Download ECRI Physician Practice Risk Management Self

Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Physician Practice Risk Management
Initial assessment by: Carie Thurk
Date: September 2013
In consultation with: Karla Amundson, Barb Mlsna, Colleen Daines, Sara Martinez, Jenny Nottestad,
Jamie Rueckheim, Danielle Marx, Sheryl Barker, Peggy Tainter, Amy Schanhofer
Date of previous assessment:
Yes
No
N/I*
NA
Comments
Credentialing/Competency
1. Is there a formal credentialing and periodic
recredentialing process for all providers (e.g.,
physicians or other licensed independent or
dependent practitioners) associated with the office
practice?
X
2. Is there a mechanism for periodically reassessing each
provider's and each employee's clinical
competence?
X
2.1. Is this evaluation documented?
X
2.2. Is there written evidence of current clinical
competence for all providers performing special or
invasive procedures and staff assisting with such
procedures in the office?
X
3.1. Are there current, written collaborative practice
agreements for midlevel providers (e.g., physician
assistants, nurse practitioners), as applicable?
X
4. Do unlicensed assistive personnel (e.g., medical office
assistants) function under the supervision of a
licensed healthcare professional?
X
5. Is there a formal office orientation program with
periodic (annual, at minimum) educational updates
for all providers and staff?
X
5.1. Is education provided in mandated areas such as
that required by the Occupational Safety and Health
Administration, the Health Insurance Portability
and Accountability Act (HIPAA), the Clinical
Laboratory Improvement Amendments of 1988
(CLIA), and the Americans with Disabilities Act
(ADA)?
5.2. Are annual programs on risk management and
patient safety included?
X
X
* “N/I” stands for Needs Improvement.
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
Tel +1 (610) 825-6000
Fax +1 (610) 8341
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
6. Are all clinical staff certified in cardiopulmonary
resuscitation (CPR) and trained in
emergency- response procedures?
X
7. Are all office providers and staff trained in the use of
office equipment during orientation and on all new
devices before the devices are placed into use?
X
No
N/I*
NA
Comments
Office Procedures
8. Is there a written manual of office procedures
addressing administrative, operational, and patient
care procedures?
8.1. Are diagnostic and/or therapeutic procedures
performed by licensed/certified personnel where
required and under the supervision of a qualified
provider?
a. Are radiologic imaging procedures performed in
the office?
b. If yes, do all potentially exposed personnel wear
radiation-monitoring devices?
c. Are protective measures taken to avoid
unnecessary radiation exposure for patients and
staff?
d. Are procedures in place to identify and handle
patients who may be pregnant?
9. Are patients identified and the site of the procedure
verified before the start of any procedure?
10. Are there procedures for handling a minor who
presents for treatment but is unaccompanied by a
parent or guardian?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
M
RP
M
D
M
D
Each department
has policies and
procedures. RP
Process Masnual
is currently being
worked on.
Dental Policy
and Procedure
Manual
Radiology
Operating &
Safety Procedure
M
D
D
M
D
M
D
M
R
D
M
Tel +1 (610) 825-6000
Consider signage
in each Dental
unit, “Tell Dental
Staff if you think
you might be
pregnant.”
Regulatory
Guidelines
regarding
treatment of
minors.
Substituted
Consent for
Treatment of
Minors and
Incompetents
Form
Fax +1 (610) 8342
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
11. Do policies provide for the use of a chaperone
during intimate patient examinations?
12. Are patients assessed and monitored before, during,
and after office procedures according to medical
need and standards of practice?
No
M
Comments
M
M
M
D
13.1. Are mock emergency drills conducted periodically,
and is the adequacy of the response evaluated?
14. Does the practice use clinical practice guidelines that
are based either on evidence from recognized
sources or on current professional knowledge by
board- certified/eligible practitioners?
NA
D
12.1. Is the use of sedation or any other nonlocal
anesthesia governed by policies and procedures
addressing provider/ staff competency, patient
eligibility, informed consent, clinical monitoring,
and emergency interventions?
