Assessment: Physician Office/Clinic

Assessment: Physician Office/Clinic Location: Site director: Date of Evaluation: Date of last Eval: Reviewer: No. of exam/treatment rooms: Type of facility: Medical Director: Number of Providers Physicians Nurse Practitioner Clinical Nurse Specialist Physician Assistant Other (list) List by name Number of Staff Employed Registered Nurse LPN Certified Medical Assistant Certified Nursing Assistant Social Worker Receptionist Medical Records Personnel Billing Personnel Other (list) In Office Services Phlebotomy Laboratory Radiology Other (list) Who employs the RNs and office staff? Who is responsible for risk management? What Procedures are performed in the office? Who is allowed to perform these procedures? CHRRG

OSHA Required/General Safety Notes Status Weight Score Do staff complete general safety training upon hire? Is it documented? Are MSDS current and available for all chemicals used in the practice? Are all hazardous chemicals stored away from patient treatment areas? Are spill cleaning procedures established? Is there a spill kit and eyewash station available? Do staff members know how to use the eyewash station? Is there a protocol in place to handle office emergencies? Are there protocols in place for the handling of infectious waste and sharps? Equipment Safety Notes Status Weight Score Do staff complete an equipment training program upon hire? Do staff complete equipment training upon purchase of new equipment? Are training programs documented with skills validation? Are equipment checks and calibrations completed as required, and are checks documented? Is there a process in place for the handling of damaged or faulty equipment? Are any instruments or equipment resterilized? N/A Are all sterilized items wrapped and labeled with an expiration date? Are sterilizers tested on a routine basis? Is all equipment free of frayed or damaged electrical cords? Is any equipment shared with other practices or sites? CHRRG

Human Resources Notes Status Weight Score Are written job descriptions available for all positions? Are they periodically reviewed and revised as necessary? Is the current staffing by position sufficient to support the number of physicians and number of patients seen? Are there written personnel policies related to orientation, performance review and improvement, complaint procedure, PTO, benefits, and harassment? Are the personnel policies reviewed every two years? Do personnel files include employment history and personal information? Are files kept in a locked location? Are background checks completed on prospective employees prior to hire? Are PPD tests performed at the time of hire and annually there after? Are staff performance appraisals conducted annually? Is TB education given to staff annually? Are all employees offered the hepatitis B vaccine free of charge? Is there a mechanism in place for evaluating staff clinical competency upon hire and periodically there after? Is there a written and documented orientation process for new employees? Is there a written confidentiality policy signed by all employees at time of hire? Do all staff wear identification while working? Do staff complete customer service training upon hire? CHRRG

Are all licensed or certified staff required to keep license/certificate current and provide a copy for their personnel file? Are all staff and providers CPR or BLS certified? Has staff received any training on violence in the workplace? Do all providers complete a credentialing process prior to joining the practice? (in addition to the credentialing process done by hospital) Is there written evidence of current clinical competence for all providers performing special or invasive procedures in the office? Are any practitioners performing invasive procedures in the office that they are not credentialed to perform in the hospital? Do staff assisting with in-office procedures receive training and is the training documented? Are any agency or contract staff used in the office? If so do you verify background check, experience, licensure, and insurance coverage? Is there a process consistently used by the practice to ensure that all employees receive and review policies, procedures, and all internal office communications? Physical Environment Notes Status Weight Is the Office entrance easily identifiable and accessible? Is handicap parking and entrance available? Is the parking area reasonably well lit and free of hazards? Is there on site security? Is there appropriate after hours security? Is the waiting area clean and orderly? Score CHRRG 4

Is education literature available in the waiting room? Are surfaces and ventilation grills free of dust? Are ceiling tiles in place and in good condition? Are electrical outlets covered when not in use? Are visitor restrooms handicap accessible? Can staff visualize patients who are in the waiting room? Are exits clearly marked and unlocked to exit during business hours? Is the emergency evacuation route posted? Are fire extinguishers present and accessible? Are smoke detectors present and tested routinely? Who tests fire extinguishers and smoke detectors? Are hallways kept clear? Does nothing come within 5 inches of the ceiling (shelves, cabinets, etc)? Do exam rooms have adequate locked storage for syringes and other supplies? Do exam room storage units have child resistant closures? Are toys in waiting area cleaned regularly and in safe and working order? Are sharp containers conveniently located, secured, and replaced as designated on container? Are all hazardous waste containers labeled and properly stored? Is the privacy policy posted in the waiting area? Are privacy policy statements given to each patient annually and is receipt documented by patient signature? Are sign-in sheets limited to acceptable information? Are records stored in a private and secure area? CHRRG 5

