Department Director/Manager’s Monthly Survey

Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.)

/

TJC

STANDARD /
Jan
/ Feb / Mar / Apr
1 /
Fire exits
  • Exit sign lights are working.
  • Exits are free of storage. Hallways are free of stretchers, equipment.Etc.
  • Fire doors close completely and are not propped opened (wedges) or latches taped open.
  • A site specific fire drill for the department has occurred in the last 3 months
  • Site specific fire drills for the department are conducted for all shifts
/ EC.02.03.01
EC.02.03.03
EC.02.03.05EC.02.05.05

LS.02.01.20

2 /
Fire extinguishers
  • Extinguishers are free from obstruction and are clearly visible
  • Securely mounted and updated with annual inspection
  • Travel distance from any point to nearest extinguisher is 75ft or less
/ EC.02.03.01
EC.02.03.05
LS.02.01.35
3 /
Storage materials
  • 18 inches from sprinkler heads, light fixtures, or the ceiling
  • Flammables stored in flame safe cabinets
  • Prohibits combustible decorations that are not flame retardant; doors with >3/4hr. rating no combustibles; informational signs only.
/ EC.02.03.01
LS.02.01.30
LS.02.01.35
LS.02.01.70
4 /
Fire safety
The employee can identify
  • The location of the nearest fire extinguisher, alarm pull station, and exit
  • Procedure to follow in the event of a fire (RACE)
  • How to properly use a fire extinguisher (PASS)
  • What the security emergency number is
  • The nearest location of an emergency telephone and flashlights
/ EC.02.03.01EC.02.03.03
5 /
Electrical safety
  • Staff can identify emergency power outlets
  • There is a 3 feet clearance of electrical panels;locked (NFPA 72)
  • Electrical outlets are covered
/ EC.02.05.01EC.02.05.03EC.02.05.05
EC.02.05.07
Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.)
/ TJC
STANDARD /
Jan
/ Feb / Mar / Apr
6 /

Emergency Preparedness: Staff can explain what the emergency codes mean, how the code is initiated and their specific responsibility

  • Code---(disaster), Code Red (fire), Code---(hazmat), Code---- (evacuation), Code---(bomb threat), Code---(recall of staff),
Code---- (rapid response team) / EM.01.01.01
7 /
Hazardous materials/Radiation safety
  • Supplies are available to clean-up a hazardous spill
  • Staff can explain what a MSDS is and how to report a spill
  • All staff who work with radiation are wearing required badges
  • Disposal of Hazardous wastes.
/ EC. 02.02.01
8 /
Required Manuals on unit or process to view via hospital intranet
  • Emergency Preparedness, MSDS, Ethics, Equipment
/ Does your Organization require this.
9 /
Performance Improvement
  • Staff can explain PI process: i.e., PDCA
Staff can explain the procedure to report an error or near miss
/ PI.01.01.01
LD.04.04.01
LD.04.04.05
10 /

Patient Safety: Staff can explain what the following patient safety codes mean, how the code is initiated and their specific responsibility

  • Code (abduction), Code (abandon-drop off baby)
  • Code (adult cardiac arrest), Code (child arrest), Code (infant arrest)
  • Staff has demonstrated knowledge of the national patient safety goals
/ EM.01.01.01
LD.04.04.03
LD.04.04.05
Current NPSG’s
11 /
Information Security
  • Staff can identify where the hospital security sensitive areas are located
  • There is no breach of computer security,
  • There is no breach of patient/employee confidentiality
/ EC.02.01.01
EC.02.01.03
IM.02.01.01
IM.02.01.03
RI.01.01.01
Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.)
/ TJC
STANDARD /
Jan
/ Feb / Mar / Apr
12 /

Equipment Safety

  • Maintenance completed on scheduled (Random check of 3 devices)
  • An up-to-date list of equipment inventory is available
  • All personal equipment must have inspections sticker
  • All equipment with clinical alarms can be tested; please demonstrate.
  • Broken equipment/furniture has been removed from unit/department
  • Staff can explain procedure for replacing broken equipment after hours and if an injury has occurred by a device.
/ EC.02.04.01
EC.02.04.03
EC.03.01.01
EC.04.01.01
13 /

Department appearance

Ceiling tiles are not stained

  • Wallpaper is not torn
  • Floors clean and free of spills, carpets are not stained
  • Handrails are mounted securely
  • Overall unit/department appearance is neat and organized. No loose papers are posted without coversheet
  • All rooms in department are clearly labeled

If patient care area – all patient supplies in appropriate locations.