13. Is there a policy and procedure for handling
emergencies that arise in the office?
N/I*
Plan to
standardize
practice of
administration of
nitrous gas in
Dental for staff
safety
Emergency
Protocol Binder
in Treatment
Rooms, Code
Blue Procedure,
Ambulance
Transfer of
Patients are
included
M
Clinical
Guidelines
Policy
M
Medication Safety
15. Is a complete drug history—including prescription
and over-the-counter medications, herbal
products/nutritional supplements, and illicit
drugs—obtained and documented at the initial
patient encounter and updated periodically?
D
16. Is patient information readily available to providers
when ordering medications/writing prescriptions?
D
17. Is a copy of all medication orders and prescriptions
maintained in the patient's office record?
D
17.1. Is a current medication list maintained in the
records of all patients on drug therapy?
18. Are all medications, including biologicals and
samples, prescription pads, and syringes, stored
securely, inventoried, and controlled?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
M
D
Tel +1 (610) 825-6000
Fax +1 (610) 8343
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
18.1. Are drug samples, syringes, and needles stored in
locations inaccessible to patients, children, and
family members?
18.2. Are all medications that are dispensed from the
office properly labeled?
No
N/I*
Comments
X
D
18.3. Is there a drug sample control program that
includes inventory, periodic checks of expiration
dates, and a recall system?
X
19. Are emergency drugs and supplies appropriate to
the populations served, periodically inspected, and
maintained?
X
20. Are medications and biologicals prescribed and
administered only by qualified providers and by
staff within the scope of their license?
X
21. Do policies prohibit the use of presigned and/or
postdated prescription forms?
X
22. Are there protocols for handling patient requests for
prescription renewals?
X
23. Is there a policy that requires a —read back— of the
complete order by the person taking verbal or
telephone medication orders to confirm that they
are correct?
24. Are patients' identities confirmed and drug orders
verified before administration of medications in the
office?
NA
Prescriptions are
sent
electronically
X
X
Scheduling
25. Does the physician practice have a written policy on
scheduling?
X
25.1. Does the scheduling policy address:
a. scheduling of initial visits (with extra time
allocated to take an adequate medical history),
b. scheduling of routine appointments, and
X
X
c. scheduling of urgent/emergent visits or
“walk-ins?”
X
26. Is there a policy regarding missed appointments or
cancellations that includes permanent
documentation and notification of the provider to
determine action on rescheduling?
X
26.1. Are calls made or letters sent offering to
reschedule missed appointments, and is this
documented?
27. Does the practice manager periodically analyze
appointment patterns and scheduling to identify
areas of delay and possible solutions?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
X
Tel +1 (610) 825-6000
Fax +1 (610) 8344
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
27.1. When appointment delays occur, are patients told
how long they can expect to wait in the office?
X
27.2. Are patients given the option of rescheduling the
appointment?
X
28. Are patients identified upon registration for all office
encounters?
X
No
N/I*
NA
Comments
Telephone Procedures
29. Has the office staff received training on telephone
etiquette?
X
29.1. Does the training include handling angry or
dissatisfied patients in person or on the telephone?
X
30. Does the practice have a system for triaging
telephone calls?
X
30.1. Is this system based on physician-approved
protocols by appropriate-level staff?
X
30.2. Are callers allowed to speak before they are put on
hold?
X
Several staff had
training and
shared with
others
Telephone
Management in
Medical
Procedure
31. If an automatic call distribution system is used, does
it include an option for patients to speak to someone
in the event of an emergency?
X
32. Does the physician practice have a written policy on
telephone advice protocols?
X
32.1. Are the protocols in compliance with professional
practice laws?
X
32.2. Is a system in place to monitor staff compliance
with the protocols?
Event Report
X
32.3. Do nurses and other staff who give telephone
advice have specific training, experience, and
documented competence in telephone assessment
techniques?
32.4. Are staff instructed to consult a physician
whenever they have doubts about proper
instructions or advice?
X
X
32.5. Are physicians instructed to be receptive to
questions by office staff regarding patient calls?