Are computer screens, fax machines, and other equipment positioned in such a way as to keep patient info private? Are exam rooms cleaned appropriately between patients? Are daily cleaning procedures documented? Are sinks and soap dispensers inside or close to all patient exam rooms? Is there a private area for staff to discuss patient information without being heard? Emergency Management Notes Status Is there a written evacuation plan? Is there a written disaster management plan? Weight Score Is front office staff trained to recognize symptoms that require immediate involvement of a provider or a call to 9 (i.e.. chest pain, hemorrhage, etc.)? Is an AED or code cart available? Is airway support available? Is O available? Are emergency medications available? Is a check of all emergency equipment and meds conducted at least monthly? Are emergency drills regularly conducted and documented? Is the office equipped with emergency supplies for both pediatric and adult patients? Medication Safety Notes Status Weight Are sample medications dispensed from the office? Are measures taken in the storage of medications to help avoid errors in dispensing (i.e.. Do not store different concentrations of the same drug next to each other)? Score CHRRG 6

Is there a process in place to ensure the proper storage, rotation, and inspections of medications? Is a log kept of all medication dispensed, including patient name, medication, dosage, lot number, amount dispensed, and pt. contact info? Is there a procedure for handling recalls of medications or supplies? Are medications routinely assessed for expiration dates? Are multiple use vials discarded at the expiration date? Are narcotics or other controlled substances kept in the office? Is the location locked? Are prescription pads kept secure, not left in exam rooms? Are syringes kept locked or in a secure non-patient area? Is there a medication refrigerator, that is clean and free of food or specimens? Is there a thermometer in the refrigerator and are temperatures documented? Does a provider review all requests for medication refills? Is a complete drug history including prescription, over the counter, herbal products, nutritional supplements, and illicit drugs obtained and documented at the initial patient encounter and updated at each visit there after? Are patient allergies clearly noted in a consistent area of the record (including food and other allergies)? Is a copy of all medication orders and prescriptions, and refills maintained in the patient record? CHRRG 7

When a prescription is called into a pharmacy does the staff member request a read back from the pharmacist to confirm that the prescription is correct? Does the practice comply with all DEA, CMS, and Indiana rules and regulations regarding medication prescribing? Is conscious sedation ever used in the office? If yes, describe the monitoring, documentation and administration processes: Are vaccines given in the office, and are vaccine information sheets given to patients and recorded in the pt. record? Is there a policy related to staff and providers meeting with pharmaceutical company representatives? Risk Management Notes Status Weight Is there a customer service policy? Is there a process by which to measure patient satisfaction? Are there any quality improvement initiatives currently on going? If yes, what are they? Score Do you track patient and visitor incidents? (prescription issues, falls, repeat visits or phone calls for same problem, near misses, etc.) Is there a committee or other regularly held forum to communicate quality and safety issues and to discuss improvement action plans and results of those plans? Has staff received risk management training within the last two years? Do you have a written procedure for handling requests for release of patient records? CHRRG 8

Do you require written authorization prior to the release of any records (even requests from attorneys)? Do you have a written procedure in place regarding the faxing of patient records? Do you have protocols in place for triaging telephone calls? Is there a policy regarding giving medical advice over the telephone? Do staff members who give telephone advice have specific training, experience and documented competence in telephone assessment techniques? Are all telephone calls (both made and received) documented in the patient's medical record (including date and time)? Are after hours telephone calls documented by the provider answering the call? Does telephone documentation include patient name, physician name, reason for call, brief history of problem, advice given, follow up plan, date, time and signature of provider? It there a protocol for patient notification of diagnostic test results? Is there an established test result tracking system? Please describe the system: Are patients told when results should be expected and to call the office if they do not receive results? Are patient identification procedures followed prior to any invasive procedures or diagnostic testing? CHRRG 9

Is there a "New Patient" pamphlet that gives info on the practice, office hours, billing, medication renewal procedures, etc.? Is there a patient complaint policy that addresses both medical and non-medical complaints? What is the average wait time to see a provider? Should be less than 0 minutes When appointment delays occur are patients informed of how long they can expect to wait? Can they reschedule? Does the provider obtain and document the patient's informed consent prior to any procedure? Is a specific separate consent obtained prior to HIV testing? Are any of the providers involved in investigational or research projects? If so what are they? Is consent obtained in writing prior to any patient being part of an investigational or research project? After Hours Procedures Notes Status Weight Score Are patients instructed on how to reach a physician after hours? Do you use an after hours answering service? How does the service communicate with you? (i.e.. Daily list of calls received?) Do you periodically test the reliability of the answering service? Are all after hours calls returned by a physician? Do physicians provide covering providers with any information related to anticipated patient care problems, and a report on hospitalized patients? CHRRG 0

Is there a process in place to ensure patient coverage for a physician who is unexpectedly absent for a long period of time? Does a physician of the same specialty provide on call coverage? Are patients who call after hours generally able to be seen on the next business day? Does the covering physician send the office documentation of any patient contact? Communication Notes Status Weight Are providers educated on active listening techniques, and the importance of being engaged with the patient? Score Do staff members and providers introduce themselves to patients? Are interpreter services available for non English speaking patients? Are patients notified of their rights under HIPAA, and do they sign documentation confirming they have received HIPAA info? Do patients receive written instructions related to new treatment, medications, diagnosis and follow up? Is a copy of all patient instructions kept in the patient's medical record? Can patients converse with reception staff and make appointments without being overheard? Can telephone calls answered in the reception area be overheard by people in the waiting room? Is there a written policy regarding termination of the physician/patient relationship? Is there a procedure in place to handle no-show patients? CHRRG

