Out-of-Hospital Premises Inspection Program—Post-Visit Inspection-Assessment Report 1 Out-of-Hospital Premises Inspection Program Post-Visit Inspection-Assessment Report Completed by the Nurse Assessment Coordinator Premises name Premises address Assessment date: Date report prepared: This report is submitted to the Out of Hospital Premises Inspection Program of the College of Physicians and Surgeons of Ontario by: Physician Assessor(s): Nurse Assessment Coordinator(s) PRESENT AT THE ASSESSMENT CPSO Physician assessor(s) Nurse Assessment co-ordinators The Premises Representing the Premises: List names of staff present on day of assessment LIST OF PHYSICIANS ASSESSED: To be completed by the Assessment Coordinators Physicians reviewed: List full name of each physician reviewed CPSO number Enclosures: Standard documents
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Post-Visit Inspection-Assessment Report - cpso.on.ca€¦ · Out-of-Hospital Premises Inspection Program—Post-Visit Inspection-Assessment Report 2 FORMAT OF THE ASSESSMENT 1. ...
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FORMAT OF THE ASSESSMENT 1. Introduction of PREMISES staff 2. Tour of PREMISES 3. Review of protocol and procedures, record keeping and quality management activities 4. Observations of Patient Procedures 5. Procedure Review 6. Exit interview (list staff) Standards used to assess this PREMISES are outlined in “Out-of-Hospital Premises (OHP) Standards”, September 2010 published and distributed by the College of Physicians and Surgeons of Ontario. Link to the Standards available on the College website at: http://www.cpso.on.ca/members/default.aspx?id=5334 OHPIP: Assessment Report Template April 21, 2011
c. Access for disabled persons complies with provincial legislation (Ontarians with Disabilities Act) and/or municipal by-law
d. Patient washrooms are wheelchair accessible
e. The layout of the premise facilitates patient care and safety
f. The following areas are physically separate,
where appropriate, allowing adequate space to ensure patient safety, privacy, confidentiality, emergency protocols and infection control standards:
administration and patient-waiting area procedure room and/or operating room recovery area clean utility area dirty-utility room non-sterile storage area sterile area staff change room and staff room
g. The site complies with all applicable building codes, including fire safety requirements
h. The size of the OHP is adequate for all procedures to be performed safely
i. All electrical devices are safety certified by CSA or equivalent (visual inspection of CSA sticker on actual equipment)
j. There are no overloaded wall plugs or overloaded extension cords in use
Electrical
k. The wires in use are not broken, worn or unshielded (e.g. no wires visible)
l. There is an emergency power source available which provides for the safe completion of the procedure and recovery
m. Any electrical renovation is approved with sign-off by the municipal inspector
2.1 Physical Standards for Procedure Rooms – Physical requirements*
Meets Meets with recom-menda-tions
Does not meet
N/A: Comments:
****All levels
a. All OHPs provide the following physical requirements:
adequate lighting for the procedures performed
the temperature is appropriately controlled floors and walls can be cleaned to meet
infection control requirements (e.g. surfaces are smooth and washable)
hand-washing premises and proper towel disposal (scrub sinks) are available
openings to the outside are effectively protected against the entrance of insects or animals by self-closing doors, closed windows, screening, controlled air current or other effective means
****Levels 2&3
b. Levels 2&3 meet the above requirements and must comply with the following:
There is adequate space to accommodate the equipment and the staff required for the procedure
There is ample space for the physician and assisting staff to move around the OR table with access to both sides of the patient, without contamination
If a sterile field is required, the walls, floors and ceiling are covered with an easily cleaned material which is smooth and free from breaks or cracks
c. Ventilation system ensures patient and staff comfort
d. Ventilation and air circulation is augmented to address procedure-related air-quality issues (e.g., cautery smoke, anesthetic gases, endoscopy, disinfecting agents [Glutacide fumes are vented directly to the outside]
****Level 2&3 only
e. Where gas sterilization is used, a positive pressure outbound system is used, vented directly to the outside
pressure outbound system is used, vented directly to the outside
g. HVAC -Heating, Ventilating and Air Conditioning (HVAC) equipment is maintained and inspected as per manufacturers recommendations (preventative Records are kept on site)
Equipment
**** All levels
g. Equipment is maintained and inspected regularly for functionality (documentation of a minimal yearly maintenance inspection program is available)
h. The following documentation for equipment is available:
equipment operating manuals equipment maintenance contracts log for maintenance of all medical devices
(e.g. suction machines)
i. A biomedical technician annually inspects all equipment (including electrical outlets, breaker/fuse boxes, and emergency light and power supplies) and reports in writing that the equipment is safe and operating according to the manufacturer’s specifications
j. Only inspected equipment is used in the procedure room
k. The equipment’s specifications are kept in an organized file
l. All equipment is on a maintenance schedule with records kept for a minimum of at least three (3) years
m. Stickers are placed on individual equipment as appropriate and written records are maintained.