X
33. Is there a consistent procedure for handling
phoned-in lab reports?
X
33.1. Does this include a policy addressing how to relay
“panic values” to the physician?
X
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
Tel +1 (610) 825-6000
Fax +1 (610) 8345
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
34. Is an answering service used during off-hours?
No
NA
Comments
X
34.1. If no, can messages be retrieved and addressed
promptly at all times?
X
34.2. If yes, are the service's policies and procedures for
answering physician office calls regularly reviewed?
X
34.3. Is the caller immediately informed that he or she is
dealing with an answering service?
X
34.4. Does the service verify the caller's name and
telephone number?
X
34.5. Is the service provided with an emergency
procedure in case the physician on call cannot be
reached?
N/I*
X
34.6. Are test calls placed periodically to assess the
performance of the answering service?
X
Health Information Management/Documentation
35. Have physicians and other staff received education
on the importance of clear, concise, timely, and
accurate documentation?
X
35.1. Does the education program on office
documentation address, for example:*
a. what to document (e.g., patient assessments,
interventions, or outcomes; all care-related
conversations with the patient and other
healthcare professionals; unsuccessful attempts
to contact the patient) and
b. how to document (e.g., write legibly, use
objective language to describe observations,
never erase or use correction fluid to correct a
mistake, never attempt to change or update the
record after notice of medical error or filing of a
lawsuit)?
36. Is dictation, transcription, and filing of reports
timely (e.g., within 24 to 48 hours)?
X
X
X
36.1. Are transcribed reports authenticated by signature
of the responsible provider in a timely manner (e.g.,
within 48 to 72 hours)?
X
37. Are medical records readily available to providers
when needed (e.g., when treating patients in the
office or over the telephone)?
X
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
Tel +1 (610) 825-6000
Fax +1 (610) 8346
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
38. Is drug, food, and other allergy information
documented prominently in the paper or electronic
record?
X
40. Is patient education regarding health problems,
medications, and plan of care documented?
X
41. Do patients receive written instructions and
information regarding self-care and follow-up?
X
41.1. Are instructions given to patients documented in
the medical record?
X
42. Is patient noncompliance and/or informed refusal of
recommended treatment documented?
43. Are all telephone calls in which a provider or staff
member provides treatment orders or advice
documented?
N/I*
NA
Comments
X
39. Are all chart entries signed and dated (by hand or
electronically)?
41.2. Are written instructions provided both in English
and in languages that represent the largest
limited-English-speaking groups?
No
X
X
X
43.1. Does this documentation include:
a. Patient name?
b. Caller name (if different from patient)?
c. Physician name?
d. Date and time of call?
e. Reason for call (caller's statement as he/she
relayed it)?
f. History of complaint, including effect of any
interventions taken at home?
X
X
X
X
X
h. Follow-up, if applicable?
X
X
X
i. Initials or signature of the staff member taking
the call?
X
g. Advice given/treatment ordered?
44. Is a random selection of medical records assessed
periodically for illegibility, inaccuracies, omissions,
alterations, or other red flags indicative of poor
charting practices?
44.1. Does documentation of procedures performed in
the office include:
a. Patient identification and verification of
procedure/site of procedure?
b. Patient assessment and monitoring?
c. Description of the procedure?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
Peer reviews
done of all
providers
X
X
X
Tel +1 (610) 825-6000
Fax +1 (610) 8347
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
d. Identification of any specimens and their
disposition?
e. Medications administered?
f. Patient condition at discharge?
45. Has the practice standardized abbreviations,
acronyms, and symbols for use throughout the
office and adopted a list of abbreviations, acronyms,
and symbols not to use?
46. Are policies and procedures in place governing
release of medical records and imaging films?
b. Requests for medical records containing sensitive
information (e.g., HIV status, psychiatric
information)?
c. Subpoenaed records and attorney requests for
records?
NA
Comments
X
X
X
X
X
X
46.3. Are appropriate staff members informed of these
policies and procedures?
