SAMPLE Nursing Services Self-Assessment Questionnaire

Transcription

1 Hospital Name: Person Completing the Assessment: Date: I. Executive Leadership Yes No 1. Are leadership meetings held regularly? 2. Do leadership meetings include all facility leaders? 3. Are patient safety issues discussed? 4. Has the organization adopted a culture of safety? 5. Do leaders conduct walking rounds? 6. Are leaders actively engaged in patient safety initiatives? 7. Are unit-based patient safety programs in place? 8. If a culture of safety is in place, is it part of the quality improvement (QI) process and are improvements measured using a standardized tool (Agency for Healthcare Research and Quality (AHRQ), Health Research and Educational Trust (HRET), Press Ganey Safety Culture Tool)? 9. Is succession planning in place for leaders at all levels? 10. Are executive leaders specifically educated in effective leadership and management? II. Nursing Quality Review Process, Evidence-Based Practice and Quality Indicators Yes No 1. Is a formal nursing service quality review process integrated within the facility s quality improvement program? 2. Does a nursing-focused quality committee oversee nursing care? 3. Does the nursing quality committee utilize evidence-based nursing clinical indicators and/or screens that reflect the scope of nursing practice, including with regard to high-risk clinical presentations/procedures? 4. Do nursing clinical indicators include: a. Medication safety issues (e.g., high-risk medications, patient identification, and medication reconciliation)? b. Pain assessment/management issues? c. Medication errors and adverse drug events? d. Structured communication issues (e.g., critical result reporting, hand-offs) e. Delegation and Chain of Command? f. Criterion-based patient safety interventions (e.g., fall prevention, skin safety, safe patient handling, restraint usage)? g. Unexpected transfers to a higher level of care? h. Documentation procedures (e.g., legibility, clinically pertinent assessments, interventions, proper completion of flow sheets, use of abbreviations)? 5. Are both clinical/service indicators and human resource screening indicators used to assess and improve staffing effectiveness (e.g., clinical/service: falls, skin breakdown, complaints, post-op infections; human resource: overtime, sick time, turnover rate, staff injuries on the job)?

2 II. Nursing Quality Review Process, Evidence-Based Practice and Quality Indicators Yes No 6. Are nursing quality initiatives centralized for participation across all units? 7. Does the nursing QI process include formal data collection, analyses, recommendations, actions and evaluations of the effectiveness of actions? 8. Are formal meeting minutes kept that reflect data presentation and review with respect to nursing quality improvement activities? 9. Are nursing quality improvement activities reported to the facility s quality oversight committee? III. Nursing Orientation, Education and Competency (High-Risk Clinical Presentations and Procedures) 1. Is a centralized process in place to ensure that competencies and certifications (e.g., ACLS, PALS) are kept current across all nursing units? 2. Are high-risk clinical presentations and procedures reviewed at the time of orientation and on an annual basis thereafter? 3. Do high-risk clinical presentations and procedures address (at a minimum): a. Competency-based medication administration (including patient ID and verification process, drug indication, dosage, route and contraindications)? b. PCA side-effects and adverse reactions? c. Cardiac, respiratory, circulatory, orthopedic and pediatric emergencies? d. Criteria-based skin care competency? e. Criteria-based fall prevention competency? f. Structured communication process (e.g. SBAR)? g. Safe lifting and transfer techniques? h. Restraint use? i. Documentation procedures for clinically pertinent assessment, intervention and communication? 4. Are staff member competencies available on each unit? 5. Is a formal annual educational plan in place? 6. Is a competency assessment process in place? 7. Are leadership training, formal education and competency evaluation processes in place for supervisors and charge nurses? 8. Does the general nursing orientation process address new employees, as well as agency/traveler nurses? Yes No