n. All equipment repairs and changes are done by a bio-medical technician with records kept for a minimum of three (3) years
o. Personal protective equipment is available for all appropriate procedures
a. A sink for hand washing is immediately accessible
b. Electrical outlets that meet required codes are available
Size and layout
c. The size of the recovery area corresponds with planned use and accommodates the volume of patients expected for a minimum of two hours operating room time.
d. The recovery area allows for transfer of patients to/from a stretcher and performance of emergency procedures
Equipment
e. In the recovery area, appropriate monitoring, suction, oxygen, and bag-valve-mask devices, adequate intravenous and other medical/surgical supplies are immediately available as:
Blood pressure monitoring equipment Separate pulse oximeter available for each
patient Temperature Monitoring Device Stethoscope Blood glucose monitoring equipment Resuscitation Equipment and Emergency
Drugs as per OHPIP standard 4.4.3.1 and 4.4.3.2
Easy access to the following: Difficult Intubation Cart MH Cart if applicable Cutaneous warming device
a. A general medication inventory record is maintained
b. Medications are periodically inspected for: drug name drug dosage expiration date D.I.N.
c. Medications are labeled in accordance with the Food and Drug Act (FDA) and the Controlled Drugs and Substances Act (CDSA) and its regulations
d. Medications are stored according to the manufacturer’s recommendations (e.g., refrigeration if required, fridge is at correct temperature and checked daily, refrigerator is not used for food storage)
e. Medications are stored in a manner suitable for security and restocking:
f. stock drugs are stored in designated non- patient care area
g. organized for easy access in appropriately labeled bins/cupboards
h. Medications administered are documented in the patient record
i. Medications dispensed at discharge are accompanied by verbal and written instructions that are given to the patient and/or accompanying adult
j. OHPs should make available resources to determine appropriate drug dosages and usage. Resources may include:
CPS: Compendium of Pharmaceuticals and Specialties: The Canadian Drug Reference for HealthCareProfessionals
Electronic Medication References such as Lexi-Comp and e-CPS electronic medication references tool that provides decision support for health care professionals.
k. Pediatric doses are available for that population
l. Controlled substances are handled and administered in accordance with Food and Drug Act (FDA) and the Controlled Drugs and Substances Act (CDSA) and its regulations
m. There is one qualified designated staff (e.g. RN, RPN with medication skills, physician) assigned to managing controlled substances
n. Controlled substances are stored in a designated locked cabinet and double locked.
