Hospital Name: Person Completing the Assessment: Date: I. Executive Leadership Yes No 1. Do executive leaders and department medical staff members meet routinely? 2. Is the oversight of actionable plans to improve patient safety with regard to events discussed at the executive level to ensure appropriate oversight and follow through? 3. Are quality improvement activities meaningful and do they reflect action on local performance or patient safety events that impact the patients served by the individual organization or community? 4. Do leaders provide the departments with the resources to implement meaningful quality and performance improvement initiatives? 5. Is patient safety part of the organization s current strategic plan? 6. Have leaders established a code of conduct and implemented a process for reporting and addressing disruptive behavior? 7. Are safety culture surveys conducted using reliable tools? 8. Do leaders conduct executive safety walking rounds? 9. Are executive leaders and department managers specifically educated in healthcare leadership, risk, and patient safety? II. Quality Review Process Yes No 1. Has a behavioral health services multidisciplinary practice committee been established? 2. Does the behavioral health service have a quality plan? 3. When practice protocols, policies, and procedures are developed, are they evidence-based (when possible) and in compliance with the guidelines and recommendations of professional organizations and licensing, regulatory, and accreditation bodies? 4. Is a process in place to review the standards, recommendations, and/or guidelines of professional organizations and licensing, regulatory, and accreditation bodies when developing a new policy, procedures, and/or protocols or updating the current ones? 5. Do the quality indicator screens reflect the scope of practice of the behavioral health department, including high-risk clinical presentations (medical and psychiatric emergencies, suicide risk, etc.)? 6. Does the medical staff conduct peer review based on behavioral health data?
II. Quality Review Process Yes No 7. Does the medical staff review outcome-specific quality indicators and quality data? 8. Are actions taken in response to data? 9. Has the department implemented a high-reliability approach (e.g., team training, structured communication)? III. Nursing Education and Competency Yes No 1. Do RN job descriptions include behavioral health-specific qualifications? 2. Are criminal background checks performed for all new employees in behavioral health areas? 3. Are job descriptions for each behavioral health unit position that include jobspecific requirements for experience, training, and certification and job-specific duties in place? 4. Are behavioral health-specific orientation and competency requirements in place? 5. Do the nursing orientation and annual competency programs include the following: a. Unit safety (staff and patient) protocols? b. Infection prevention and control? c. Cultural diversity and sensitivity? d. Patient rights and ethical aspects of care, treatment, and services and the process used to address ethical issues? e. Medication administration/medication safety/medication reconciliation? f. Incident reporting? g. Chain of command? h. Communication (SBAR) and hand-offs? i. Time-outs (e.g., ECT treatments)? j. Vulnerable adult care and reporting? k. Pediatric safety and security? l. Telephone triage? m. Procedures for handling physical or verbal threats, actions of violence, inappropriate behavior, or other escalating and potentially dangerous situations (including when to summon security or police)? n. Patient assessment (initial and ongoing), observation, and documentation? o. Restraints and seclusion? p. ECT (including potential anesthesia complications and post-procedure adverse reactions and complications)? q. Professional boundaries/boundary violations? r. Addiction/substance abuse therapies/detox (alcohol,
III. Nursing Education and Competency Yes No methadone, opiates, etc.)? s. Dual diagnoses? t. Search and seizure procedures? u. Suicide prevention, precautions, and treatment plan? v. Environmental risk management? w. Managing medical emergencies? 6. Do temporary, float, contract, and agency staff members receive a formal orientation to the unit? 7. Do annual competencies include psychiatric medications? 8. Is the nursing director of the behavioral unit a registered nurse with a master s degree in psychiatric or mental health nursing or its equivalent? 9. Is an experienced behavioral health RN available on all shifts? 10. Are criminal background checks and reference checks performed for all new behavioral health employees? 11. Is an orientation checklist completed for all new employees and physicians? 12. Are formal competencies in place for: a. Suicide assessment and prevention? b. Behavior management? c. Elopement prevention and intervention? d. Psychotropic medications? e. Care of ECT patients (if applicable)? IV. Behavioral Health Credentialing, Privileging, Peer Review, and Orientation Yes No 1. Is a formal credentialing, privileging, and reappointment process in place for behavioral health physicians and advanced practice professionals working in the service? 2. Is a tracking mechanism in place to ensure that licensure is current at all times? 3. Have at least two peers and/or faculty members knowledgeable about the applicant s professional performance been queried/provided a reference regarding the applicant s experience, ability, and current competence as related to requested privileges? 4. Do credentialing files include evidence of board certification in psychiatric medicine or specialized education and training in psychiatric medicine? 5. Are behavioral health core privileges established? 6. Does reappointment occur at least every two years? 7. Is ongoing professional practice evaluation included in the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal?