X
46.4. Is there a mechanism in place to monitor
compliance with these policies and procedures?
X
47. Are medical records maintained securely and in a
manner that reduces the likelihood of
confidentiality breaches?
N/I*
X
X
X
46.1. If original imaging films are released, is there a
tracking system in place to retrieve them?
46.2. Do policies and procedures address both state law
and requirements of the HIPAA privacy rule for:
a. Requests for medical records from patients,
physicians, and others?
No
X
Confidentiality
48. Do all office staff who have access to patient
information receive training on maintaining patient
confidentiality?
X
48.1 Does confidentiality training address:
a. patient sign-in procedures,
b. procedures for relaying test results to patients,
X
X
c. procedures for facsimile (fax) transmission of
patient information, and
X
d. procedures for sending patient information via
electronic mail (e-mail)?
X
49. Has the office implemented environmental controls
(e.g., privacy windows, curtains) and allocated
private space for patient registration, examination,
treatment, and discharge?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
Tel +1 (610) 825-6000
Fax +1 (610) 8348
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
50. Is written patient consent obtained for the release of
information from the medical record in accordance
with applicable laws?
X
51. Has the physician practice implemented procedures
to comply with the health information privacy rule
under HIPAA?
X
No
N/I*
NA
Comments
51.1. Do these procedures include the following:
a. A notice of privacy practices and authorization
form describing the uses and disclosures of
protected health information (PHI) that the
physician practice may make, as well as the
patient's rights and providers' responsibilities
with respect to PHI, which should be provided to
patients with a good-faith effort to obtain
patients' signatures acknowledging receipt of the
notice before providing care
b. A process for keeping records of documented
disclosures of PHI and for accounting of and
responding to requests for disclosures made
51.2. Has the physician practice addressed the security
of individually identified protected health
information that is stored or transmitted
electronically, as required under the HIPAA
security rule?
51.3. Is there a security plan that includes
administrative, physical, and technical safeguards
for PHI that is collected, maintained, used, or
transmitted?
X
X
X
X
51.4. Does the security plan include remote access to
office information systems and the use of portable
computers such as personal digital assistants?
X
51.5. Does each provider and staff member who is
authorized to access office information systems
have a unique password?
X
51.6. Are electronic data systems backed up periodically
(e.g., nightly) to avoid loss of information?
X
Communication and Teamwork
52. Is there a process for tracking pending lab and other
test results, consultation reports, and other
pertinent documents to ensure their receipt by the
practice?
52.1. Is there a mechanism to ensure that lab and other
test results, consultation reports, and other
pertinent documents are acknowledged and
documented by the physician before filing?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
X
Tel +1 (610) 825-6000
Fax +1 (610) 8349
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
52.2. Is there a mechanism for reporting urgent
information to the physician immediately?
X
52.4. Is patient notification of test results documented?
X
52.5. Are patients told when test results are expected
and to call in by a certain date if they do not hear
from the office?
X
52.6. Is there a mechanism to ensure that arrangements
are made for recommended consultations, referrals,
or tests in a timely fashion?
X
52.7. Are there protocols in place for the use and
documentation of electronic communication (e.g.,
e-mail) with patients and/or between providers?
X
D
54.1. Is the answering service notified of these coverage
arrangements?
D
54.2. Are covering providers in the same specialty with
a comparable scope of practice available?
D
54.4. Do covering physicians have access to patient
records/information?
NA
Comments
X
54. Are policies in place to govern practice coverage
arrangements when physicians are unavailable?
54.3. Do physicians provide covering providers with
information regarding any anticipated patient care
problems and a report on hospitalized/acutely ill
patients before taking leave or becoming
unavailable?
N/I*
X
52.3. Is there a policy that requires patient notification of
lab results and other tests, even if results are within
normal limits?
53. Has the practice implemented a verification process
for taking verbal or telephone orders that requires a
“read back” of the complete order by the person
taking the order to confirm that it is correct?
No
X
X
Informed Consent
55. Are physicians and practice managers familiar with
informed-consent laws and regulations?
