Readiness Rounds Checklists

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Patient Safety, Quality of Care & Experience

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INDEX

1

3

4

6

9

10

12

14

16

High Reliability Platform

Overview

Closed Medical Record

Clinical Quality

Hand Hygiene

Restraints

Medication Management

Human Resources

Environment of Care

Patient Experience

Executive Leadership 18

Patient Care Rounding 20

Discharge Calling 22




Dashboard

Distribution

Executive Summary

Facility Dashboard

Checklists Dashboard

Department Dashboard

Physician Dashboard

Standards Dashboard

Executive Team / Board

Quality Management

Committee Review / Risk Management /

Quality

Department Managers

Medical Staff

Quality

Clinical Quality

Patient Experience

Operational Quality

Readiness Rounds High Reliability Platform

Event/Incident Management

1



2

The following are samples extracted from

Readiness Rounds Templates

3

Sample Hospital - Closed Med Record Review (5117)Checklist October 2013Survey

2N (077)13 10 077 2nd HospitalMainFloorArea BuildingCampus

Due Date

Oct 2013Date (mm/dd/yy)

/ /Reviewer First Name Reviewer Last Name

DEMOGRAPHICS/ADVANCE DIRECTIVES

Mark "Compliant" if the documentation is present. Filed - Location:

Unique Identifier0301 Follow-Up: Department CompliantNon CompliantAre the medical record number and account number documented on the facesheet? Std:

RC.01.01.01 EP4Instructions

N/ANot Scored

Mark "Compliant" if patient's full name is documented. Filed - Location:

Patient Name0302 Follow-Up: Department CompliantNon CompliantIs patient's full name present? Std: RC.02.01.01 EP1

Instructions

N/ANot Scored

Mark "Compliant if documentation is present. Filed - Location:

Patient's Sex0303 Follow-Up: Department CompliantNon CompliantIs sex of patient documented? Std: RC.02.01.01 EP1

Instructions

N/ANot Scored

Mark "Compliant" if date of birth is documented. Filed - Location:

Patient DOB0304 Follow-Up: Department CompliantNon CompliantIs patient's date of birth present? Std: RC.02.01.01 EP1

Instructions

N/ANot Scored

Mark "Compliant" if the address is documented. Filed - Location:

Patient Address0305 Follow-Up: Department CompliantNon CompliantIs patient's address present? Std: RC.02.01.01 EP1

Instructions

N/ANot Scored

Mark "Compliant" if documentation present in the medical record. Filed - Location:

Authorized Representative0306 Follow-Up: Department CompliantNon CompliantIs the name of name of any legally authorized representative documented in the medical record?

Std: RC.02.01.01 EP1Instructions

N/ANot Scored

Mark "Compliant" if documentation is present.Filed - Location:

Patient's Language0307 Follow-Up: Department CompliantNon CompliantIs the patient's preferred language documented? Std: RC.02.01.01 EP1, RI.01.01.03 EP1

Instructions

N/ANot Scored

Mark "Compliant" if documentation is present. Filed - Location:

Advance Directives0311 Follow-Up: Department CompliantNon CompliantDoes documentation in the medical record show that the patient was asked if they had an

advance directive? Std: RI.01.05.01 EP5Instructions

N/ANot Scored

Mark "Compliant" if documentation is present in the medical record. Filed - Location:

Advance directive documentation0309 Follow-Up: Department CompliantNon CompliantIt is documented whether or not the patient has an advance directive? Std: RI.01.05.01 EP9

Instructions

N/ANot Scored

Mark "Compliant" if the advance directive is present in the medical record. Filed - Location:

Advance Directive in Record0312 Follow-Up: Department CompliantNon CompliantIf the patient has an advance directive, then is the advance directive present in the medical

record? Std: RC.02.01.01 EP4, RI.01.05.01 EP5 ...Instructions

N/ANot Scored

Mark "Compliant" if documentation is present that the information was given tothe patient.Filed - Location:

Honor advance directives0308 Follow-Up: Department CompliantNon CompliantWas information on the extent to which the hospital is able, unable, or unwilling to honor

advance directives given to the patient? Std: RI.01.05.01 EP8Instructions

N/ANot Scored

ˆAcAD2j00CaR7|Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]

Readiness Rounds 5117.1310.169.3. 1

Version 2.74

Sample Hospital - Closed Med Record Review (5117)Checklist October 2013Survey


Due Date



ORDERS

Mark "Compliant" if all respiratory services are ordered by a physician and it isdocumented. Filed - Location:

Respiratory Services1015 Follow-Up: Department CompliantNon CompliantAre all respiratory services ordered by a doctor of medicine or osteopathy?

Instructions

N/ANot Scored


MD Name1003 Follow-Up: Department CompliantNon CompliantTelephone orders contain the name of the ordering physician.

Instructions

N/ANot Scored

Mark "Compliant" if the discharge order includes all of the above items. Filed - Location:

Discharge Order Written1007 Follow-Up: Medical Staff CompliantNon CompliantWas a discharge order written to include activity, diet, medications, special instructions and

follow-up? If no, add in the comments section what missing.PHY ID# ________________Instructions

N/ANot Scored

OPERATIVE PROCEDURES

Mark "Compliant" if pre-procedural treatment and services are documented. Filed - Location:

Pre-procedural treatment1219 Follow-Up: Medical Staff CompliantNon CompliantBefore operative or other high-risk procedures are initiated, or before moderate or deep sedation

or anesthesia is administered, the hospital provides the patient with pre-procedural treatmentand services, according to his or her plan of care and it is documented in the medical record.Std: PC.03.01.03 EP3Instructions

N/ANot Scored


48 hours prior1220 Follow-Up: Medical Staff CompliantNon CompliantIs there documentation present of a pre-anesthesia evaluation by an individual qualified to

administer anesthesia within 48 hours prior to surgery or a procedure requiring anesthesiaservice? Std: PC.03.01.03 EP18Instructions

N/ANot Scored


Plan of Anesthesia1213 Follow-Up: Medical Staff CompliantNon CompliantIt is documented that before administering moderate or deep sedation or anesthesia, a licensed

independent practitioner planned, or concurred with the plan for anesthesia. Std: PC.03.01.03EP7Instructions

N/ANot Scored

Mark "Compliant" if the pre-sedation or pre-anesthesia patient assessment wascompleted completed prior to the sedations/anesthesia and is documented. Filed - Location:

Pre Sedation Assessment1212 Follow-Up: Medical Staff CompliantNon CompliantIs a pre-sedation or pre-anesthesia patient assessment completed before moderate or deep

sedation or anesthesia? Std: PC.03.01.03 EP1Instructions

N/ANot Scored

Mark "Compliant" if reevaluation is documented. Filed - Location:

Anesthesia Reevaluation1222 Follow-Up: Department CompliantNon CompliantIs it documented that the patient was reevaluated immediately before administration of moderate

or deep sedation or anesthesia? Std: PC.03.01.03 EP8Instructions

N/ANot Scored

Mark "Compliant" if the pre procedure assessment is documented. Filed - Location:

Postprocedure care1218 Follow-Up: Medical Staff CompliantNon CompliantBefore operative or other high-risk procedures are initiated, or before moderate or deep sedation

or anesthesia is administered, the hospital assesses the patient's anticipated needs in order toplan for the post-procedure care. Std: PC.03.01.03 EP2Instructions

N/ANot Scored

ˆAcAD2j00CaRJ+Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 2.75

Sample Hospital - Basic INTRA (5125)Checklist October 2013Survey


Due Date



OPEN MEDICAL RECORD REVIEW

Mark "Compliant" if all of the above are documented in the medical record. Filed - Location:

Pt Educ-Anticoagulation Management0111 Follow-Up: Department Compliant (Yes)Non Compliant (No)For patients on anticoagulant therapy where the clinical expectation is that the patient's

laboratory values for coagulation will remain outside the normal values: Documentation that thepatient/family received anticoagulant therapy education regarding the importance of follow-upmonitoring, compliance issues, dietary restrictions and potential for adverse drug reactions andinteractions. Std: NPSG.03.05.01 EP7Instructions

Follow-Up Completed_

N/ANot Scored


Pt Educ-Falls0130 Follow-Up: Department Compliant (Yes)Non Compliant (No)Documentation that the patient and patient's family are educated on the fall reduction program

and any individual fall reduction strategies. Std: PC.01.02.08 EP2, PC.02.03.01 EP10Instructions


N/ANot Scored

Mark "Compliant" if documentation is found in the medical record. Filed - Location:

Pt Educ-Reporting Concerns0131 Follow-Up: Department Compliant (Yes)Non Compliant (No)Documentation that the patient/family are educated on available reporting methods for concerns

and complaints related to their care, treatment, services and patient safety issues. Std:PC.02.03.01 EP27, RI.01.07.01 EP7Instructions


N/ANot Scored

Mark "Compliant" if the above documentation is present in the medical record. Filed - Location:

Pt Educ-Infection Control0132 Follow-Up: Department Compliant (Yes)Non Compliant (No)Documentation that the patient/family was provided with information regarding infection control

measures for hand hygiene practices, respiratory hygiene practices, and contact precautionsaccording to the patient's condition within 24-48 hours or hospital entry. Std: IC.01.05.01 EP7,IC.02.01.01 EP7 ...Instructions


N/ANot Scored


Pt Educ-Surgery0133 Follow-Up: Department Compliant (Yes)Non Compliant (No)For Surgical Patients: Documentation that the patient/family was educated regarding measures

that will be taken to prevent adverse events in surgery (i.e. patient identification practices,prevention of surgical infections, marking of procedure sites). Std: NPSG.07.05.01 EP2,PC.03.01.03 EP4Instructions


N/ANot Scored

Mark "Compliant" if documentation is present in medical record. Filed - Location:

Pt Educ-Suicide Risk0136 Follow-Up: Department Compliant (Yes)Non Compliant (No)Documentation that information (i.e. crisis hotline) was provided to the patient at risk for suicide

and their family members. Std: NPSG.15.01.01 EP3Instructions


N/ANot Scored

Mark "Compliant" if education is documented.Filed - Location:

Pt Educ-Change Pt Condition0137 Follow-Up: Department Compliant (Yes)Non Compliant (No)Documentation of education for the patient/family on how they can seek assistance if they have

concerns about the patient's worsening condition. Std: PC.02.01.19 EP4Instructions


N/ANot Scored

ˆ9nAD4t00CaRS„Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 4.66



Due Date



OBSERVATION

Observe staff providing care. Mark "Compliant" if staff uses two patient identifiers.Acceptable identifiers may be the individual's name, an assigned identification number,telephone number, or other person-specific identifier. The patient's room number or physicallocation are not used as identifiers.

Patient ID-General0201 Follow-Up: Department Compliant (Yes)Non Compliant (No)Does staff use at least 2 patient identifiers when providing care, treatment or services (including

medications and blood transfusions)? Std: NPSG.01.01.01 EP1Instructions


N/ANot Scored

Observe staff providing care. Mark "Compliant" if staff actively involves thepatient/family/designated caregiver in the identification process. Acceptable identifiers may bethe individual's name, an assigned identification number, telephone number, or otherperson-specific identifier. The patient's room number or physical location are not used asidentifiers.

Patient ID-Pt Involvement0202 Follow-Up: Department Compliant (Yes)Non Compliant (No)Does staff actively involve the patient/family/designated caregiver in the identification process

prior to specimen collection, medication administration, transfusion, and/or treatment? Std:NPSG.01.01.01 EP1Instructions


N/ANot Scored

Mark "Compliant" if staff uses two patient identifiers. Acceptable identifiers maybe the individual's name, an assigned identification number, telephone number, or otherperson-specific identifier. The patient's room number or physical location are not used asidentifiers.

Patient ID-Specimens0203 Follow-Up: Department Compliant (Yes)Non Compliant (No)Does staff use two patient identifiers when collecting blood samples and other specimens for

clinical testing? Std: NPSG.01.01.01 EP1Instructions


N/ANot Scored

Observe meal trays being delivered. Mark ""Compliant"" if staff uses two patientidentifiers. Acceptable identifiers may be the individual's name, an assigned identificationnumber, telephone number, or other person-specific identifier. The patient's room number orphysical location is not used as an identifier."

Patient ID-Dietary0204 Follow-Up: Department Compliant (Yes)Non Compliant (No)Does staff use two patient identifiers when delivering diet trays? Std: NPSG.01.01.01 EP1

Instructions


N/ANot Scored

Observe a lab staff member. Mark "Compliant" if the lab staff labels the specimencontainer in in the presence of the patient.

Patient ID-Containers0205 Follow-Up: Department Compliant (Yes)Non Compliant (No)Are containers used for collection of blood and other specimens labeled by staff in the presence

of the patient? Std: NPSG.01.01.01 EP2Instructions


N/ANot Scored

Mark "Compliant" if staff member completed hand hygiene as above.

Hand Hygiene-General0210 Follow-Up: Department Compliant (Yes)Non Compliant (No)Do staff members wash hands before entering and upon exiting patient room? If hands are not

visibly soiled, did they use hospital approved hand antiseptic? Std: IC.02.01.01 EP2,NPSG.07.01.01 EP1Instructions


N/ANot Scored

Observe staff delivering a food tray. Mark " Compliant" if the staff memberwashed their hands after delivery of the food tray if patient care items or the patient is touched?

Hand Hygiene-Food0211 Follow-Up: Department Compliant (Yes)Non Compliant (No)Does staff wash hands after delivery of food trays if patient care items or the patient is touched?

Std: IC.02.01.01 EP2, NPSG.07.01.01 EP1Instructions


N/ANot Scored

ˆ9nAD4t00CaR7iŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 4.67



Due Date



STAFF INTERVIEW-GENERAL

Mark "Compliant" if staff member is able to describe how they are made aware ofa new or updated policy that is to be implemented?

Policy Implementation1644 Follow-Up: Department Compliant (Yes)Non Compliant (No)How do you learn about a new or updated patient care policy that is to be implemented? Std:

LD.04.01.07 EP2Instructions


N/ANot Scored

Mark "Compliant" if staff member answers "yes" or in the affirmative. If "yes",have staff member describe how the student is supervised while providing patient care.

