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
The lab is CLIA approved or certified
The staff member named on the CLIA certificate establishes policies and procedures that define which waived test results are used in patient care, treatment and service
Quantitative test result reporting in the patient's record are accompanied by reference intervals specific to the test
Criteria for conformity testing for each test is specified in policy and procedures
The staff member named on the CLIA certificate establishes staff responsible for performing and supervising testing
Usage is in compliance with hospital policies
Staff is identified for performed lab tests; signatures are affixed to proper documentation
Supervisors and Directors are identified
Employees demonstrate competency by test performance and certification
Quality checks are performed at scheduled intervals
Quality control checks are performed daily on specified equipment and instruments include:
How the test is used
Reagant stability
Manufacturer's recommendations
Hospital's experience with testing
Current acceptable guidelines
All quality tests are documented including internal, external, liquid and electronic
Test results are documented in the patient's record
Audit trail can be established between physician orders, patient's results report and nursing documentation