/ EC.01.01.01
EC.02.02.01
EC.02.06.01
14 /
Employee appearance
  • All staff have ID badges on
  • Uniforms are clean and appropriate according to policy
  • Approved hair coverings are worn when appropriate
  • Shoe covers are not worn outside of approved areas
  • Staff is courteous and approachable
/ EC.02.01.01
IC.01.03.01
IC.02.03.01
LD.04.04.03
15 /
Competencies
  • 100% compliance for mandatory education: to be determined by organization; e.g. life safety 1st qtr, mission and values 2nd qtr, patient safety 3rd qtr, performance evals 4th qtr
  • 100% compliance for CPR for identified staff
  • 100% compliance for current licenses and annual PPDs
/ HR.01.05.03
HR.01.06.01
Complete this section only if you have oxygen or medical gases in your area.
Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.) / JCAHO
STANDARD /
Jan
/ Feb / Mar / Apr
16 / Medical gas cylinders (oxygen…)
  • Properly secured with a chain or cart
  • Secured during storage.
  • Full tanks are separated from empty tanks
  • Oxygen signs are displayed in rooms where oxygen is in use
  • There are not multiple anesthetic gases bottles opened in work areas
  • There is an accountability system in place for the storage, distribution, use and disposal of anesthetic gases
/ EC.01.01.01
EC.02.05.09
LS.01.02.01
17 /
Medical gas shutoff valves
  • Staff can explain who is responsible for medical gas shut-off valves
  • Staff can identify location of medical gas shut-off valves and areas that will affected
/ EC.01.01.01
EC.02.05.09
Complete this section only if it is a patient care/clinical area
18 /

Medication safety

  • Medication area is neat and organized
  • There are no sample medications are stored in the department
  • Multi-dose medication vials are dated when opened, initialed, and the date does not exceed 30 days
  • Multi-use ophthalmic solutions containers are dated and initialed after opening and the date does not exceed 30 days
  • Drugs that have been brought to hospital by patients are sent home with the family or sent to pharmacy. A physician order is obtained before the use of patient’s medication from home
  • All medications are stored in separate containers based on dosage form, separate bins, shelves, and pegs on a pegboard and have not expired
  • Syringes containing any injectable solution must be labeled with drug, concentration, date prepared and initialed
  • Medications are not stored with disinfectants or external solutions
  • Large volume infusion solutions are not left hanging in medication preparation room for multiple employee use to prepare flushes
/ MM.01.01.01MM.01.01.03
MM.02.01.01
MM.03.01.01
MM.03.01.05
MM.05.01.07
MM.05.01.09
NPSG.03.03.01
NPSG.03.04.01
Complete this section only if it is a patient care/clinical area
Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.) / JCAHO
STANDARD /
Jan
/ Feb / Mar / Apr
19 /

Medication carts

  • Carts with medications (including anesthesia…) are locked when unattended.
  • Narcotics are doubled locked
  • Medication carts stored remotely should have the ability to be secured to the building if they are left unattended
  • All medications are secured in the department (regardless of the department) and can not be diverted by unauthorized personnel They are not located on top of med cart, by the pneumatic tube or at patient desk areas
/ MM.03.01.01MM.03.01.03
NPSG.03.03 .01
20 /

Medication Administration System--Pyxis System,Omnicell, Accu-dose (if applicable)

  • User`IDs are not posted on or near dispensing cabinet
  • All discrepancies on the medication administration Rx cabinets are resolved prior to the end of the shift
  • Medication orders are accurate/clear
  • Proper labeling when medications administered at a later time
/ MM.04.01.01MM.05.01.01
MM.05.01.09MM.05.01.11
MM.06.01.01
NPSG.03.03.01
21 /

Narcotics

  • Narcotic sheet is signed by 2 licensed personnel
  • Narcotic keys are located on a licensed personnel
  • All controlled substance waste is documented on the narcotic record and signed by 2 licensed personnel
  • Controlled substance theoretical count and actual count is equal at all times
/ MM.03.01.01MM.03.01.03
MM.05.01.01
MM.06.01.01
Complete this section only if it is a patient care/clinical area
Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.) / TJC
STANDARD /
Jan
/ Feb / Mar / Apr
22 /