55.1. Is informed consent obtained and documented for
all invasive procedures or treatments associated
with more than a minimal amount of risk and for
those required by law?
56. Are informed-consent discussions documented by
the physician in the patient's office medical record?
57. Is specific informed consent for HIV testing
obtained?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
D
M
D
M
D
M
D
M
Tel +1 (610) 825-6000
Fax +1 (610) 83410
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
58. Is patient consent obtained and documented for the
taking of photographs, videotapes, or other
individually identifiable images of patients?
No
N/I*
NA
Comments
D
M
Legal and Regulatory Compliance
59. Is the physician practice evaluated for compliance
with Title I (employment provisions) of ADA?
X
59.1 Does this review ensure that, for example:
a. Employment applications are in compliance (e.g.,
they do not contain questions that seek
information about past or present medical
conditions)?
b. Preemployment testing requirements test only
for job- related abilities?
c. Hiring practices are in compliance?
d. Information obtained in postoffer physical
examinations is used only to assess the
candidate's ability to perform functions that are
job related and only in accordance with ADA?
e. Confidentiality of employee physical or medical
examination information is protected?
f. Employee benefits are available equally to
disabled and nondisabled employees?
60. Is the physician practice evaluated for compliance
with Title III (public accommodations) of ADA?
X
X
X
X
X
X
X
60.1. Does this review ensure that, for example:
a. Parking spaces for disabled persons are provided
near the entrance to the facility and are clearly
marked?
X
b. Signage is used to clearly mark
handicapped- accessible entrances?
X
c. A drop-off area is provided near the facility's
entrance?
X
d. Building and office entrance doors are easy for
disabled individuals to open?
e. The office is wheelchair accessible?
X
X
f. A pathway is provided from the parking area to
the entrance?
X
g. Doors are wide enough to accommodate people
on crutches, with walkers, or in wheelchairs?
X
h. The waiting area is large enough to
accommodate and maneuver wheelchairs?
X
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
Tel +1 (610) 825-6000
Fax +1 (610) 83411
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
i. The rest rooms are handicapped accessible and
maneuverable and that signage exists to indicate
this?
j. Examination rooms are handicapped accessible
and maneuverable?
N/I*
NA
Comments
X
X
k. Hallways are free of obstructions that may be
obstacles to visually impaired patients (e.g.,
protruding water fountains, telephones)?
X
l. Assistance can be provided to disabled
individuals who present themselves for services
(e.g., sign-language interpreter for
hearing- impaired patients)?
X
61. Is the practice in compliance with Title VI of the
Civil Rights Act?
No
X
61.1. Has the practice addressed the cultural
competence of the providers and staff by providing
pertinent educational programs?
X
61.2. Has the practice arranged for translators and
interpreters for patients of limited English-speaking
proficiency?
X
Billing and Compliance
62. If the physician practice participates in federal
healthcare programs, has a voluntary corporate
compliance program (CCP) been implemented to
help identify erroneous and fraudulent claims?
X
62.1. If yes, does the CCP include
a. Standards of conduct for all employees?
b. Designation of a compliance officer?
X
X
c. Training and education of providers and
employees?
X
d. A procedure for periodic audits of claims and
medical records for coding, documentation, and
billing accuracy?
X
e. The establishment of a hotline for the reporting
of potential fraudulent activities?
X
f. Disciplinary actions for failure to comply with
compliance policies and procedures?
X
g. Prompt investigation of potential violations and
reporting of the violations to the DHHS Office of
Inspector General?
63. Are physician marketing practices and any product
sales from the office reviewed by risk
management/legal counsel to avoid allegations of
pricing or fraudulent conduct?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
X
Tel +1 (610) 825-6000
Pricing reviewed
by Board
Fax +1 (610) 83412
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
64. Are there general policies and procedures in place
governing billing and collection?
64.1. Do billing procedures allow for the identification
of situations that require review and consideration
for special payment arrangements?
No
NA
Comments
X
X
65. Is advice of legal counsel sought when a
complication results from a physician's actions and
a fee waiver or reduction is being considered?
