Pre-Visit Questionnaire: Out-of-Hospital Premises Inspection Program

Transcription

1 Submission Checklist Please ensure you include the following documentation in your completed submission: Completed Pre-Visit Questionnaire Submission Checklist Completed and signed Pre-Visit Questionnaire Copy of your Policy and Procedure Manual Copies of certifications for formal training in sterilization/reprocessing current within the past 5 years. (see question 1) Copies of current BLS*/ACLS**/PALS certificates as applicable for each non-anesthesiologist at the premises involved in administering anesthesia, monitoring, and/or recovering patients. (See questions 1 and 2c) Copies of certificates from regulatory body documenting non-physicians have the required certification as outlined in the OHP Standards. (See question 3) Copies of documentation of training only for those physicians that are not RCPSC-certified as outlined in the OHP Standards. (See question 4) *As per the OHP Standards, the minimum certification for any RN or RPN is BLS **As per the OHP Standards, an ACLS course MUST include a theory and hands-on training component This questionnaire must be completed by the premises Medical Director. Please PRINT in black or blue ink. Name of Medical Director: Does this premises also have an IHF license? Yes No If Yes, identify the IHF Quality Advisor: Name of Premises: Address of Premises: Hours of Operation: OHP procedures are performed at this premises for patients age 14 and under : Yes No Best Contact Information for Medical Director (complete all that are applicable): Premises Phone: Premises Fax: Pager: Cell: Other: C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 1 of 13

2 A. STAFF & QUALIFICATIONS 1. List OHP personnel and indicate their work term, certification and role (as applicable) in procedures. (Please provide copies of BLS*/ACLS**/PALS certificates for all nursing staff) Names of Nursing Staff Nurse Practitioner RN RPN PA Full- Time Part- Time BLS* ACLS** PALS Recovers Patients With patients for overnight stays Administers Anesthesia Monitors Patients intraprocedure Name of staff involved in the Reprocessing/sterilizing (provide training certificate***): Names of additional personnel (admin, other technicians---provide training certifications): *As per the OHP Standards, the minimum certification for any RN or RPN is BLS **As per the OHP Standards, an ACLS course MUST include a theory and hands-on training component ***As per the PIDAC Infection Prevention and Control for Clinical Office Practice: staff responsible for sterilization/reprocessing must have Regular education (including orientation & CME) in infection control. Certification should be current within the past 5 years. C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 2 of 13

3 2. a) List all** physicians (e.g. surgeons, anesthesiologists) providing services at the premises: (If needed, please make additional copies of this form.) Physician Name(s): CPSO # Specialty Most common procedures performed OR Procedures anesthesia most commonly provided for Frequency of attendance at this OHP location Has Current Hospital Privileges Name of Hospital(s) where physician has current privileges Has current BLS/ACLS/ or PALS C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 3 of 13

4 2. b) All premises physicians that administer anesthesia, monitor and/or recover patients are anesthesiologists. Yes No c) If no, please list all non-anesthesiologist physicians at the premises involved in the following procedures. Physician Name(s): Administers Anesthesia Monitors Patients Recovers Patients Has current BLS Has current ACLS* Has current PALS Provide copies of current BLS/ACLS*/PALS certificates as applicable for each of these physicians. *As per the OHP Standards, an ACLS course MUST include a theory and hands-on training component C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 4 of 13

5 3. List any International Medical Graduates (IMGs)/Fellows/Residents or physicians working under supervision and explain their roles (select all checkboxes that apply and provide any relevant certifications). All are expected to have notified they work at the premises using the online notification form. Name(s): IMG Fellow Resident Practising under Supervision Name of Supervising Physician Outline duties or responsibilities at Premises C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 5 of 13

6 4. Does each regulated health professional (non-physician) meet the required qualifications to practice in their scope of practice within Ontario? Yes: No: If No, please explain: Please attach copies of certificates from their regulatory body documenting that non-physicians have the required certification as outlined in the OHP Standards. 5. Does each non-rcpsc certified physician meet the required qualifications (as outlined in the OHP Standards) to practice in their scope of practice within Ontario? Yes: None of our physicians are non-rcpsc certified: No: If No, please explain: Please attach copies of documentation of training for only those physicians that are not RCPSC certified. 6. Does the Medical Director ensure that all regulated health profession staff maintain current and track their Continuing Professional Development? Yes: No: If No, please explain: 7. Does delegation occur at your premises? Yes: No: If Yes, please explain: C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 6 of 13

7 B. PREMISES S PROCEDURES & ANESTHESIA 8. Please provide the following information about the procedures performed at the premises: (If needed, please make additional copies of this page to complete your list of physicians.) Type/Scope of Surgical Procedure done at Premises (e.g., ophthalmology, cosmetic surgery, interventional pain) Specific Procedure(s) Performed Type of Anesthesia for each Procedure (general, IV sedation and/or analgesic, major regional block, retrobulbar block, local, other) Number of ADULT Procedures per Month Number of Pediatric Procedures per Month C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 7 of 13