Student Supervision1617 Follow-Up: Department Compliant (Yes)Non Compliant (No)Do students receive supervision when providing patient care, treatment and services? Std:

HR.01.02.07 EP5Instructions


N/ANot Scored

Ask any security personnel (city, county, federal, etc) directly. Mark "Compliant" ifthey answer "yes" to all of the items.

Security Personnel1618 Follow-Up: Department Compliant (Yes)Non Compliant (No)Have law enforcement and security personnel (assigned to supervise patients) been oriented on

the following:-How to interact with patients-Procedures for responding to unusual clinical events and incidents-The hospital's channels of clinical, security, and administrative communication-Distinctions between administrative and clinical seclusion and restraint Std: HR.01.04.01 EP7Instructions


N/ANot Scored

Mark "Compliant" if employee able to discuss how patients are assessed for fallrisk, able to describe how a specific patient was screened on admission, and able to identifypatient's fall risk level.

Assessment-Fall Risk Level1602 Follow-Up: Department Compliant (Yes)Non Compliant (No)How are patients assessed for their risk of falls? Can you show me how this patient was

screened on admission and what their risk level is? Std: PC.01.02.08 EP1Instructions


N/ANot Scored

Mark "Compliant" if employee answers, "socks, staff hourly rounding,patient/family fall prevention education, unit specific fall risk assessment, etc.", or similar. Mark"Non- Compliant" if employee unaware of unit interventions to reduce risk of falls.

Fall Prevention-Intervention1603 Follow-Up: Department Compliant (Yes)Non Compliant (No)What interventions have been implemented on your Unit to reduce the patient's risk of falling?

Std: PC.01.02.08 EP2Instructions


N/ANot Scored

Interview an employee who performs patient care. Mark "Compliant" if employeeable to describe where to locate the latest infection surveillance, prevention, and controlinformation.

IC-Surveillance Info1604 Follow-Up: Department Compliant (Yes)Non Compliant (No)Where Is the latest infection surveillance, prevention, and control information available? How

did you receive it or where can you find it? Std: IC.02.01.01 EP8Instructions


N/ANot Scored

(Insert hospital specific process for communicating patient infection information toreceiving facilities) Mark "Compliant" if employee able to correctly describe process.

IC-Transferred/Infection1606 Follow-Up: Department Compliant (Yes)Non Compliant (No)If patient is transferred to another hospital who has an infection requiring monitoring, treatment,

and/or isolation, what is the process for communicating that information to the receivingorganization? Std: IC.02.01.01 EP10Instructions


N/ANot Scored

ˆ9nAD4t00CaRJÀŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 4.68

Sample Hospital - Hand Hygiene (5161)Checklist October 2013Survey

Sample Area - All Questions13 10 999 ALL Blank BuildingBlank CampusFloorArea BuildingCampus

Due Date



OBSERVATIONS

Compliant (Yes) Non Compliant (No)

Fingernails observed short and no chipped nail polish? Std: NPSG.07.01.01 EP1 Document name and ID# of noncompliant staff.

3009 Fingernails Short

Instructions

N/ANot Scored


Follow-Up: Department

Compliant (Yes) Non Compliant (No)

No artificial nails or extenders observed in designated high-risk areas. (OR, Nurseries, ICU, Special Proceduresareas). Std: NPSG.07.01.01 EP1 Document name and ID# of noncompliant staff.

3010 Fingernails Artificial

Instructions

N/ANot Scored



EDUCATION

Pass Fail

In which of the following situations should hand hygiene be performed?A. Before donning sterile glovesB. Before inserting an a invasive device (e.g. intravascular catheter, foley catheter)C. When moving from a contaminated body site to a clean body site during an episode of patient careD. After having direct contact with a patient or with items in the immediate vicinity of the patientE. After removing glovesF. All of the above Std: IC.02.01.01 EP1, NPSG.07.01.01 EP1 ... All of the above must be met. If failed, reeducate and mark "follow-up completed".

3101 Hand Hygiene Performed

Instructions

N/ANot Scored



Pass Fail

If hands are not visibly soiled or visibly contaminated with blood or other proteinaceous material, which of the followingregimens is the most effective for reducing the number of pathogenic bacteria on the hands of personnel?A. Washing hands with plain soap and waterB. Washing hands with an antimicrobial soap and waterC. Apply 1.5 ml to 3 ml of alcohol-based hand rub to the hands and rubbing hands together until they feel dry Std:IC.02.01.01 EP1, NPSG.07.01.01 EP1 ... Answer: C. Apply 1.5 ml to 3 ml of alcohol-based hand rub to the hands and rubbing hands togetheruntil they feel dry. If failed, reeducate and mark "follow-up completed".

3102 Not Visibly Soiled

Instructions

N/ANot Scored



Pass Fail

How are antibiotic-resistant pathogens most frequently spread from one patient to another in health care settings?A. Airborne spread resulting from patients coughing or sneezingB. Patients coming in contact with contaminated equipmentC. From one patient to another via the contaminated hands of clinical staffD. Poor environmental maintenance Std: IC.01.05.01 EP2, IC.02.01.01 EP1 ... Answer: C. From one patient to another via the contaminated hands of clinical staff. If failed, reeducateand mark "follow-up completed".

3103 Spread of Pathogens

Instructions

N/ANot Scored



Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]

Readiness Rounds

ˆH0AD1100CaR8jŠ5161.1310.63.3. 2

Version 1.49

Sample Hospital - Restraint Audit (5160)Checklist October 2013Survey

Master - Inpatient Acute Care Areas13 10 016 ALL HospitalMainFloorArea BuildingCampus

Due Date



OPEN MED REC REVIEW

(Insert hospital specific policy for monitoring patients in restraints) Mark"Compliant" if monitoring documented per policy.

Restraint-Intervals0244 Follow-Up: Department Compliant (Yes)Non Compliant (No)Are the intervals (as per hospital policy) for monitoring a patient in restraints documented in the

medical record properly? Std: PC.03.05.15 EP1Instructions


N/ANot Scored

Application Time0201 Follow-Up: Department Compliant (Yes)Non Compliant (No)Application time is documented. Std: PC.03.02.05 EP6, PC.03.05.15 EP1

InstructionsFollow-Up Completed_

N/ANot Scored

Mark "Compliant" if documentation present.

Skin Checks0209 Follow-Up: Department Compliant (Yes)Non Compliant (No)Skin checks were checked at least every 2 hours. Std: PC.03.02.07 EP1, PC.03.02.07 EP2 ...