3 IV. Nursing Staffing Ratios, Supervision, and Delegation Yes No 1. Is a formal process in place to ensure that the nursing service is appropriately staffed with RNs, LPNs and other personnel to provide nursing care to patients? 2. Does the staffing effectiveness program correlate patient acuity with staffing allocations? 3. Is a formal process in place to evaluate patient events in conjunction with staffing effectiveness? 4. Is a skilled nursing supervisor and/or charge nurse available on all shifts? 5. Are delegation and delegation acceptance addressed by a policy, procedures and/or a competency? 6. Does an RN supervise and evaluate the nursing care for each patient? V. Admission Assessment Yes No 1. Does a structured admission assessment document prompt patient assessment for: a. Fall risk? b. Pressure ulcer/skin breakdown risk? c. Pain/pain management needs? d. Advance directives? e. Depression and suicidal ideations? f. Medical, surgical, social and family histories? g. Medication history (including current medications, allergies and sensitivities)? 2. Are risk scoring mechanisms utilized for pain, fall and skin assessments? 3. Does risk factor identification direct patient care planning, interventions and reassessment frequencies? 4. Are clinical pertinence audits performed to evaluate risk assessment documentation (fall, pressure ulcer, pain) and patient safety intervention processes?

4 VI. Nursing Communication and Monitoring, High-Risk Emergency Response, Codes, Critical Lab Values and Chain of Command 1. Are the following medication safety practices in place: a. Bar coding? b. Double-check processes/checklists? c. Pre-printed standardized order sheets? d. Evidence-based protocols? 2. Is a standardized process in place for verifying and documenting telephone/verbal orders? 3. Are quarterly audits performed to evaluate telephone/verbal order documentation and double-check processes? Yes No VII. Documentation (Clinically Pertinent Assessment, Intervention, Communication and Documentation) 1. Are policies and procedures in place to address nursing documentation? 2. Are documentation templates for high-risk presentations used to prompt comprehensive clinically pertinent assessment, intervention, communication and documentation? 3. Is documentation legible and does it reflect the care, treatment and patient response to treatment? 4. Is a standard medical record format used to facilitate consistent and ready retrieval of clinical information? 5. Does the documentation in the medical records clearly reflect the discharge planning process? 6. Is a process in place for performing quality audits of the documentation of individual nursing staff members? If yes, does it include review of: a. Legibility? b. Clinically pertinent assessment? c. Interventions? d. Communication? e. Abbreviation use? f. Proper completion of flow sheets? Yes No

5 VIII. Discharge Process and Instructions Yes No 1. Are written discharge instructions provided to every patient? 2. Are written discharge instructions: a. Diagnosis-specific? b. Documented in a manner the patient can understand? c. Written without using medical terminology and abbreviations? d. Documented to permit and encourage patient questions? 3. Do discharge instructions include: a. Specific follow-up care guidance? b. Immediate medical provider contact information (and signs and symptoms for concern)? c. Medication reconciliation and instructions for all medications on the discharge sheet? 4. Is there documentation that the patient verbalized understanding of the discharge instructions? 5. Are clinical pertinence audits performed to evaluate discharge documentation practices? IX. Ethical Considerations Yes No 1. Does education on privacy and confidentiality address the use of social media and cell phones? 2. Do policies and procedures address the management of patients in police custody? 3. Has an ethics committee been identified to address ethical issues in patient care? 4. Do policies and procedures address withdrawal of patient care and the withholding of treatment? 5. Do policies and procedures address do-not resuscitate (DNR) orders? 6. Do policies and procedures address interpreter services for the hearing impaired and those with language barriers? 7. Does annual education address cultural diversity, including with regard to ethnicity, religion and subcultures? 8. Do policies and procedures address the management of patients who wish to smoke during inpatient stays?

6 X. Environment of Care Yes No 1. Does a multi-disciplinary team conduct environmental rounds on a regular basis? 2. Is a checklist utilized to guide the scope of environmental rounds? 3. Does a policy and procedures address equipment maintenance and cleaning? XI. Safety and Security Yes No 1. Is access to all nursing units controlled and monitored? 2. Are patients, family members and visitors monitored? 3. Are potential security risks identified during the initial assessment? 4. Are restraints used appropriately to keep patients and visitors safe?