o. Controlled substances are accounted for in a “Log of Controlled Substances”
p. For each controlled substance, the following information is specified:
Name quantity date received expiry date loss (damaged, expired, spilled) date and quantity and stock balance
q. For patient administration, the following information is collected:
patient name drug name amount removed from inventory and stock
balance date and time quantity used and waste name of staff administering the medication
r. An end-of-day balance of the inventory of controlled substances is calculated by physical count and verified by the signatures of two qualified (regulated) staff
s. In the event of a discrepancy, is an investigation conducted and documented with the appropriate action taken
a. Premises adhere and maintain documentation for the following:
Accepted standards of infection control practices pertinent to the specific procedures performed
b. Universal precautions (i.e. all human blood and human body fluids are treated as if known to be infectious for HIV, HBV, and other blood borne pathogens) are followed
c. “Infection Control in the Physicians’ Office” published by the College is available
d. In order to minimize risk of infection in the OR, the following actions are undertaken:
Disinfectants are properly used for the sterilization of instruments and equipment
e. Medical equipment that uses water is properly maintained (e.g. automated endoscope reprocessors).
f. Proper ventilation requirements for specialized care environments (e.g. airborne infection isolation, protective environment and ORs )
g. Water intrusion into OHP structural elements in the OR are managed promptly
h. Accepted standards of waste handling are implemented
I. POLICIES ARE IN PLACE FOR THE FOLLOWING:
Documentation of staff mantoux tests kept Documentation of staff immunization kept Flu Shots MMR Hep B TDP Chickenpox Immunity
FOR: Dermatitis on hands Disseminated shingles Diarrhea Written policy on Bloodborne Pathogen
Follow-up
k. ALL PATIENT CARE AREAS HAVE: Soap and water available Alcohol-based hand rubs available
l. WAITING ROOM HAS: infection control signs at entry Infection control signs at reception desk Alcohol-based hand cleaner at Reception
with signage Tissue boxes available Garbage Cans available Patient segregation area available Clean toy and soiled toy bins available
m. RECEPTION AREA HAS: Personal Protective Equipment (PPE)
available Patient masks Staff fluid resistant masks Staff gloves Reception staff can maintain 1 meter
distance with patients Telephone screening protocol has been
developed and implemented
n. EXAMINATION/CONSULTATION ROOMS HAVE:
Hand washing sinks with soap available in all rooms
Exam rooms only have essential supplies
o. STAFF PERFORM HAND HYGIENE: Before direct patient contact. After direct patient contact After removing gloves Before performing invasive procedures (e.g.,
placing an IV) After contact with blood, body fluids, or
contaminated surfaces (even if gloves are worn)
p. GLOVES FOR ROUTINE PRACTICES ARE:
Worn for procedures that might involve contact with blood or body fluids
Worn when handling potentially contaminated patient equipment
Removed before moving to the next task and/or patient
Scrub attire Operating room attire Sterile field Clean air exchanges Storage of sterile supplies
v. INJECTION PRACTICE (injectable medications, saline, other infusates)
Needles are used for only one patient. Syringes are used for only one patient. Medication vials are always entered with a
new needle. Medication vials are always entered with a
new syringe. Medications that are pre-drawn are labeled
with the time of draw, initials of the person drawing, medication name, strength, and expiration date or time
Single dose (single-use) medication vials are used for only one patient
Manufactured prefilled syringes are used for only one patient.
Bags of IV solution are used for only one patient
• Medication administration tubing and connectors are used for only one patient
Multi-dose injectable medications are used for only one patient. If they are not, the rubber septum must be disinfected with alcohol prior to each entry.
