording to items a) and b)in the intent statement signsthe discharge in the patientrecord.






Criterion 17.5.3.7


Compliance

NA NC PC C


Recovery area arrival anddischarge times are recorded.

Criterion 17.5.3.8


Compliance

NA NC PC C


Signatures of those handingover and of those receivingthe patient are recorded.






17.6 Quality improvement17.6.1 Standard

A formalised proactive quality improvement approach is maintained in the theatreand anaesthetic services.

Standard Intent: This refers to the implementation of organisational quality improvementprocesses (Service Element 8). It is the responsibility of the management of the organisation to ensure that standards areset throughout 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 managementstructures or systems. Departmental managers use available data and information toidentify priority areas for quality monitoring and improvement. Quality monitoring could include items from the WHO Surgical Safety Checklist(www.safesurg.org) such as:a) surgical site infectionb) unplanned return to the operating theatrec) surgical deathsd) case lengthe) length of the operating dayf) the number of times blood was not available. 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• 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 17.6.1.1


Compliance

NA NC PC C


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

Criterion 17.6.1.2


Compliance

NA NC PC C


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






Criterion 17.6.1.3


Compliance

NA NC PC C


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

Criterion 17.6.1.4


Compliance

NA NC PC C


A documentation auditsystem is in place.

17.7 Patient Rights17.7.1 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 patient care processes, patient recordaudits and patient interviews.


Criterion 17.7.1.1


Compliance

NA NC PC C


There are processes thatsupport patient and familyrights during care.

Criterion 17.7.1.2


Compliance

NA NC PC C


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






Criterion 17.7.1.3


Compliance

NA NC PC C


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

17.8 Prevention and Control of Infection17.8.1 Standard

The department/service implements infection prevention and control processes.

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


Criterion 17.8.1.1


Compliance

NA NC PC C


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

Criterion 17.8.1.2


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of respiratory tractinfections.

Criterion 17.8.1.3


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of urinary tractinfections.






Criterion 17.8.1.4


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of infection throughintravascular invasivedevices.

Criterion 17.8.1.5


Compliance

NA NC PC C


Infection control processesinclude prevention of thespread of infection throughsurgical wounds.

17.9 Risk Management17.9.1 Standard

The department/service implements risk management processes.

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


Criterion 17.9.1.1


Compliance

NA NC PC C


The department conductsongoing monitoring of risksthrough documentedassessments as part oforganisational riskmanagement processes.

Criterion 17.9.1.2


Compliance

NA NC PC C


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






Criterion 17.9.1.3


Compliance

NA NC PC C


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

Criterion 17.9.1.4


Compliance

NA NC PC C


Fire safety measures areimplemented.

Criterion 17.9.1.5


Compliance

NA NC PC C


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


STANDARDS FOR HOSPITALS - Gov

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