Hospital Inspection Template by nma21016

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									                                                     CHAN CHILDREN’S HOSPITAL
                                                   ENVIRONMENT OF CARE ROUNDS
                                                      SURVEY QUESTIONNAIRE


Department___________________________________              Location – Building: ___________ Floor: ____ Room(s): _________________

Survey Conducted on: ___/___/___ Time : _________ By: ______________________________________________________________
                                                                                                  Print name & signature
Department Head _______________________________________ Department Manager________________________________________
                                                                                                  Print name & signature
Notes attached to SURVEY QUESTIONNARIE [ ] Yes [ ] No
Survey Questionnarie Routing Original: Safety Officer
                             Copy:     Department Head [ ] Department Manager [ ] Administration [ ]

                                                                                                                    Page 1 of 3
         SAFETY MANAGEMENT
No.      Statement                                                           Method Used to Survey        Yes No NA           Comments

*1.      Staff have received instruction                                     Leadership verification      [ ][ ][ ]           ______________
         on Department Specific Safety Plan

 2.      Department Specific Safety Policy reviewed every                    Obtain Policy & review       [ ][ ][ ]           ______________
         3 years

* 3.     Document completion of Department specific                          Leadership verification      [ ][ ][ ]           ______________
         Safety Education for all associates, I.e. Review of your
         Department’s Fire Response and Evacuation Procedure.

 4.      Staff knows process to report patient safety events                 Random staff interview       [ ][ ][ ]           ______________
         & associate injury events

*5.      Staff can describe their role in the event of an                    Random staff interview       [ ][ ][ ]           ______________
         equipment failure E.g., (placement of Defective Tag
         on equipment/take out of service/report)

*6       One or more Staff has completed Crisis Response Training            Leadership verification      [ ][ ][ ]           ______________

         SMOKING

 7.      Staff knows how to report evidence of smoking violations.           Random visual inspection     [ ][ ][ ]           ______________

         SECURITY

8.       Patient valuables are secure                                        Random visual inspection     [ ][ ][ ]           ______________

9.       Staff valuables are secure                                          Random visual inspection     [ ][ ][ ]           _____________

*10.     Offices are kept locked when not occupied to deter Theft            Random visual inspection     [ ][ ][ ]           ______________

*11.     Cables to lock down lap tops and computers in use in                Random visual inspection     [ ][ ][ ]           ______________
         common areas to deter Theft

*12.     Staff can describe the procedure for response &                     Random staff interview       [ ][ ][ ]           ______________
         reporting Code Pink incident e.g., infant or
         child abduction.

*13.     Staff displaying ID badge at all times                              Random visual inspection     [ ][ ][ ]           ______________

*14.     Staff can describe their Units procedure for response &             Random staff interview       [ ][ ][ ]           ______________
         reporting Security incident e.g., Code Grey = thefts, work place
         violence

         HAZARDOUS MATERIALS & WASTE

*15.     Staff can describe their role in the event of a                     Random staff interview       [ ][ ][ ]           ______________
         Hazardous material spill or release

16.      Only those hazardous chemicals listed on the                        Random visual inspection     [ ][ ][ ]           ______________
         Department’s Chemical Inventory is present


17.      Sharps/Syringes properly stored.                                    Random visual inspection     [ ][ ][ ]           ______________



                                                                                                                                               1
* = Performance Monitors
                                                     CHAN CHILDREN’S HOSPITAL
                                                      SURVEY QUESTIONNAIRE
                                                                                                     Page 2 of 3
        HAZARDOUS MATERIALS & WASTE MANAGEMENT (continued)
No.     Statement                         Method Used to Survey                          Yes No NA   Comments

*18.    Staff can identify precautions to follow              Random staff interview     [ ][ ][ ]   ______________
        when working with hazardous materials.
        E.g. Use appropriate personal protective equipment.

*19.    Staff demonstrate the ability to access               Random visual inspection   [ ][ ][ ]   ______________
        MSDS via 3E Company’s MSDS FAX on
        DEMAND SERVICE, or 3E Company’s
        ONLINE SERVICE

20.     Hazardous materials including waste is                Random visual inspection   [ ][ ][ ]   _______________
        appropriately labeled and segregated


21.     Compressed gas cylinders are properly                 Random visual inspection   [ ][ ][ ]   _______________
        stored & secured.

        EMERGENCY PREPAREDNESS MANAGEMENT

*22.    Staff can describe their role in the event            Random staff interview     [ ][ ][ ]   ________________
        of a Mass Casualty. (Code Triage)

*23.    Staff knows the location of the                        Random staff interview    [ ][ ][ ]   ________________
        Environment of Care manual and that it contains Department
        Specific Safety information including Emergency operations
        response procedures and response to Utilities failure.