X
66. Before an overdue account is sent to a collection
agency, is it first reviewed by the physician
involved with the case?
X
67. Is there an area where confidential discussions can
be held regarding billing and payment?
N/I*
X
OSHA Regulations
68. Is a hazard communication program in place at
physician practices to ensure compliance with
OSHA's hazard communication standard?
X
68.1. Does the program include a written policy?
X
69. Is a current list maintained of all hazardous
chemicals used in the physician office?
X
69.1. Are material safety data sheets (MSDSs) for each
chemical available to all potentially exposed
employees?
69.2. Do labels and warnings meet the standard's
requirements?
70. Are potential hazards identified and corrected?
71. Are spill cleanup procedures established?
72. Is an individual designated to monitor the program?
73. Does employee training include, at minimum:
a. Proper work practices and personal protective
equipment (PPE)?
X
X
X
X
X
X
b. Recognition of hazardous-material releases?
X
X
c. Identification of spills that require specialized
equipment and training to clean up?
X
d. Notification of the appropriate authorities to
initiate an emergency response?
X
e. Information on appropriate first aid, emergency
procedures, and the likely symptoms of
overexposure?
74. Are policies and procedures in place to ensure
compliance with OSHA-established exposure limits
for toxic substances used in the physician's office
(e.g., disinfectants, formaldehyde, ethylene oxide)?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
Hazard
Communication
Procedure
X
X
Tel +1 (610) 825-6000
Fax +1 (610) 83413
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
75. Are policies and procedures in place to ensure
compliance with OSHA's occupational injury and
illness record-keeping requirements?
N/I*
NA
Comments
X
75.1. Are mechanisms established to ensure reporting of
occupational injuries and illnesses?
X
75.2. Are employees trained to report occupational
injuries and illnesses?
X
76. Is an exposure control plan (ECP) in place to ensure
compliance with OSHA's bloodborne pathogens
standard?
No
X
Bloodborne
Pathogen
Exposure
Control Plan
76.1. Does the ECP include descriptions of:
a. The exposure-determination process and lists of
the job categories and tasks that involve
employee exposure?
X
b. Specific exposure-control measures
implemented, including safer medical devices,
general infection control (universal precautions)
and work practices, and PPE?
X
c. The process used for consideration and selection
of safer medical devices and the frontline
healthcare workers who participated in the
process?
X
d. Environmental control measures, including
housekeeping/ decontamination schedules,
laundry procedures, and waste disposal?
X
e. A hepatitis B vaccination program?
X
f. Postexposure evaluation and follow-up
procedures?
h. Exposure incident evaluation process?
X
X
X
i. Record-keeping procedures, including the sharps
injury log?
X
j. Employee training programs, schedules, and
participant lists?
X
g. Hazard communication methods?
77. Are adequate equipment and devices (e.g.,
needlestick-prevention devices, gloves, gowns,
masks, sharps disposal containers, waste
receptacles) provided to protect employees from
exposure to bloodborne pathogens?
78. Are procedures in place to ensure that all personnel
use universal precautions?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
X
Tel +1 (610) 825-6000
Fax +1 (610) 83414
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
79. Are policies and procedures in place to ensure
compliance with current regulations on
occupational exposure to tuberculosis (TB)?
80. Is there is a control plan in place to identify and
manage patients suspected of having TB according
to CDC's levels of risk and to comply with OSHA
TB enforcement policies, as well as general
airborne/respiratory infection control procedures?
80.1. Are protocols established to help first-contact
employees (e.g. receptionists) identify individuals
who might have active TB?
No
N/I*
NA
Comments
X
X
X
Communicable
Disease
Procedure
CLIA
81. Is there a mechanism to ensure that the office's
clinical lab performs only examinations or
procedures that it is certified to perform?
X
81.1. Are state regulations for clinical laboratories
examined to ensure compliance (some states have
regulations more stringent than CLIA's)?
