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1.1.1.1 The Governing Body ensures that the Vision and Mission
statements, goals, objectives and values are identified and
documented; and these reflect the Facilitys roles and
aspirations in the community that it serves. These are as
follows:
1.1.1.3 The services provided by the Facility meet the needs of the
community and also address Patient and Family Rights.
1.1.3.4 The Governing Body has established the Medical Staff By-Laws
which include the following policies and procedures for medical
practitioners:
Appointment of a Chairperson
Terms of Reference
Committee members
Tenure of membership
Frequency of meetings
Appointment of Chairperson
Terms of Reference
Committee members
Tenure of membership
Frequency of meetings
1.1.5.3 There are signed agreements by the Governing Body, staff and
medical practitioners on preserving confidentiality of all matters
relating to the Facility.
1.2.2.2 There are written and dated specific job descriptions for all staff
which include:
b) lines of authority;
c) qualifications held;
e) clinical placements;
i) disciplinary action.
1.2.3.6 There is evidence that staff are involved in the appraisal of their
performance.
a) lines of communication;
g) Indemnity.
1.5.1.2 There are documented plans for systematic safety and quality
improvement activities that include:
a) Planned activities
b) Data collection
1.5.1.4 There are safety and quality improvement activities in place that
include tracking and trending of specific performance indicators
not limited to but at least two (2) of the following:
HOSPITAL COMMENTS
Std. No: __________
SURVEYOR COMMENTS
Std. No: __________
SURVEYOR RECOMMENDATIONS
Std. No: __________