N/ANot Scored


Elimination0210 Follow-Up: Department Compliant (Yes)Non Compliant (No)Elimination needs were assessed at least every 2 hours. Std: PC.03.02.07 EP1, PC.03.02.07

EP2 ...Instructions


N/ANot Scored


Nourishment/Hydration0217 Follow-Up: Department Compliant (Yes)Non Compliant (No)Nourishment/hydration needs were assessed at least every 2 hours, while awake. Std:

PC.03.02.07 EP2, PC.03.03.07 EP6 ...Instructions


N/ANot Scored


ROM Performed0211 Follow-Up: Department Compliant (Yes)Non Compliant (No)ROM were performed at least every 2 hours, when indicated. Std: PC.03.02.07 EP2,

PC.03.03.07 EP6 ...Instructions


N/ANot Scored


CS Checks0212 Follow-Up: Department Compliant (Yes)Non Compliant (No)Circulation/Sensation checks were performed at least every 2 hours. Std: PC.03.02.07 EP1,

PC.03.02.07 EP2 ...Instructions


N/ANot Scored

Injuries Documented0213 Follow-Up: Department Compliant (Yes)Non Compliant (No)Injuries to the patient are documented. Std: PC.03.02.07 EP1, PC.03.05.15 EP1


N/ANot Scored


Patient Debriefing0255 Follow-Up: Department Compliant (Yes)Non Compliant (No)Debriefing was completed after the use of restraints according to policy. Std: PC.03.03.29 EP1


N/ANot Scored


Education to Patient0215 Follow-Up: Department Compliant (Yes)Non Compliant (No)Education was provided to patient and family. Std: PC.03.03.09 EP4


N/ANot Scored

Education Not Given0216 Follow-Up: Department Compliant (Yes)Non Compliant (No)If education was not given, the reason is documented. Std: PC.03.03.09 EP4, PC.03.03.11

EP6Instructions


N/ANot Scored

ˆD5AD1400CaRAèŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 2.010

Sample Hospital - Restraint Audit (5160)Checklist October 2013Survey

Master - Inpatient Acute Care Areas13 10 016 ALL HospitalMainFloorArea BuildingCampus

Due Date



OPEN MED REC REVIEWRestraint Protocol for Non-Behav0236 Follow-Up: Department Compliant (Yes)

Non Compliant (No)If restraint protocol is used for non-behavioral health purposes, is this documented in themedical record? Std: RC.02.01.05 EP2Instructions


N/ANot Scored

OBSERVATION

Mark "N/A" if unable to assess.

Face-to-Face0501 Follow-Up: Department Compliant (Yes)Non Compliant (No)A physician/trained staff performs a face-to-face evaluation within one hour of application of

restraints. Std: PC.03.05.11 EP1Instructions


N/ANot Scored

Least Restrictive0506 Follow-Up: Department Compliant (Yes)Non Compliant (No)Is the least restrictive form of restraint or seclusion being used? Std: PC.03.05.01 EP4


N/ANot Scored

Constant Monitoring0502 Follow-Up: Department Compliant (Yes)Non Compliant (No)Safety checks are done at least every 15 minutes by a trained staff member who provides

constant monitoring. Std: PC.03.02.07 EP1Instructions


N/ANot Scored

Simultaneous Restraint & Seclusion0505 Follow-Up: Department Compliant (Yes)Non Compliant (No)Is the patient who is simultaneously restrained and secluded continually monitored by trained

staff either in-person or through the use of both video and audio equipment that is in closeproximity to the patient? Std: PC.03.05.13 EP1Instructions


N/ANot Scored

Non- Behavioral Patient Monitoring0503 Follow-Up: Department Compliant (Yes)Non Compliant (No)Is the patient being monitored and their needs addressed every two hours at a minimum? Std:

PC.03.02.07 EP2Instructions


N/ANot Scored

STAFF INTERVIEW

Mark "Compliant" if staff responds "yes" or in the affirmative.

Staff Educ-Restraints0601 Follow-Up: Department Compliant (Yes)Non Compliant (No)Have you been trained on the use of restraint and seclusion, and assessed your competence at

the following intervals:-At orientation-Before participating in the use of restraint and seclusion-On a periodic basis thereafter Std: PC.03.05.17 EP2Instructions


N/ANot Scored

Mark "Compliant" if staff responds "yes" or in the affirmative.

Restraints-Immediate Safety0602 Follow-Up: Department Compliant (Yes)Non Compliant (No)Do you use restraints or seclusion only to protect the immediate physical safety of the patient,

staff or others? Std: PC.03.05.01 EP1Instructions


N/ANot Scored

Mark "Compliant" if staff responds that restraints are not used as a means ofcoercion, discipline, convenience, or staff retaliation,

Restraints Appropriate0603 Follow-Up: Department Compliant (Yes)Non Compliant (No)Are restraints or seclusion never used as a means of coercion, discipline, convenience, or staff

retaliation? Std: PC.03.03.11 EP3, PC.03.05.01 EP2Instructions


N/ANot Scored

ˆD5AD1400CaRB,Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 2.011

Sample Hospital - Medication Management (5126)Checklist October 2013

MR#

Survey


Due Date



PATIENT CARE AREASNursing Station Meds0310 Follow-Up: Department Compliant

Non CompliantNo unsecured medications are present at Nursing station. Std: MM.03.01.01 EP3Instructions


N/ANot Scored

Check Crash Cart to ensure it is locked. If Cart is locked marked "Compliant".

Crash Carts - Locked0301 Follow-Up: Department CompliantNon CompliantCrash carts are locked. Std: MM.03.01.01 EP3, MM.03.01.01 EP6


N/ANot Scored

(Insert specific hospital process for securing and logging Crash Cart locks) CheckCrash Cart logs and securement. Mark "Compliant" if hospital process is followed.

Crash Carts - Locks Inventory0302 Follow-Up: Department CompliantNon CompliantLocks are secured and logged properly. Std: MM.03.01.01 EP3, MM.03.01.01 EP6

Instructions


N/ANot Scored

Check Crash Cart logs/medication sheet and mark "Compliant" if : 1. No missing days on log except when clinics closed on weekends/holidays.2. The expiration date of the next drug to expire is listed.

Crash Carts - Documented0303 Follow-Up: Department CompliantNon CompliantCrash carts are checked and documented according to hospital policy. Std: MM.03.01.01

EP18, MM.03.01.01 EP3 ...Instructions


N/ANot Scored

Check patient care areas for accessibility of emergency medications andassociated supplies. Mark "Compliant" if emergency medications and associated supplies arepresent and accessible.

Emergency Meds - Available0316 Follow-Up: Department CompliantNon CompliantEmergency medications and their associated supplies are readily accessible in patient care

areas. Std: MM.03.01.03 EP2Instructions


N/ANot Scored

Check medications stored in patient care areas. Mark "Compliant" if medicationsare available in unit-dose, age-specific, and ready-to-administer forms whenever possible.

Meds - Ready To Use0309 Follow-Up: Department CompliantNon CompliantMedications in patient care areas are available in the most ready-to-administer forms

commercially available or, if feasible, in unit doses that have been repackaged by the pharmacyor a licensed repackager. Std: MM.03.01.01 EP10Instructions


N/ANot Scored

Check each area where emergency medications are stored. Mark "Compliant" ifemergency medications are available in unit-dose, age-specific, and ready-to-administer formswhenever possible.

Emergency Meds - Unit Dose0317 Follow-Up: Department CompliantNon CompliantWhenever possible, emergency medications are available in unit-dose, age-specific, and

ready-to-administer forms. Std: MM.03.01.03 EP3Instructions


N/ANot Scored

(Insert specific hospital process for replacement of emergency medications) Mark"Compliant" if evidence is present that hospital policy or procedure is being followed.