8 C. OHP LEVEL AND STANDARDS 9. The OHP level has two determinants: anesthesia and procedure the level is decided by the higher ranking of the two (as per the OHP Standards). Please indicate which level best describes your OHP: OHP Level OHP Level 1 OHP Level 2 OHP Level 3 Anesthesia Procedure Select the level that applies to this Premises with a checkmark Local infiltration Minor nerve block (e.g. digital) Tumescent anesthesia < 500cc of infiltrate solution IV Sedation Regional anesthesia (e.g., major nerve blocks, spinal, epidural, or caudal) Tumescent anesthesia > 500cc of infiltrate solution Minimally Invasive: No surgical wound is created and Procedure does not interfere with target organ function or general physiological function. Limited Invasiveness: Surgical wound is created, but not for the purpose of penetration of a body cavity or viscus (e.g., rhinoplasty, facelift) and Procedure has minimal impact on target organ or general physiological response and/or Liposuction 1 to 1000cc of aspirate and/or A small subcutaneous implant is inserted (e.g. lip, chin) General anesthesia Significantly Invasive: Surgical wound allows access to a body cavity or viscus (e.g., laparoscopic banding surgery, arthroscopy), OR A significant amount of liposuction aspirate is removed ( cc.) OR A large prosthesis is inserted (e.g., augmentation mammoplasty). Additional Comments or Reasoning C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 8 of 13

9 D. ONSITE EQUIPMENT & MAINTENANCE 10. Please list the equipment currently in use at this premise. If needed, please make additional copies of this page to complete your list. (Please have the calibration records, as applicable, available for the assessor(s) on the day of the inspection). Type of Equipment (e.g., ECG, EKG which need to be quality checked and/or calibrated) Year of Manufacture Manufacturer Equipment is CSAapproved or licensed for Canada: Y/N Serial No. Date Acquired Modifications & Upgrades Daily Inspection Documented (enter name, title of staff person who documents or indicate N/A) Regular Maintenance Performed by qualified personnel (indicate the name of staff, contractor or N/A) 11. Is there a plan for updating, upgrading and/or renewing equipment? YES NO C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 9 of 13

10 12. Specific equipment is available for the management of: a. Malignant hyperthermia b. Cardiac arrest c. Difficult airway management d. Latex allergy e. Emergency patient transfer E. RECORD-KEEPING 13. Which describes your records? a) Hand written/paper records b) Electronic medical/clinical/patient records If electronic: Specify the software/vendor Is the system password protected? Yes: No: 14. Are all medical records are kept at the premises? Yes: No: 15. What language do you use for your records? English French 16. There is space assigned in the patient record for the following recovery room score items, if they are applicable to the OHP level and the related procedures provided: YES NO N/A a) Vital signs b) Fluid balance c) Medication d) Repeated pain assessment F. POLICIES & PROCEDURES Your premises should have a Policy and Procedure Manual relevant to the type of procedures being performed in C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 10 of 13

11 the premises (see pages of the OHP Standards or see next page). A copy of this (and documentation requested elsewhere in this questionnaire) must be provided to the College with questionnaire. For help, see page 1 Pre-Visit Questionnaire Submission Checklist. this completed 17. Where, on site, is your Policy and Procedure manual kept? 18. How frequently is the Policy and Procedure Manual reviewed, signed and dated by staff? 19. Are the following included in the premises s Policy and Procedure Manual: (a) Administrative Policies (b) Staff Job Descriptions (c) OHP Organizational Chart (d) Scope and Limitation of Services Provided (e) Adverse Events (f) Combustible and Volatile Materials (g) Delegating Controlled Acts (h) Emergency Evacuation (i) Equipment: Maintenance and Calibration (j) Infection Control (k) Medications Handling and Inventory (l) Medical Directives (m) Patient Booking System (n) Patient Consent (o) Patient Preparation for Procedures (p) Response to Latex Allergies (q) Safety Precautions (i.e. fire, electrical) (r) Urgent Transfer of Patients (s) Waste and Garbage Disposal (t) Forms (u) Inventories/Lists of Equipment and Medications (v) External policies YES NO C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 11 of 13

12 If you answered NO to any in the above list, explain why this is not relevant to your premises: 20. Are there additional policies in place for the following: (a) Patient Identification (b) Patient monitoring during surgery/procedure (c) Attended Recovery post surgery/procedure (d) Regular monitoring of O.R. Anesthetic Gas Pollution YES NO Note: A copy of your Policy & Procedure Manual must be sent to the College either in hard copy, by attachment in PDF format, CD or USB. All formats provided to the College will be maintained in our records and will not be returned to the premises following the inspection-assessment. I certify that the information provided on this questionnaire is correct and complete. Name of MEDICAL DIRECTOR signing this form (please print) : Signature : Date: C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 12 of 13

13 CONSENT TO DISCLOSE INFORMATION FOR OUT-OF-HOSPITAL PREMISES INSPECTION PROGRAM I,, the Medical Director of (Name of Medical Director) (Name of Premises) Authorizes the Out-of-Hospital Inspection Program at the College of Physicians and Surgeons of Ontario to disclose information pertaining to the premises to the following individual(s): Name of Individual Role at the Out-of-Hospital Premises While I authorize the individuals above to obtain information with regards to the premises, I understand that it is my role as the Medical Director to keep informed on all matters relating to the premises outlined within the Out-of-Hospital Premises Inspection Program Standards. I also understand that as the Medical Director of the premises I am responsible for the premises. Lastly, I understand that I must provide written notice to the Out-of-Hospital Premises Inspection Program immediately if I have revoked consent for any of the above named individuals. Signature of Medical Director Date C:\Users\sgopaul\Desktop\PVQ Final March 2015.doc Page 13 of 13