Readiness Assessment

Of the 188 standards that are part of the SC accreditation set of standards, six (6) – outlined below - are good predictors of the readiness of a healthcare organization for accreditation.

Please respond to each of the following questions to help determine how close the organization is to being ready for a SafeCare Accreditation survey.

1. Is there an organization-wide quality improvement and patient safety program already in place and active that brings the concepts of continuous improvement to every managerial and clinical process within the entire organization?

a. Leadership for quality and patient safety is clearly present throughout the healthcare organization.
b. Governance and management jointly approve the healthcare organization clinical quality and patient safety plan and set priorities for healthcare organization improvement actions.
c. Governance and management seek out best practices from national and international sources.
d. Governance and management receive regular reports on the clinical quality and patient safety program.

2. Are all the following World Health Organization (WHO) researched and tested measures, currently used in the organization to improve patient safety:

a. The healthcare organization develops and implements a process to improve the accuracy of patient identification.
b. The healthcare organization develops and implements processes to ensure safe surgical practices.
c. The healthcare organization develops and implements a process to reduce the risk of harm to in-patients resulting from falls.
d. The healthcare organization develops and implements processes to improve the safety of high-alert medications.

3. Are clear and timely internal and external communication channels in place among practitioners to support excellence focused care for all patients?

a. The healthcare organization identifies those patients and populations likely to benefit from improved care integration.
b. The healthcare organization explores potential processes for the real time exchange of patient care information among the care providers for the identified patients and populations.
c. The healthcare organization works to integrate the care of the identified patients and populations through an integrated care plan.
d. The healthcare organization has a process to facilitate continuing care for the identified patients and populations with social, religious and other agencies or resources in the community when appropriate.

4. Is an organization-wide risk management plan and program in place and active?

a. A qualified/experienced individual/team is responsible for risk management.
b. All risks, both clinical and non-clinical, are identified and recorded in a risk register.
c. Based on the identified risks corrective and/or preventive actions (CAPA) are defined and implemented.
d. All staff receive on-going in-service training about risk management.

5. Is an organization-wide infection control plan and program in place and active?

a. Policies and procedures on infection prevention control (IPC) are in place and guide the staff in the implementation of the organization-wide program.
b. A qualified member of staff monitors the infection control program.
c. Regular in-service training is given to all staff on the subject of infection control.
d. Data from IPC monitoring is analyzed for internal use and external reporting to the appropriate external public health agencies.

6. Are clinical practice guidelines used to standardize and reduce variation in patient care and treatment?

a. Clinical practice guidelines, from recognized authoritative sources, are present and used to guide care for the services provided by the healthcare organization.
b. Staff is orientated and can explain how and when to use the clinical practice guidelines.
c. Guidelines are reviewed and kept current and new guidelines reviewed and adopted.
d. Actual guideline use is monitored, and the results used for continuous improvement in clinical services.

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Accreditation readiness assessment part 2

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