Emergency Meds - Replaced0318 Follow-Up: Department CompliantNon CompliantWhen emergency medications or supplies are used, the hospital replaces them as soon as

possible to maintain a full stock. Std: MM.03.01.03 EP6Instructions


N/ANot Scored

ˆBHAD2v00CaRA9Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.412

Sample Hospital - Medication Management (5126)Checklist October 2013

MR#

Survey


Due Date



STAFF INTERVIEW

Mark "Compliant" if staff member answers all of the following: process, time,frequency, route, and dose.

Meds-Self-Admin/Competency0417 Follow-Up: Department CompliantNon CompliantOn what should staff educate patients and families involved in medication self-administration

about how to administer medication? Std: MM.06.01.01 EP9, MM.06.01.03 EP4 ...Instructions


N/ANot Scored

Mark "Compliant" if staff member answers, "yes". If "yes", ask the staff member todescribe the process for review.

Meds-Duplication0403 Follow-Up: Department CompliantNon CompliantAre all medications orders reviewed for therapeutic duplication? Std: MM.05.01.01 EP8

Instructions


N/ANot Scored

Clarified with Prescriber0404 Follow-Up: Department CompliantNon CompliantAfter the medication order has been reviewed, are all concerns, issues, or questions clarified

with the individual prescriber before dispensing? Std: MM.05.01.01 EP11Instructions


N/ANot Scored

Closed Pharmacy0405 Follow-Up: Department CompliantNon CompliantDoes the hospital implement a process for providing medications to patients needs when the

pharmacy is closed? Std: MM.05.01.13 EP7Instructions


N/ANot Scored

MED REC - INPATIENT

Select an Open Medical Record and in conjunction with Nursing conduct anassessment of the medication reconciliation process. Mark "Compliant" if a complete list of themedications that patient is taking at home (including dose, route, and frequency) is created anddocumented, and the patient/ family are involved.

Med Rec - On Admission0501 Follow-Up: Department CompliantNon CompliantAt the time the patient enters the hospital or is admitted, a complete list of the medications that

patient is taking at home (including dose, route, and frequency) is created and documented. Thepatient , and as needed, the family are involved in creating this list. Std: NPSG.03.06.01 EP1,NPSG.03.06.01 EP2Instructions


N/ANot Scored

Select an Open Medical Record and in conjunction with Nursing conduct anassessment of the medication reconciliation process . Mark "Compliant", ifevidence/documentation of comparison is present.

Med Rec - Ordered in Hospital0502 Follow-Up: Department CompliantNon CompliantThe medications ordered for the patients while under the care of the hospital are compared to

those on the list created at the time of entry to the hospital or admission. Std: NPSG.03.06.01EP3Instructions


N/ANot Scored

Select an Open Medical Record and in conjunction with Nursing conduct anassessment of the medication reconciliation process. Mark "Compliant" if evident that omissions,duplications, adjustments, deletions, additions were reconciled and documented.

Med Rec - Discrepancies0503 Follow-Up: Department CompliantNon CompliantAny discrepancies (that is, omissions, duplications, adjustments, deletions, additions) are

reconciled and documented while the patient is under the care of the hospital. Std:NPSG.03.06.01 EP3Instructions


N/ANot Scored

ˆBHAD2v00CaRFuŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.413

Sample Hospital - Human Resources (5129)Checklist October 2013Survey


Due Date



ALL STAFFNutrition Personnel0512 Follow-Up: Not Specified Compliant

Non CompliantDoes the hospital have an organized dietary service that is directed by adequate qualifiedpersonnel, such as a part-time, full-time or consultant based dietician?Instructions


N/ANot Scored

If Yes: Insert location of documentation.If No: Note unmet criteria or missing document.

Written Disaster Plan - Non-License0515 Follow-Up: Department Yes (Compliant)No (Non Compliant)Does the hospital identify, in writing, those individuals responsible for assigning disaster

responsibilities to volunteer practitioners who are not licensed independent practitioners? Std:EM.02.02.15 EP2Filed - Location


N/ANot Scored

Mark "Compliant" if documentation is present in employee file.

Staff Qualifications0513 Follow-Up: HR CompliantNon CompliantStaff qualifications are specific to their job responsibilities as defined by the hospital. Std:



N/ANot Scored


Verify Job Responsibilities0514 Follow-Up: HR CompliantNon CompliantThe hospital verifies and documents that the applicant has the education and experience

required by the job responsibilities. Std: HR.01.02.05 EP3Instructions


N/ANot Scored

Hospital Policy is that staff will be trained every _______ on this topic (at leastevery three years). Mark "Compliant" if documentation is present in employee file.

Standard Precautions0510 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Standard Precautions, including the use of PPE (personal

protective equipment) to reduce the risk of infection? Std: HR.01.06.01 EP2, HR.01.06.01 EP6...Instructions


N/ANot Scored


Transmission Based Precautions0511 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Transmission Based Precautions? These could include contact,

droplet, airborne, or a combination of these precautions. Std: HR.01.06.01 EP2, HR.01.06.01EP6 ...Instructions


N/ANot Scored


General Safety0506 Follow-Up: Department CompliantNon CompliantIs there evidence of training on general safety, such as the use of PPE (personal protective

equipment), and security risks? Std: HR.01.06.01 EP2, HR.01.06.01 EP6Instructions


N/ANot Scored


Back Safety0501 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Back Safety? Std: EC.03.01.01 EP1, HR.01.06.01 EP2 ...

Instructions


N/ANot Scored

ˆD4AD1100CaR7bŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.514

Sample Hospital - Human Resources (5129)Checklist October 2013Survey


Due Date



PATIENT CARE-STAFF


Special Training0421 Follow-Up: Department CompliantNon CompliantStaff, other than doctors of medicine or osteopathy must have special training for blood

transfusions and intravenous medicationsInstructions


N/ANot Scored

Hospital Policy is that staff will be trained every _______on this topic ( at leastevery three years). Mark "Compliant" if documentation is present in employee file.

Abuse and Neglect0401 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Abuse and Neglect? Std: HR.01.04.01 EP6, HR.01.06.01 EP2

Instructions


N/ANot Scored


Cultural Diversity0402 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Cultural Diversity? Std: HR.01.04.01 EP5, HR.01.06.01 EP2

...Instructions


N/ANot Scored


Infection Control0407 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Infection Prevention? Std: HR.01.04.01 EP4, HR.01.06.01

EP2 ...Instructions


N/ANot Scored


Needs of Dying Pt.0409 Follow-Up: Department CompliantNon CompliantIs there evidence of training on the specific needs of the dying patient? Std: HR.01.04.01 EP6,



N/ANot Scored


Pain Management0412 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Pain Management? Std: HR.01.04.01 EP4, HR.01.06.01 EP2

...Instructions


N/ANot Scored


Fall Reduction0405 Follow-Up: Department CompliantNon CompliantIs there evidence of training on Fall Reduction? Std: HR.01.05.03 EP8, HR.01.06.01 EP2 ...

