Community Hospital Self Assessment

Community Hospital
Self Assessment

Instructions	Licensure and Insurance	HIPAA	Employee Training	Lab	Anesthesia	Emergency Room	Risk Management
Quality Improvement	Environment of Care	Restraint Use	Infection Control	Falls Management	Patient Management	Documentation	Pharmaceutical Management

CRITERIA MEASURE	Met	Not Met	Comments	Refer to Department
Orientation is complete before working in designated department
Annual required training is complete and documented to include at least:
Annual Safety Training
Infection Control
Customer Service
Incident Reporting
Risk Management
Fire and Disaster Preparedness
Confidentiality
New laws and regulations
Competency skills are measured at least annually
Required CEUs are current for licensure
Anti-coagulant therapy educational and safety programs are taught to all appropriate staff
Falls management is conducted at orientation and at least annually
Employees participate in a community wide emergency drill annually
Restraint regulations and applications training is provided on orientation and at least annually
There is a method in place for anonymous reporting of abuse or neglect
Required HIPAA standards are trained at orientation and at least annually
Employees are trained to report sentinel events according to hospital policy
Managers are trained to conduct Root Cause Analysis for Sentinel Events
Employees are trained to implement changes identified through QA and Risk Management
Employees know the hospital's mission statement, vision, goals, objectives and plans
Employees are educated regarding criminal acts, abuse, neglect, rape
Lab employees are trained according to CLIA requirements