Medication refrigerator

  • Medication refrigerators free of food and/or drink, batteries, breast milk, and reagents
  • Medication refrigerator and freezer temperatures logged daily including weekends when medication is stored. The approved refrigerator range is 35-45 degrees
  • Medication refrigerator is defrosted
  • Medication refrigerators are locked
  • Refrigerated controlled substances are doubled locked
/ EC.01.01.01EC.02.04.03EC.02.06.01IC. 02.02.01MM.03.01.01
23 /

Biohazards

  • Sharps containers not more than 2/3rds full
  • Red biohazard bags sealed tightly when full
  • All biohazard waste containers are clearly labeled
  • Regular trash/bio-hazardous trash placed in the correct designated container.
/ EC.02.01.01EC.02.02.01
24 /

Waive testing

  • Glucose strips are stored appropriately
  • Glucose controls dated and completed
  • Hemoccult developer is not on unit
/ WT.01.01.01
WT.02.01.01
WT.03.01.01
WT.04.01.01
WT.05.01.01
25 /

Infection control

  • PPE is worn at all times when appropriate for universal precautions and isolation
  • Soap dispensers contain the appropriate soap.
  • Staff knows the location of PPE equipment.
  • Staff is observed practicing proper hand washing techniques.
  • Staff can demonstrate verification of NEGATIVE air pressure in a Negative Pressure Isolation Room.
/ EC.02.01.01EC.02.02.01
IC.01.04.01IC.02.02.01
IC.02.03.01
NPSG.07.01.01
Complete this section only if it is a patient care/clinical area
Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.) / TJC
STANDARD /
Jan
/ Feb / Mar / Apr
26 / Patient Nutrition:
  • Food/drink opened dated/initialed and no expired items are present
  • Refrigerator temperatures are documented
  • Refrigerator is clean and defrosted
  • Refrigerator is free of staff food or food from patient trays
  • Microwave is clean
/ EC.01.01.01EC.02.04.03
EC.02.06.01
IC.02.02.01
PC.02.02.03
27 /

Linen

  • Soiled linen placed in designated linen containers
  • Linen covered in all areas
  • Clean linen is not in dirty utility room
/ EC.01.01.01
IC.02.03.01
28 / Resuscitation Services
  • Crash cart is locked
  • Crash cart is reviewed every shift and documented on QC form
  • Crash cart lock number is the same number on QC form
  • Documentation present on QC form when cart has been used, restocked, and locked
  • Supplies in crash cart have not expired
  • Supplies in crash cart agree with content list of crash cart
/ MM.03.01.01MM.03.01.03
IC.02.02.01
29 /

Supplies

  • All supplies have not expired
  • All packs, sterile supplies, and kits containing medications bear a reminder label to check expiration date and lot number
  • All packs, sterile trays, and kits containing medications listed on a recall report have a copy of the report attached to the outside
  • Patient supplies are stored a minimum of 4 inches above the floor
  • Patient supplies are not in the dirty utility room
/ MM.03.01.01MM.03.01.03
IC.02.02.01
IC02.03.01
30 /

Nurses station

  • White boards do not break patient confidentiality
  • There is no food or drink present at the station
  • Patient Education materials are clearly labeled and staff can identify the location of them
/ IC.02.03.01IM.02.01.01
PC.02.03.01
PC.02.02.03
RI.01.01.01
RI.01.03.05
Complete this section only if it is a patient care/clinical area
Readiness Survey (Answer yes/no to each section. Complete an action plan for each identified issue.) / TJC
STANDARD /
Jan
/ Feb / Mar / Apr
31 /

Reference material (if utilized)

  • Medication safety manual on unit
  • A metric-apothecary conversion chart is present on all patient care areas
  • Current Medication manual
  • Current reference books
/ HR.01.06.01
Med Mgmt Stds.
32 /

Patient rooms/patient care areas

  • Patient’s rights manual located in every patient room
  • Beds have lockable casters
  • Call lights are in reach of patients
  • Patient curtains are hung properly and not soiled
  • Patient’s rights are respected. Staff knocks when entering a patient room. Privacy curtains are utilized
  • There are no medications stored at the bedside without a physician order
  • Sinks in patient areas are clear of supplies
/ EC.02.06.01
IC.02.03.01
MM.03.01.05
RI.01.01.01

Survey Performed by:______Date:______

Director’s Signature:______Date:______

Readiness Survey /Clinical Survey Action Plan

Date / Item # / Problem Identified / Action Plan / Date Implemented/Resolved
1
2
3
4
5
6
7
8
9
10
11
12

Revised: 8/09Page 1 of 10