Instructions


N/ANot Scored


Warning signs0423 Follow-Up: Department CompliantNon CompliantIs there evidence of training that addresses how to identify early warning signs of a change in a

patient's condition and how to respond to a deteriorating patient, including how and when tocontact responsible clinicians? Std: HR.01.05.03 EP13Instructions


N/ANot Scored


Patient Safety0413 Follow-Up: Department CompliantNon CompliantIs there evidence of training on National Patient Safety Goals? Std: HR.01.06.01 EP2,



N/ANot Scored

ˆD4AD1100CaR9zŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.515

Sample Hospital - Environment of Care (5111)Checklist October 2013Survey

Master - Patient (527)13 10 527 ALL Blank BuildingBlank CampusFloorArea BuildingCampus

Due Date



INFECTION CONTROLSignage0808 Follow-Up: Department Compliant

Non CompliantIs isolation/precaution signage used according to policy on doors and charts? Std: IC.02.01.01EP1, IC.02.01.01 EP2 ...Instructions


N/ANot Scored

Reusable Patient Care Items0806 Follow-Up: Department CompliantNon CompliantAre reusable patient care items properly cleaned and disinfected between each patient use?

Std: IC.02.02.01 EP5Instructions


N/ANot Scored

Segregated Storage0807 Follow-Up: Department CompliantNon CompliantIs there segregation of clean and dirty storage? Std: IC.02.01.01 EP1, IC.02.02.01 EP4


N/ANot Scored

Food Refrigerators0809 Follow-Up: Department CompliantNon CompliantAre all food refrigerators clean and defrosted? For Patient Refrigerators: Were thermometers

present, temperatures logged daily, action taken if out of range, and food covered, labeled, anddated? Std: IC.02.01.01 EP1, PC.02.02.03 EP11 ...Instructions


N/ANot Scored

Ventilation System0817 Follow-Up: Engineering CompliantNon CompliantIn areas designed to control airborne contaminants (such as biological agents, gases, fumes,

dust), does the ventilation system provide appropriate pressure relationships, air-exchangerates, and filtration efficiencies? Std: EC.02.05.01 EP6Filed - Location


N/ANot Scored

PRIVACYPHI on Fax0314 Follow-Up: Department Compliant

Non CompliantIs there PHI unattended on fax machines? Std: IM.02.01.03 EP5Instructions


N/ANot Scored

PHI on Computers0311 Follow-Up: Department CompliantNon CompliantAre computers with PHI visible to visitors? Std: IM.02.01.03 EP5


N/ANot Scored

PHI on Sign-In Sheet0318 Follow-Up: Department CompliantNon CompliantDoes the sign-in sheet request PHI? Std: IM.02.01.03 EP5


N/ANot Scored

PHI in Recycling0320 Follow-Up: Department CompliantNon CompliantWas any PHI found in regular recycle container? How often is PHI picked up? By whom? Std:

IM.02.01.03 EP5, IM.02.01.03 EP6Instructions


N/ANot Scored

PHI in Overhead/Intercom Pages0322 Follow-Up: Department CompliantNon CompliantOverhead and intercom pages, if applicable, do not include PHI. Std: IM.02.01.03 EP5


N/ANot Scored

ˆ9PAD7000CaRP7Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.916

Sample Hospital - Environment of Care (5111)Checklist October 2013Survey

Master - Patient (527)13 10 527 ALL Blank BuildingBlank CampusFloorArea BuildingCampus

Due Date



MEDICAL EQUIPMENTRed Plug Use0706 Follow-Up: Department Compliant

Non CompliantIs critical equipment such as monitors, IV pumps, ventilators and crash carts plugged into redplugs? Std: EC.02.05.03 EP5Instructions


N/ANot Scored

Life Supp Equip Tested0710 Follow-Up: Bio Med CompliantNon CompliantDoes the hospital document inspections, testings, and maintenance of all life support

equipment? Std: EC.02.04.03 EP2Filed - Location


N/ANot Scored

Crash Cart Expiration Date0707 Follow-Up: Department CompliantNon CompliantIs the crash cart within its expiration date? Std: EC.02.04.03 EP2


N/ANot Scored

Crash Daily Checks0708 Follow-Up: Department CompliantNon CompliantIs the crash cart checked daily, cleaned and annotated in accordance with policy? Std:

EC.02.01.01 EP3, PC.02.01.11 EP2Instructions


N/ANot Scored

OTHER PHYSICAL RQMTSCleaning Overall1009 Follow-Up: EVS Compliant

Non CompliantIs overall cleaning satisfactory? Std: EC.02.06.01 EP20Instructions


N/ANot Scored

Pt Area Clean1005 Follow-Up: EVS CompliantNon CompliantAre areas used by patients clean, sanitary, and free of offensive odors? Std: EC.02.06.01

EP20Instructions


N/ANot Scored

Bathrooms Clean1010 Follow-Up: EVS CompliantNon CompliantAre bathrooms well cleaned, including sinks, toilets, showers? Std: EC.02.06.01 EP20


N/ANot Scored

Floor Finish1011 Follow-Up: EVS CompliantNon CompliantAre floors clean, free of dust and dirt, with a consistent high level of shine? Std: EC.02.06.01

EP20Instructions


N/ANot Scored

Vents Clean1024 Follow-Up: EVS CompliantNon CompliantAre vents clean and free from dust? Std: EC.02.06.01 EP20


N/ANot Scored

Paper & Soap Stocked1012 Follow-Up: EVS CompliantNon CompliantAre paper products and soap well stocked? Std: EC.02.06.01 EP1


N/ANot Scored

ˆ9PAD7000CaRCiŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.917

Sample Hospital - Executive Leadership (5137)Checklist October 2013Survey


Due Date



STAFF INTERVIEW- ALL

If Yes: "What is your role in achieving the goals?"If No: "Let's discuss the goals and your role in achieving them."

Leader Shares Goals0101 Follow-Up: Department YesNoHave your leaders shared with you the goals of the hospital? Std: LD.02.01.01 EP3

Instructions


N/ANot Scored

If Yes: "What is your role in keeping patients safe and ensuring patientsexperience quality?"If No: "Let's discuss your role in keeping patients safe and ensuring patients experience quality."

Department Shares Data0102 Follow-Up: Department YesNoDoes your department management share data and information regarding patient safety and

quality with employees? Std: LD.03.02.01 EP3Instructions


N/ANot Scored

If Yes: Have staff member give examples.If No: Discuss the methods used for Performance Improvement.

Performance Improvement0103 Follow-Up: Department YesNoCan you name the methods used for Performance Improvement? Std: PI.02.01.01 EP1,

PI.03.01.01 EP1Instructions


N/ANot Scored

If Yes: Have staff member give examples.If No: Discuss the department Performance Improvement initiatives and staff member's role.

Name PI Initiative0104 Follow-Up: Department YesNoCan you name the Performance Improvement initiatives in your department? Std: PI.01.01.01

EP1Instructions


N/ANot Scored

If Yes: Have staff member give examples.If No: Discuss the data being collected.

Name PI Data0105 Follow-Up: Department YesNoCan you describe the Performance Improvement data being collected on your department? Std:



N/ANot Scored

If Yes: Give an example of "team approach".If No: What do you feel could be done to improve this?

Team Approach0106 Follow-Up: Department YesNoHave leaders established a team approach among all staff at all levels? Std: LD.03.01.01 EP7

Instructions


N/ANot Scored

If No: Do you have too little staff or not the right type of staff? What mix of staffwould be able to handle the workload?