X
81.2. Do policies and procedures exist to ensure that
laboratories in the physician office comply with
CLIA and/or applicable state regulations?
X
82. Do laboratory policies and procedures address the
integrity and handling of specimens to include
patient identification, as well as specimen collection,
preparation, labeling, and tracking?
Health Center is
CLIA waived
X
Fire and Life Safety
83. Is the physician practice site in compliance with
building and fire codes?
84. Are fire drills conducted according to the practice's
building occupancy classification in accordance
with the National Fire Protection Association's
(NFPA) Life Safety Code?
85. Is there a fire and emergency evacuation plan posted
at the physician practice site?
86. Are fire extinguisher and emergency telephone
numbers readily available at the site?
86.1. Are fire extinguishers in good working order?
87. Is the office staff trained in emergency procedures in
case of fire or other disaster?
88. Is smoking prohibited?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
X
X
X
X
X
X
Tel +1 (610) 825-6000
Fax +1 (610) 83415
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
No
N/I*
NA
Comments
Safety and Environment
89. Are floor coverings intact, clean, and free of
obstructions and tripping hazards to pedestrians?
X
90. Are electrical cords placed where they do not create
a tripping hazard?
X
91. Are step-ups and step-downs clearly marked?
92. Is ventilation and lighting adequate?
X
93. Is emergency lighting provided?
X
X
94. Are cover plates present and intact for all switch and
outlet boxes?
X
95. Is furniture sturdy, easy to get in and out of, and in
good repair?
X
96. Is the parking lot adequately lighted and free of
potential hazards?
X
97. Is the physician practice site in compliance with state
and local regulations regarding underground
storage tanks?
X
97.1. Do underground storage tanks require leak
detection and monitoring procedures?
X
98. Is the physician practice site in compliance with
federal, state, and local regulations regarding air
quality management (e.g., limiting emissions from
fossil-fuel-fired boilers)?
99. Is the physician practice site in compliance with
guidelines and regulations regarding indoor air
quality (e.g., ventilation guidelines) recommended
by ASHRAE?
100. Is the physician practice site in compliance with
federal, state, and local regulations regarding waste
management?
100.1. Is potentially infectious waste separated from
other waste at the point of generation?
X
X
X
X
100.2. Is radioactive infectious and cytotoxic waste
separated from other infectious waste?
100.3. Are regulations regarding the containment,
transport, storage, and disposal of sharps and other
infectious wastes strictly observed?
X
X
100.4. Are employees trained in the proper handling of
all waste?
X
100.5 Is there a contingency plan for waste disposal in
case the normal disposal method is unavailable?
X
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
Tel +1 (610) 825-6000
Fax +1 (610) 83416
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
101. Have sharps disposal containers been secured
through locked wall mounts or other secure means
to prevent unauthorized access?
No
N/I*
NA
Comments
X
Infection Control
102. Are there written infection control policies and
procedures for the physician practice?
M
Dental Infection
Control
Guidelines
Dental In
Progress
D
102.1. Do the policies and procedures address:
a. handwashing,
b. cleaning and disinfection/sterilization of patient
care equipment,
c. separation of infected and uninfected patients,
and
d. housekeeping procedures?
M
D
D
M
M
D
D
103. Is there a control plan to identify and manage
suspected transmittable diseases (e.g., tuberculosis,
SARS)
M
D
104. Is equipment that is used for disinfection/
sterilization purposes subject to quality control
procedures?
M
D
M
Procedures are
being updated
Need written
procedure for
Medical similar
to Dental
Communicable
Disease
Screening
Procedure
Equipment Safety
105. Does all equipment at the physician practice site
undergo periodic inspection, testing, and preventive
maintenance?
X
105.1.Are inspection and preventive maintenance
procedures documented?
X
105.2. Are office personnel instructed on what to do if a
device malfunctions?
X
105.3. Are all device-related incidents reported to risk
management?
X
106. Do all office-based users of medical devices receive
adequate training before use on patients?