*24.    Staff can describe decontamination                    Random staff interview     [ ][ ][ ]   ________________
        procedures they should follow if contaminated.

*25.    All associates can identify the designated phone      Random staff interview     [ ][ ][ ]   ________________
        extension to call to report any Hospital emergency
        I.e. FIRE - SECURITY – MEDICAL

        FIRE PREVENTION MANAGEMENT

26.     Staff know Fire response procedures (RACE)            Random staff interview     [ ][ ][ ]   ________________

*27.    Staffs know the 3 Steps of Evacuation.                Random staff interview     [ ][ ][ ]   ________________

28.     Storage minimum 18” from sprinkler head               Random visual inspection   [ ][ ][ ]   ________________

29.     Staff can locate Medical Gas shut off valve           Random staff interview     [ ][ ][ ]   ________________

*30.    In the event of a Fire, if deemed necessary,          Random staff interview     [ ][ ][ ]   ________________
        Nursing staff can identify staff person on Unit
        responsible for shut-off of the Oxygen

31.     Hazardous Areas are maintained with self-             Random visual inspection   [ ][ ][ ]   ________________
        closing door & positive latching
        E.g., Soiled/Clean Utility Rooms, Laboratories

32.     Fire extinguisher inspection tags are current         Random visual inspection   [ ][ ][ ]   ________________

33.     Staff can identify need to clear hallways of          Random visual inspection   [ ][ ][ ]   ________________
        equipment as second step to Unit Fire Response.
        (After closing doors)

34.     Fire & smoke doors, emergency “Stairs Exit”           Random visual inspection   [ ][ ][ ]   ________________
        doors are not blocked or wedged open

35.     All fire protection equipment has clear access        Random visual inspection   [ ][ ][ ]   ________________
        E.g., fire hose/portable fire extinguisher cabinets

36.     Fire & smoke doors, emergency “Stairs Exit”           Random visual inspection   [ ][ ][ ]   ________________
        doors close automatically & latch

*37.    Emergency Exit egress corridors is unobstructed       Random visual inspection   [ ][ ][ ]   ________________

38.     Emergency “Stairs”, “Exit” signs are illuminated      Random visual inspection   [ ][ ][ ]   ________________

39.     Extension cords are not used                          Random visual inspection   [ ][ ][ ]   ________________


* = Performance Monitors                                                                                                2
                                                      CHAN CHILDREN’S HOSPITAL
                                                       SURVEY QUESTIONNAIRE

          FIRE PREVENTION MANAGEMENT

40.       Portable heating devices are not used                     Random visual inspection      [ ][ ][ ]   _______________
          In patient care areas

                                                                                                              Page 3 of 3
EC.1.6    MEDICAL EQUIPMENT MANAGEMENT
No.       Statement                                                 Method Used to Survey         Yes No NA   Comments

*41.      Patient caregivers can hear and or provided with a        Random staff interview        [ ][ ][ ]   ________________
          System that otherwise alerts them in the event of a
          Medical Equipment Alarm activation within their
          Nursing Unit or other Clinical Care Area

*42.      Clinical staff demonstrate the ability to                 Random visual inspection      [ ][ ][ ]   ________________
          access Patient care equipment inventory
          & PM inspection record information via
          Advocate On Line. I.e. Cardiac Monitor, Ventilator

EC.1.7    UTILITIES MANAGEMENT

*43.      Department Leadership is educating and                      Leadership verification     [ ][ ][ ]   ________________
          documenting on an annual basis their Associate’s
          competency on the appropriate interventions
          (Preparations to Make to Minimize Each Potential Problem)
          and response (Assessment of the situation & Action required)
          during a utility interruption. I.e. Loss of Electricity, Oxygen, or Water


44.       Staffs know location(s) of Red outlets                    Random staff interview        [ ][ ][ ]   ________________
          servicing life support equipment located
          within their work area.

                                                                SURVEY TEAM NOTES

To be completed by the Survey Team & Department representative at the closing of the Validation

Recommendations




Associate Emergency Handbook or other document designed for quick reference to emergency procedures.

Displayed in the department                                                     Yes No NA
                                                                                [ ][ ][ ]
Comments _______________________________________


CODE RED (Department Specific Fire Plan Information) is current                 Yes No NA
                                                                                [ ][ ][ ]
Comments _______________________________________

CODE RED (Department Specific Fire Plan) is                                     Yes No NA
displayed in the department.                                                    [ ][ ][ ]

Comments__________________________________________________________________________________________

___________________________________________________________________________________________________


* = Performance Monitors                                                                                                         3

								
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