IV. Behavioral Health Credentialing, Privileging, Peer Review, and Orientation Yes No 8. Is a formal orientation program in place for behavioral health physicians and advance practice professionals? 9. Does the orientation program include the following: a. Documentation? b. Emergency medical and psychiatric transfer protocols? c. On-call responsibilities, including response? (A policy, bylaws, and/or rules and regulations for on-call responsibilities should be in place.) d. Use/location of emergency equipment? e. State laws pertinent to minors, sexual assault, chemical/drug testing, mandatory reports of disease and injury, abuse and neglect, and coroner cases? f. Clinical practice protocols? g. Policies and procedures related to the treatment of psychiatric patients? h. Admission criteria? i. Risk management procedures (informed consent, refusal of treatment, AMA, DNR, etc.) and responsibilities for on-call coverage? 10. Is a proctoring/mentoring/focused professional practice evaluation review process in place for all new applicants and new privileges? 11. Is a quality review conducted at the time of reappointment? a. Does the review include the results of internal peer review, external quality/peer review, CME credits, clinical activity data from the previous 24 months, and utilization review information relevant to applicant s acceptable levels of practice and competency? V. High-Risk Clinical Presentations Yes No 1. Do policies, procedures, and/or protocols provide direction for the following: a. Documentation requirements for clinically pertinent assessment based on admitting diagnosis? b. Structured communication procedures for hand-offs? c. Nursing plan interventions and documentation? 2. Does the medical record documentation contain complete medical and psychiatric histories? 3. Is informed consent for medication therapy documented in the medical record? 4. Does the medical record documentation reflect the facts surrounding any medical event? 5. Does the facility perform a focused QI review of potential/actual psychiatric emergency presentations? 6. Does the facility include medical record reviews in the quality review/outcome
V. High-Risk Clinical Presentations Yes No measure monitoring process to ensure that all required components of nursing assessments, interventions, communications, and documentation are included? 7. Is a suicide assessment protocol or pathway utilized? 8. Does the facility have an elopement policy and procedures in place? a. Do the policy and procedures address appropriate reporting and investigation of elopement events? b. Are elopement drills conducted? 9. Does the facility have a policy and procedures for acute detoxification that are based on professional standards, guidelines, regulatory requirements, and evidence-based guidelines? 10. Does the facility have clinical and administrative guidelines for managing abusive patients? a. Does the facility provide competency-based training on an annual basis regarding these techniques? 11. Does the facility have policies and procedures that specifically apply to medical emergencies (including emergency transfers) in the behavioral health environment? 12. Does the fall prevention program address assessment/ reassessment, a scoring mechanism to identify fall risk, a multidisciplinary assessment, interventions (call light, alarms, video monitoring), patient/family education, communication among healthcare team, and discharge education? 13. Are fall reassessments documented when there is a change in clinical condition, change in medications, post-fall, and on every shift? 14. Is fall prevention education provided to the patient/family at the time of discharge and documented in the medical record? VI. Clinical Treatment and Critical Junctures in Treatment (Admissions, Change in Level of Care, Change in Medical Treatment, Transfer, Discharge, Refusal of Treatment) 1. Does the medical record reflect documentation that includes an admission assessment, treatment plans, and the discharge planning process? 2. Does the hospital have a written policy addressing insurer s denial of authorization for admission or continued stay for a patient who needs psychiatric care? 3. Does each patient receive a thorough history and physical? 4. Is a staff chaperone/witness present during all physical exams? 5. Are patients with medical conditions regularly monitored by a medical practitioner to determine if the medical management is within the scope of the unit? Yes No
VI. Clinical Treatment and Critical Junctures in Treatment (Admissions, Change in Level of Care, Change in Medical Treatment, Transfer, Discharge, Refusal of Treatment) 6. Does the medical record reflect documentation that includes authorization for admission and continued stay for each behavioral health patient? 7. Is a process in place to ensure that the treatment plan is continually evaluated and modified as the patient s condition changes or treatment approaches require revision? 8. Are patients with medical conditions regularly monitored by a medical practitioner to determine if the medical management is within the scope of the unit? 9. Does the patient s medical record include a discharge plan that supports a safe and successful termination from treatment? 10. Is a formal transfer protocol or policy that would meet federal EMTALA requirements in place for behavioral health patient transfers from the ED to another facility? 11. Are transfers reviewed through the quality improvement process? 12. Is there a protocol to follow when a patient refuses treatment or is non-compliant? 13. Do medical records reflect complete documentation of admission, transfer, and discharge circumstances? Yes No VII. Medication Safety Yes No 1. Is medication reconciliation conducted upon admission and discharge? 2. Are patient drug levels monitored appropriately? 3. Is informed consent documented for psychotropic medications? 4. Is there a policy addressing serum drug levels and laboratory tests required for psychotropic medications? 5. Do medical records include results of serum drug levels and laboratory testing as appropriate for certain psychotropic medications (e.g., divalproex sodium, clozapine, lithium?)