X
Violence Prevention and Control
107. Has a security audit been conducted to identify the
potential for violence at the physician practice site?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
Tel +1 (610) 825-6000
Fax +1 (610) 83417
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
108. Have providers and staff of the practice received
training to recognize risk factors for violence?
108.1. Does the training include de-escalation
techniques and prevention, management, and
control of violent incidents?
No
N/I*
NA
Comments
X
X
Managed Care Liability
109. Are managed care contracts and agreements
reviewed by risk management/legal counsel?
X
110. Are patient care decisions and recommendations
based on clinical issues and not on payer source?
X
111. Are clinically indicated referrals communicated to
the patient and to the managed care organization
(MCO) with documentation of the provider's
recommendations when the referrals are outside the
MCO's network or for a noncovered procedure?
112. Is there a policy requiring that confidential
information (e.g., peer-review data) undergo risk
management review before it is released to an
MCO?
113. Do physicians document all patient-related
communication with MCOs or utilization review
firms in the patient's medical record?
114. Do providers utilize appeal procedures for disputes
with MCOs regarding coverage decisions?
X
X
X
X
Risk Management/Quality Improvement
115. Is there a written patient safety/risk management
plan for the office?
X
115.1. Is a proactive risk analysis of a high-risk process
(e.g., follow-up of diagnostic tests) conducted
annually?
X
115.2. Are identified process failures redesigned and
tested for effectiveness in error reduction or
potential error reduction?
X
Event Reports
116. Are practice promotional/ marketing materials
reviewed by risk management/ legal counsel?
X
116.1. If applicable, is the practice's Web site content
and/or other electronic medical information
reviewed by risk management/legal counsel?
117. Does the practice make employee assistance
programs available to providers or staff who may
be involved in a serious adverse event or an error
involving a patient?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
X
Tel +1 (610) 825-6000
Fax +1 (610) 83418
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
118. Is there a designated individual to handle
complaints by patients and families?
118.1. Are significant complaints and/or those with a
high potential to result in a liability suit acted on by
the office manager and/or the provider without
delay?
118.3. Are the results of the assessment used to improve
office services?
X
119.1. Is the patient notified in writing by registered or
certified mail?*
X
120.1. Is there an approved event reporting form (paper
or electronic) available to providers and staff of the
practice to report events, near misses, hazards, and
patient safety issues?
120.2 Are reported events, patient safety issues, and near
misses investigated through interviews, medical
record reviews, inspections, and observations?
120.3. Are reports and investigations analyzed to
identify areas for quality and safety improvement?
120.4. Is there a committee or other forum regularly
held to communicate quality and safety issues and
to discuss improvement action plans and results of
actions taken?
Event Report
done
immediately and
investigation of
complaint
X
X
120. Does the practice have a formal, nonpunitive
system for reporting events, near misses, hazards,
and patient safety issues?
Comments
Event Report
119. Is there a policy in place that includes criteria for
termination of care/discharge from the practice?
119.3. Are records made available to the new physician
upon receipt of the patient's authorization?
NA
X
X
119.2. Does the termination letter inform the patient
about how to obtain the services of another
physician and clearly state the effective termination
date?
N/I*
X
118.2. Is there a mechanism in place for assessing
patient/family satisfaction?
118.4. Is there documentation and tracking of
complaints to identify trends and make
improvements?
No
X
X
Event Report
X
X
X
X
X
Staff Process
Improvement
Committee
120.5. Is feedback provided to the practice managers,
providers, and staff?
120.6. Does the committee review reports of patientvolume-adjusted events (e.g., events per 1,000 office
visits) compared to previous reporting periods?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
X
Tel +1 (610) 825-6000
Fax +1 (610) 83419
Physician Office Safety Guide
Self-Assessment Questionnaire
May 2008
Yes
121. Does the practice endorse open communication
with patients, and has it adopted a practice of
disclosing to patients when an unanticipated
adverse event or error has occurred?
ECRI Institute 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA
1275
Web www.ecri.org
E-mail [email protected]
No
N/I*
NA
Comments
X
Tel +1 (610) 825-6000
Fax +1 (610) 83420