Staff - Workload0107 Follow-Up: Department YesNoDo you have the right mix of staff to handle the workload in your department? Std: LD.03.06.01

EP3Instructions


N/ANot Scored

If No: What do you need?

Tools & Equipment0108 Follow-Up: Department YesNoDo you have the tools and equipment you need to do your job in your particular department?

Std: LD.04.01.11 EP5Instructions


N/ANot Scored

If No: Give an example and describe how you would change the way the situationwas handled.

Manage Disruptive Behavior0109 Follow-Up: Department YesNoDo leaders appropriately manage behaviors that undermine a culture of safety? Std:



N/ANot Scored

ˆHpAD0Y00CaR7-Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 0.618

Sample Hospital - Executive Leadership (5137)Checklist October 2013Survey


Due Date



STAFF INTERVIEW- ALL

If Yes: Give an example.If No: Give an example and describe how people could have better supported one another.

Staff - Support0111 Follow-Up: Department YesNoDo people support one another on this Department? Std: LD.02.01.01 EP1, PI.03.01.01 EP1

...Instructions


N/ANot Scored

If No: What should be changed?

Safety-Staff0112 Follow-Up: Department YesNoDo you feel safe here? Std: LD.03.01.01 EP1, LD.03.01.01 EP2 ...


N/ANot Scored

STAFF INTERVIEW- PATIENT CARE

If Yes: "Give examples."If No: "Can you give examples of what needs to be done to improve patient safety?"

Patient Safety - Proactive0212 Follow-Up: Department YesNoIs this department actively doing things to improve patient safety? Std: LD.04.04.05 EP4,



N/ANot Scored

If No: "Who do you feel is not comfortable and why?"

Discuss Pt Safety0204 Follow-Up: Department YesNoAre all staff, including physicians, able to openly discuss issues of patient safety and quality?

Std: LD.03.01.01 EP8Instructions


N/ANot Scored

If Yes: "In what do you participate?"If No: " In what initiatives would you like to participate?"

Opportunity to Participate0205 Follow-Up: Department YesNoAre you provided the opportunity to participate in patient safety and quality initiatives? Std:



N/ANot Scored

If Yes: "Give examples."If No: "What would you like to see from hospital management?"

Leadership Intervention0213 Follow-Up: Department YesNoDo the actions of hospital management show that patient safety is a top priority? Std:

LD.03.01.01 EP1, PI.01.01.01 EP30Instructions


N/ANot Scored

If Yes: "Can you give examples?"If No: "What could we do better?"

Patient Safety - Grading0211 Follow-Up: Department YesNoIs our approach to patient safety excellent? Std: LD.03.03.01 EP1, LD.03.03.01 EP3 ...

Instructions


N/ANot Scored

If Yes: "What is the process and why do you feel it is effective?"If No: "What would make the current process more effective?"

Communication - Shift Change0201 Follow-Up: Department YesNoDo you use an effective process to communicate patient care information at time of handoff?

Std: LD.03.04.01 EP1, LD.03.04.01 EP4 ...Instructions


N/ANot Scored

If Yes: "Give an example."If No: "Give an example of ineffective communication and describe how it could be improved."

Communication Methods0202 Follow-Up: Department YesNoAre our communication methods effective? Std: LD.03.04.01 EP7

Instructions


N/ANot Scored

ˆHpAD0Y00CaR89Š Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 0.619

Sample Hospital - Patient Care Rounding (5127)Checklist October 2013Survey


Due Date



INTRODUCTION

Complete AIDE process with patient and score yes when completed

Introduction - AIDE0101 Follow-Up: Department YesNoBefore commencing:

A - Acknowledge - Good Morning/ AfternoonI - Introduce - I am _______ from ___________D - Duration - I have a few questions that will take about 10 minutes of your time. Is that OK?E - Explanation - We want to be sure we are providing excellent service and quality care so wetalk to a lot of our patients about their stayInstructions


N/ANot Scored

If No: What are your specific concerns and I will follow up the Clinical Director,(give name of director) over this area. If Yes: Has this also happened when you have been in treatment areas outside of your room?

Introduction - Staff AIDE0102 Follow-Up: Department YesNoAre staff introducing themselves to you, explaining what they are planning to do, and letting you

know how long it will take, every time they come into your room? Std: LD.03.04.01 EP1Instructions


N/ANot Scored

STAFF COMMUNICATION

If No: What are your specific concerns and I will follow up the Clinical Director,(give name of director) over this area.

Pt Knows RN / MD3007 Follow-Up: Department CompliantNon CompliantOur staff is working together as a team to care for you.

Do you know who your RN and MD are who are caring for you today? Std: RI.01.01.01 EP4,RI.01.01.01 EP5Instructions


N/ANot Scored

If No: What are your specific concerns and I will follow up the Clinical Director, (give name ofdirector) over this area. If Yes: Have there been any occasions were you have felt the nursing or medical staff havebeen rushed?

RN / MD Updated Plan of Care3008 Follow-Up: Department CompliantNon CompliantHas the RN or MD updated you on your plan of care and what may happen next? Std:

RI.01.01.01 EP4, RI.01.01.01 EP5


N/ANot Scored

RESPONSIVENESS

If No: What are your specific concerns and I will follow up the Clinical Director,(give name of director) over this area. If Yes: Have there been any times you have had to wait?

Needs Addressed Quickly3207 Follow-Up: Department CompliantNon CompliantDid you find that the staff came to your room quickly to address your need(s)?

Instructions


N/ANot Scored

If Yes: When did he/she last visit?If No: I will have them come to see you.

Nurse Manager3201 Follow-Up: Department YesNoDo you know who the Nurse Manager is on the floor, and have they been to visit you?

Instructions


N/ANot Scored

If No: When was the last time staff checked on you?If Yes: This is happening every day?

Rounding - Frequency3202 Follow-Up: Department YesNoIs the staff coming in to check on you every hour during the day and every two hours at night?

Std: PC.01.02.01 EP23Instructions


N/ANot Scored

ˆBIAD3600CaR7KŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.520

Sample Hospital - Patient Care Rounding (5127)Checklist October 2013Survey


Due Date



RESPONSIVENESS

If No: What are your specific concerns and I will follow up the Clinical Director,(give name of director) over this area. If Yes: Do they always check on your pain and comfort?

Rounding - Specifics3203 Follow-Up: Department YesNoWhen they come to your room, do they ask specific questions, such as, do you need help in the

bathroom, what is your pain status, and is your environment clean? Std: PC.01.02.01 EP23Instructions


N/ANot Scored

If No: Is this an on going problem for you? If Yes: Have there been any times you have had to wait?

Help to Bathroom3205 Follow-Up: Department YesNoAre you getting help to the bathroom when needed? Std: RI.01.01.01 EP4

Instructions


N/ANot Scored

If No: Tell me more about their experiencesIf Yes: So you have had no problems waiting for test or procedures?

Scheduling On Time3206 Follow-Up: Department YesNoAre your test and procedures scheduled and on time?

Instructions


N/ANot Scored

PAIN MANAGEMENT

If No: What are your specific concerns and I will follow up the Clinical Director,(give name of director) over this area. If Yes: You are satisfied your pain is well controlled?