Multi-dose medications used for more than one patient are dated when they are first opened and discarded within 28 days of opening or according to manufacturer’s recommendations, whichever comes first
Multi-dose medications, used for more than one patient, are not stored or accessed in the immediate areas where direct patient contact occurs
w. PREVENTION OF SHARPS INJURY All sharps are disposed of in a puncture-
resistant sharps container (e.g. needles, blades, razors and other items capable of causing punctures)
Sharps containers are replaced when the fill line is reached
Staff are trained to use safety engineered devices
Safety engineers are provided to reduce risk to staff re. sharp injury
During operative procedures, sharps are passed using a transfer tray
Post-exposure prophylaxis is available for staff with blood and body fluid exposure
x. CLEANING OF GLUCOMETER A new single-use, auto-disabling lancing
device is used for each patient The glucose meter is not used on more than
one patient unless the manufacturer’s instructions indicate this is permissible
The glucose meter is cleaned and disinfected after every use
y. MANAGEMENT OF INFECTIOUS DISEASES
Patients are screened for MRO's and Infectious Diseases and assessed if appropriate for OHPs
Appropriate additional precautions are applied as necessary re: Airborne, Contact/Droplet or Contact Precautions
Staff wear appropriate PPEs Patients are isolated from other patients
upon admission
z. DISPOSAL OF WASTE General, biomedical and pathological. GENERAL office waste, used gloves or non-
sharp medical equipment, may be disposed of in regular waste and requires no special handling other than containment during disposal and removal
BIOMEDICAL waste is handled and disposed of in such a way as to avoid transmission of potential infections.
Non-anatomical waste, such as liquid blood or body fluid drainage (e.g. chest tube drainage containers, IV blood filled tubing), must also be packaged as biomedical waste
Anatomical waste such as body parts is classified as PATHOLOGICAL waste and must be disposed of according to the regulations for handling pathological waste
a. A OHPIP committee has been established and is comprised of all staff providing patient care with documentation maintained of this activity
Monitoring Quality of Care
b. The premises has a written quality improvement program in place which includes surveys or projects which:
Monitor and evaluate patient care
c. Evaluate methods to improve patient care
d. Identify and correct deficiencies within the
premises
e. Alert the Medical Director to identify and resolve problems
f. The OHP has a documented process in place to regularly monitor the quality of care provided to patients. These activities include, but are not limited to a review of the following:
Non medical staff performance
g. Individual physician care performance to assess:
• Patient selection to ensure appropriateness
h. Procedure selection to ensure appropriateness
i. Patient outcomes
j. Evaluation of complications and adverse events
k. At least annually, a random selection of approximately 5-10 patient records is reviewed to assess the following:
Record completion and documentation of informed consent
a. Anesthetic and ancillary equipment (selection, installation, maintenance) comply with both the Canadian Standards Association (CSA) standards and applicable recommendations arising from provincial legislation.
b. Medical compressed gas and pipelines comply with both Canadian Standards Association (CSA) standards and applicable recommendations arising from provincial legislation.
c. A second supply of oxygen (normally a spare cylinder) with pressure gauge, regulator, and wrench is available.
****Level 3 only
a. Level 3 OHPs provide the following: An anesthesia machine An anesthetic drug cart
Note: depending on the procedure performed, not all standards may apply.
7. Monitoring and resuscitation equipment required on OHP premises
Indicator Yes No N/A
**** Level 1 only
a. AED
**** All Levels
a. IV setup
b. Adequate equipment to manage local anesthetic toxicity i.e. BP Cuff, Stethoscope, ability to manage airway and do CPR, drugs as per OHPIP Standards 4.4.8.2
c. Appropriately sized equipment for infants and children, if required.
****Levels 2 and 3 only
a. Assortment of disposable syringes, needles, and alcohol wipes
b. Cardiopulmonary resuscitation equipment with current ACLS/PALS-compatible defibrillator
c. ECG monitor
d. Intubation tray with a variety of appropriately sized blades, endotracheal tubes, and oral airways
e. Laryngeal mask airways
f. Means of giving manual positive pressure ventilation (e.g., manual self-inflating resuscitation device)
Out-of-Hospital Premises Inspection Program Observational Assessment Protocol This observational component is comprised of observations/ review of policies and procedures/documentation within the patient record.
