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
Hospital wide infection control program is implemented, monitored and measured for success
The hospital has a system for reporting infection surveillance, prevention:
Appropriate staff
Local public health, state and federal authorities
Systems for investigation outbreaks are in place
Policies and Procedures are reviewed and updated at least annually
Risk analysis is conducted at least annually to identify inadequate IC protocols
Hospital acquired infections are tracked and trended
Infection control goals are established and updated at least annually
Recurring infection types are analyzed and eliminated in a timely manner
The hospital adheres to CDC guidelines for hand washing
Sterile field is maintained according to professional standards
Staff is trained to maintain sterile fields
Environmental Services uses appropriate disinfectant on surfaces
Personal Protective Equipment is available at all work stations
Staff are offered flu vaccine on site