What is the procedure? Is there a policy regarding minor patients who present for treatment but are unaccompanied by a parent or guardian? Do policies require the use of a chaperone during intimate patient exams? Does the practice follow the Joint Commission list of do not use abbreviations? Do patients indicate in writing that it is or is not ok for staff to leave information on an answering machine, fax, work number etc.? Are providers aware that test results should not be sent to a patient without including an explanation of those results? Medical Records Notes Status Weight Is the patient required to sign a consent to be treated/financial agreement at each office visit? Is an electronic medical record system used? Are records consistently organized throughout the practice so information can be easily located? Is a uniform charting method used for each patient visit (i.e.. SOAP, visit worksheet, etc.)? Score Have providers and staff received education on the importance of clear, concise, timely and complete documentation? Are provider notes dictated, handwritten, or typed? Are all entries in the medical record signed? If any part of the medical record is handwritten are writing legibility audits conducted periodically? CHRRG

Are appropriate security procedures in place for all electronic systems? Are all referral letters or communications to other providers or to patients read by the physician prior to being sent? Are all dictated notes read by the provider prior to being entered in the medical record? Are records retained as required by state law? Do you obtain a copy (or portions) of each patient's inpatient records after a hospitalization? How do you know when a referral has been completed? How do you know when a provider has received, reviewed and notified a patient of diagnostic test results? When a patient has abnormal vital signs during an office visit are they repeated and is a notation made as to treatment, plan, or referral? Do you inquire if patients have advanced directives, and if so do you keep a copy in the medical record? Are medical records ever thinned or purged? Is there a policy detailing thinning and purging procedures? Do you use off site storage of medical records and is it secure? Do staff members transport or access any patient information (either in written or electronic format) outside the office? Are medical records free of incident reports, any correspondence regarding a claim, inappropriate statements, or derogatory remarks? Staff and Patient Safety

Do you have a policy regarding patient and visitor falls? Is there a screening process for latex allergic patients and are latex free supplies available? Is there potential for employee exposure to anesthetic gasses, formaldehyde, or radiation? Is there a written TB exposure plan? Is appropriate personal protective equipment available and used as needed? Do you have written infectious disease and isolation procedures? Is there a process in place for the handling and cleaning of laundry? Are devices in place to reduce the risk of sharps exposure (i.e.. Safety lock syringe, etc.)? Is contaminated sharps recapping prohibited? Is there an exposure control plan in place, and is it available to all employees? Does the plan provide for evaluation and follow up after an exposure? Are specimens ever transported to a separate location by employees or patients? If specimens are transported by a contracted company are they placed in a locked or monitored area until picked up? Please describe the specimen labeling process: Ancillary Services Notes Status Weight Score Does the office have onsite laboratory services? Is the lab CLIA certified or waived? Is a Quality Control log kept for each instrument? Is there a method for tracking specimens received to results sent out? CHRRG 4

Are there procedures in place to keep all patient information confidential? Is eating, drinking, etc. prohibited in the lab area? Does the office have radiology services? Is all radiology equipment properly maintained, licensed, and inspected? Are the necessary certificates posted in the radiology area? Who conducts maintenance and calibration checks? Are radiology personnel licensed? Are exposure badges worn and monitored? Are all radiology reports over read by a radiologist? Is lead shielding mandatory for all patients and staff? Are pregnancy warning signs posted in the area? Are female patients specifically asked if there is a chance of pregnancy? Is there a system in place to ensure radiology results are reported to the ordering physician and to the patient? Is there a process in place to contact patients if a radiologist's over read differs from a physician's first read? Are EKG's done in the office? Are all EKG's reviewed by a cardiologist or internist? Potential Claims Notes Status Weight Do you notify Clarian Health Risk Retention Group of any unexpected or irregular complication resulting from a practitioner or staff member's actions? Do you notify Clarian Health Risk Retention Group prior to doing more than writing off an office bill? (i.e.. Give the patient money or pay other providers) Score CHRRG 5

Are patient records that may be involved in a claim against a provider sequestered appropriately? Does a representative from the practice attend the CHRRG Quarterly Risk Management Forums? Do you have any concerns or questions related specifically to this office or to risk management in general? Scoring Results Summary Points Points Section Available Received OSHA/General Safety 8 Equipment Safety 7 Human Resources 46 Physical Environment 45 Emergency Management Medication Safety 46 Risk Management 69 After Hours Procedures Communication 7 Medical Records 40 Staff and Patient Safety 8 Ancillary Services 4 Potential Claims 8 Total 48 CHRRG 6