VIII. Behavioral Health Policies and Procedures Yes No 1. Are formal policies and procedures in place for the following: a. Off-unit appointments/diagnostic testing/passes/leaves? b. Smoking? c. Duty to warn? d. Patient observation/monitoring? e. Search and seizure? f. Emergency response? g. Boundary violations? h. Telephone triage? i. Vulnerable adult care and reporting? j. Pediatric safety and security? IX. Informed Consent Yes No 1. Does the facility have a written policy and procedures for obtaining an informed consent based on the legal status of the patient (e.g., minor, voluntary/involuntary committal, court-ordered guardian)? 2. Do the policy and procedures ensure that the procedure and/or treatment identified on the consent form are written in terms the patient can understand? 3. Does the informed consent process require a discussion between the patient and the physician that addresses the following elements: a. Risk, benefits, and alternatives to proposed treatment; medications and/or procedures/therapies? b. Ramifications that could result from refusal to consent to a recommended medical procedure or treatment protocol? c. Assessment of patient capacity to understand the required elements of the informed consent discussion? 4. Does the patient s medical record reflect documentation of informed consent?
X. Electroconvulsive Therapy (ECT) Yes No 1. Does the facility have an ECT policy, procedures, and protocols that establish criteria for patient selection and specify contraindications? 2. Does the facility have a separate and distinct informed consent for ECT? 3. Is a court order obtained/in place for ECT for committed patients (if required by the state)? 4. Does the psychiatrist apply the ECT electrodes? 5. Does the ECT protocol include directions on how to handle medical emergencies that may occur during or after an ECT procedure? 6. Is a policy in place to clean electrode wires and describe barrier precautions to be taken if the patient has been diagnosed with a communicable disease? 7. Is an anesthesia provider present during all ECT treatments? 8. How are anesthesia/sedation processes managed during ECT procedures? 9. Is ECT treatment documentation complete and evaluated through the quality improvement process? XI. Restraint and Seclusion Yes No 1. Does the facility have a policy and procedures that establish what constitutes a restraint (both physical and chemical)? 2. Do the policy and procedures specify when the physician must be notified and when the physician needs to see the patient? 3. Do the policy and procedures establish patient observation and documentation requirements? 4. Does the medical record reflect proper assessment of patients in restraints? 5. Are patients in seclusion continuously monitored? 6. Is all restraint use/seclusion use monitored through the quality improvement process?
XII. Infection Prevention Yes No 1. Is a policy in place describing required surface cleaning and decontamination of patient care and activities equipment and the general behavioral health environment? Does the policy address: a. Common areas (e.g., lounge, dining and group rooms)? b. Exercise equipment (e.g., mats, stationary bicycles, balls)? c. Patient examination and treatment equipment? 2. Are all potential psychiatric patients assessed for the presence of TB or multi-drug resistant organism (MDRO) infection during pre-admission screening? 3. Is an infection prevention plan completed for the behavioral health unit on an annual basis? Does the plan include the following: a. Provisions for patient and staff member hand hygiene? b. Securing of hand antiseptic containers to prevent misuse or ingestion of antiseptics by patients? c. Management and placement of infectious patients on the behavioral health unit? XIII. Environmental Safety Yes No 1. Does the facility have a policy that addresses behavioral health environmental safety? 2. Does the facility have a process to assess all bathrooms in all units and elsewhere within the facility where a patient may have access to ensure that any fixtures that may pose a potential safety issue to patients admitted with self-harming thoughts and/or suicidal ideations are removed and/or corrected? 3. Does the facility have a formal process for conducting environmental safety rounds? 4. Are windows, mirrors, and framed art covers constructed of Plexiglas or other shatterproof material? 5. Are patient care equipment, art supplies, and sharp items kept in locked areas? 6. Are sharps containers brought to patient rooms and removed as soon as the injection/procedure is done? 7. Are medications secured and inaccessible to patients? 8. Are hazardous materials (e.g., cleaning agents, chemicals) secured and inaccessible to patients? 9. Do locked doors release in case of fire or evacuation emergency?