PROCEDURAL STANDARDS
Indicator Meets Meets with Recommendations
Does not Meet
N/A: Comments
****All levels
1. Patient Admission requirements
a. The patient is admitted to premises by a registered nurse
b. The following information is obtained and documented by a health care provider under the supervision of a physician:
Pulse oximetry
Vital signs
Allergies
NPO status
Height, weight
Medication taken on morning of surgery
c. A preoperative checklist is utilized
2. Verification Process
a. The marks are made by the physician performing the procedure and must be:
Placed using a permanent marker at or near the incision/insertion site
Visible at time of patient preparation and visible at time of incision
Explicit (e.g. initials) to indicate the intended site of incision or insertion
b. If site marking meets exemption criteria as outlined in 6.1.3.1 of the OHP standards, this is documented in the patient’s record
c) The first verification takes place in the pre-procedure area.
d) The patient is awake and aware
e)The nurse preparing the patient for the procedure Confirms the patient identity, procedure, site
and/or side with the patient/substitute decision-maker/legal guardian
Documents the first verification on the “Surgical Safety Checklist”
Second Verification
f. The second verification must be conducted during the time-out in the location where the procedure takes place, immediately before starting the procedure
g. The entire procedure team confirms the patient identity, procedure, site and/or side and acknowledges their agreement: nurse(s), attending physician, attending anesthesiologist [if applicable], and physician-assistant [if applicable]
3. Intra-operative Patient Care
a. The nurse assisting in the procedure room/OR:
Completes an operative record with appropriate and accurate documentation regarding the procedure (e.g. pre-procedure assessment, consent form)
Verifies with the physician the correct patient position and availability of correct implants or special equipment required for the procedure prior to starting the procedure
Patient monitoring e.g., pulse, blood pressure and electrocardiography are in continuous use for the duration of anesthetic care
Audible and visual alarms are activated
4. Post Procedure Patient Care (Level 2 & 3)
a. Staffing requirements for the recovery area meet the premises standards
verbal report provided to appropriate recovery-area staff which includes but is not limited to the following:
Name and age of patient
Procedure performed
Pertinent history including allergies, medical/physical limitations
Types of anesthesia/sedation used
Other medications given
Any unusual or adverse events pertaining to patient
Estimated fluid or blood loss
Anesthetic course
Post-Anesthetic Recovery Room Record
c. Registered nurse trained in recovery room procedures remain in continuous attendance to the patient
4. Post Procedure Patient Care (level 2 & 3)
d. Recovery area staff caring for patients in phase I, II, or III recovery provide care and document the following in the patient record. Information includes but is not limited to:
Patient identification
Date and time of transfer to recovery area
Initial and routine recording of blood pressure, pulse respiration, temperature, level of consciousness, oxygen saturation, pain score, procedure site and general status
Continuous monitoring of vital signs until the patient has met requirements of discharge criteria using an objective scoring system from time of transfer to recovery area until discharge from Phase II recovery
Any medications administered including dose, time, date, route, site, reasons and effects
Any treatments given and effects of such treatments
The name and signature of the post anesthetic care nurse
Is the post-anesthetic recovery room record included in the patient record?
e. The anesthesiologist/physician remains on site until the patient has met discharge criteria
f. Recovery area staff carry out action(s) according to a direct order or a medical directive as described in the premises policies and procedures
5. Patient Discharge
a. An anesthesiologist or physician is responsible for writing the discharge order based on the discharge criteria
b. The anesthesiologist or other physician qualified to administer IV sedation remains on the premises of the facility until the patient meets the documented pre-determined recovery criteria
c. A minimum of one ACLS certified staff member must be present in the facility until all patients recovering from anesthesia have met criteria for discharge from the facility
d. The patient is accompanied from the facility by a responsible adult
e. Appropriate verbal and written post-discharge instructions are given to the patient and accompanying adult.
f. The patient and accompanying adult are instructed to notify the OHP of any unexpected admission to hospital within 10 days of the procedure
g. Appropriate protocols and/or transfer arrangements to hospital are in place for ongoing care if patients do not meet required discharge criteria