Pain Help3302 Follow-Up: Department YesNoHave we done everything that we can to keep your pain under control? Std: PC.01.02.07 EP4,

RI.01.01.01 EP8Instructions


N/ANot Scored

ENVIRONMENT OF CARE

If No: Is there anything we could to make it quieter? Any issues with corridor noise?If Yes: Can you share with me what is keeping you from resting?

Comfortable Rest3406 Follow-Up: Department NoYesWe want to be sure you are getting the rest you need:

Is there anything that is keeping you from resting comfortably at during the day or night? Std:EC.02.06.01 EP1


N/ANot Scored

If No: We will have housekeeping correct this for you today. If Yes: Would you like it cleaner? Has it ever not been clean?

Room Cleaning3401 Follow-Up: EVS YesNoIs your room and your bathroom kept clean enough? Std: EC.02.06.01 EP20

Instructions


N/ANot Scored

If No: What are your specific concerns and I will follow up the Clinical Director,(give name of director) over this area.

Bed Linen / Washing3403 Follow-Up: Department YesNoHave you been offered a bed bath or shower and have your linens been changed regularly?

Std: RI.01.01.01 EP4Instructions


N/ANot Scored

If No: Tell me how we can improve.If Yes: What are some of the food items you really like?

Food3404 Follow-Up: Food Service YesNoIs the food good?

Instructions


N/ANot Scored

ˆBIAD3600CaR8WŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 1.521

Sample Hospital - Discharge Follow-Up Call (5128)Checklist October 2013Survey


Due Date



DISCHARGE CALL

Complete AIDE process with patient and score yes when completed.

Introduction - Inpatient0101 Follow-Up: Department YesNoBefore commencing:

A - Acknowledge - Good Morning/AfternoonI - Introduce - I am ______ from ______ hospital.D - Duration - I have a few questions about your recent stay with us. It will take about 5 minutesof your time. Is that OK?E - Explanation - We want to be sure we are providing excellent service and quality care so wetalk to a lot of our patients about their stay. We particularly want to be sure that you have all theinformation and support you need since leaving the hospital.Instructions


N/ANot Scored

If No: "I will get your discharge instructions and call you to review what you needto know."If Yes: "Can you tell me your main health problem?" "Are the instructions easy to read andunderstand?"

Discharge Instructions-Covered0102 Follow-Up: Department YesNoDid we go over your discharge instructions with you before you left the hospital? Do you have a

copy? Lets review together. Std: PC.02.03.01 EP25, PC.04.01.05 EP8Instructions


N/ANot Scored

If No: "What questions do you have?" (note questions in comments and arrangefor follow up)If Yes: "Do you have any concerns?"

Discharge Instructions-Questions0103 Follow-Up: Department YesNoHave all of your questions about your discharge been answered? Std: PC.04.01.05 EP8

Instructions


N/ANot Scored

If No: "Do you have new or worsening symptoms?" Do you have fever? (Arrangefor follow up with Primary Care Physician or other as needed)If Yes: "Do you have any additional concerns about your condition?

Condition Improving0113 Follow-Up: Department YesNoDo you feel that your condition has improved since you left the hospital? Std: PC.01.03.01

EP22Instructions


N/ANot Scored

If Yes: Have you tried ice or warmth?

Symptoms - Sore Throat0114 Follow-Up: Department NoYesAre you experiencing a sore throat (or inability to swallow)? Std: PC.01.02.03 EP3


N/ANot Scored

If Yes: Are you able to hold down fluids?

Symptoms - Nausea and/or Emesis0115 Follow-Up: Department NoYesAre you experiencing nausea and/or emesis? Std: PC.01.02.03 EP3


N/ANot Scored

If Yes: Are you concerned about the bleeding/drainage? (Arrange for nursetriage or physician follow up)If No: Do you have any concerns about your incisions?

Symptoms - Bleeding0116 Follow-Up: Department NoYesAre you experiencing any bleeding? Std: PC.01.02.03 EP3

Instructions


N/ANot Scored

If No: Call your physician's office. (Assist with arranging phone call or nursetriage)If Yes: Is there any burning during urination?

Symptoms - Voiding (if urological)0117 Follow-Up: Department YesNoAre you able to urinate? Std: PC.01.02.03 EP3

Instructions


N/ANot Scored

ˆCzAD1l00CaR7LŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 2.022

Sample Hospital - Discharge Follow-Up Call (5128)Checklist October 2013Survey


Due Date



DISCHARGE CALL

If Yes: Are you taking your pain medicine? (Arrange for physician follow up ornurse triage)

Symptoms - Fever0118 Follow-Up: Department NoYesDo you have a fever? Std: PC.01.02.03 EP3

Instructions


N/ANot Scored

If No: Review problems/danger signs.If Yes: "What signs are you watching for?" " What should you do if they occur?"

Watch For Problems0108 Follow-Up: Department YesNoDo you know what problems to watch for and what you should do if they occur? Std:



N/ANot Scored

If No: Arrange for medication list and follow up call.If Yes: "Do you have any problems with the medications?" "What is your schedule?" "Have anymedications been added or taken off?"

Medication List0111 Follow-Up: Directable YesNoDo you have a list of your medications? Can you get the list so we can review? Std:

NPSG.03.06.01 EP4Instructions


N/ANot Scored

If No: "What is preventing you from getting that done?" What can we do to getthose filled? (make arrangement for follow up if needed)If Yes: "Do you have any questions about how to take them?"

Prescriptions Filled0104 Follow-Up: Directable YesNoHave you filled all of your prescriptions? Std: NPSG.03.06.01 EP5

Instructions


N/ANot Scored

If Yes or No: "It is very important for you to take the medications as prescribed.Will you make sure that this happens?"

Medications-Taken0106 Follow-Up: Directable YesNoHave we explained how important it is for you to take the medications as prescribed? Std:

NPSG.03.06.01 EP5Instructions


N/ANot Scored

If No: "What questions do you have?" ( note feedback in comments and arrangefor follow up with pharmacy if needed)

Medications-Understood0105 Follow-Up: Directable YesNoHave all of your questions about your medication been answered? Std: NPSG.03.06.01 EP5,



N/ANot Scored

If No: "How can we make sure this happens?" Do you have what you need inorder to make the appointments? If Yes: "When are your appointments scheduled?" Do you have transportation?

Follow-Up Doctors Appointments0107 Follow-Up: Department YesNoHave your follow-up appointments been scheduled? Std: PC.02.02.01 EP3

Instructions


N/ANot Scored

If No: "What are you doing to handle that?" (Review compliance with prescribedpain medications, arrange for follow up with physician if needed)

Pain0112 Follow-Up: Department YesNoAre you comfortable? Is your pain (if any) under control? Std: PC.01.02.07 EP4

Instructions


N/ANot Scored

ˆCzAD1l00CaR8XŠ Phone: 800-705-3401 - Fax: 1-877-542-4450Web: www.ReadinessRounds.com - Email: [email protected]


Version 2.023

112 E. 10th Street + P.O. Box 612 + Eudora, KS 66025 Phone: (800) 705-3401

Fax: (877) 542-4450

www.readinessrounds.com



Documents

Readiness Rounds Checklists