SAMPLE Perioperative Self-Assessment Questionnaire Hospital Name: Person Completing the Assessment: Date: I. Executive Leadership Yes No 1. Do executive leaders have a defined mode of regular communication with medical and departmental staff members? 2. Have executive leaders provided and encouraged participation in a culture of safety survey for the organization? 3. Do executive leaders provide resources for meaningful quality improvement initiatives? II. Quality Review Process/Evidence-Based Practice Yes No 1. Does the surgery/anesthesia department have a quality plan? 2. Are perioperative practice protocols evidence-based and consistent with the guidelines and/or recommendations of professional organizations/regulatory and accreditation bodies? 3. Are clinical indicator/quality screens re-evaluated on a regular basis? 4. Does the multidisciplinary committee discussion include: a. Review of outcome-specific quality indicators/data? b. Actions taken in response to data? c. Evaluations of the actions that were taken to determine the effectiveness of those actions? d. Peer review for surgical and anesthesia services? e. Review of new protocols/policies/procedures or service lines? 5. When practice protocols, policies, and procedures are developed, are they evidence-based and in compliance with the guidelines and/or recommendations of professional organizations and licensure, regulatory, and accreditation body requirements?
SAMPLE Perioperative Self-Assessment Questionnaire III. Nursing Competency/Orientation Yes No 1. Does the perioperative nursing orientation include review of high-risk clinical presentations and situations, such as implanted electronic devices (IEDs), counts, ESU/laser safety, surgical fire safety, latex safety, medication safety, hypo/hyperthermia, DVT prevention, positioning, and infection prevention? 2. Does the perioperative nursing annual competency include review of high-risk clinical presentations and situations such as the informed consent process, patient identification and verification, pain management, OR safety, skin preparation, communication, care of the obese patient, positioning, counts, nursing assessments, and monitoring and documentation requirements? 3. Is a process in place to determine the topics to be included in annual competencies? 4. Are mock codes (e.g., fire, medical) conducted on a regular basis? 5. Is a policy, protocol, and/or process in place to prepare for pediatric emergencies? 6. Do required competencies for perioperative nursing staff members include BLS, PALS, ACLS, CNOR, CAPA, and CPAN certifications, as appropriate to the staff member s role? IV. Credentialing, Privileging, Proctoring, and Peer Review Yes No 1. Is a formal process in place for conducting credentialing, privileging, proctoring, and peer review for all surgical and anesthesia procedures? 2. Are clinical privileges granted consistent with professional and evidence-based recommendations? 3. Are peer review and proctoring processes in place for new surgeons, anesthesiologists, and CRNAs? 4. Is a formal process in place regarding the scope of practice and supervision of advanced practice providers? 5. Is the credentialing and privileging process for the surgical staff used for advanced practice providers as well? 6. Are practitioners who administer moderate sedation credentialed to do so? 7. If the organization provides bariatric services, do credentialing policies reflect criteria specific to the practice of bariatric services? 8. Have a formal policy and process been implemented to addresses ongoing professional practice evaluation (OPPE)?
IV. Credentialing, Privileging, Proctoring, and Peer Review Yes No 9. Have a formal policy and process been implemented to address focused professional practice evaluation (FPPE)? V. Informed Consent (Surgery, Anesthesia, DNR) Yes No 1. Is the surgical informed consent policy in accordance with current CMS guidelines? 2. Is the anesthesia informed consent policy in accordance with current CMS guidelines? 3. Does the informed consent policy outline the roles and responsibilities of the surgical team? 4. Does the policy address consent for minors, incompetent patients, and emergency situations? 5. Does the anesthesia informed consent specifically address the risks, benefits, and alternatives to specific types of anesthesia? 6. Are advance directives or do-not-resuscitate (DNR) wishes identified prior to surgery and other procedures? VI. Intraoperative Procedures (Sponge, Needle, and Instrument Counts; Positioning; Patient Identification; Site Verification; and Briefing/Debriefing) 1. Are policies and procedures in place for counting sponges, sharps, and instruments in all areas where surgical and invasive procedures are conducted? 2. Are surgical count discrepancies reported through the quality improvement process? 3. Has a policy been developed to address the Universal Protocol? 4. Have medical staff members, anesthesia providers, and staff members been educated regarding site and procedure verification? Yes No
VI. Intraoperative Procedures (Sponge, Needle, and Instrument Counts; Positioning; Patient Identification; Site Verification; and Briefing/Debriefing) 5. During the timeout process: a. Are all other activities suspended? b. Are counts consistently and audibly reported to and acknowledged by the surgeon? c. Are initial and final counts audibly reported to and acknowledged by the surgeon? d. Is the timeout initiated by a designated member of the team? 6. Does the site verification policy address: a. Patient/family involvement? b. Timing of verification? c. Documentation of verification? d. Management of discrepancies? 7. Does the surgical team regularly participate in briefings and debriefings? 8. Does the positioning policy address: a. Timing of skin assessment/reassessment? b. Accepted positions? c. Documentation requirements? 9. Do anesthesia policies and procedures address the minimum qualifications and supervision requirements for each category of practitioner who is permitted to provide analgesia services, including moderate sedation? 10. Are pre-anesthesia evaluations performed within 48 hours of a surgical procedure for each patient who receives general, regional, or monitored anesthesia? Yes No 11. Do policies and procedures address specimen handling and labeling? 12. Has a formal process has been implemented to ensure that a briefing takes place prior to the start of a surgical procedure and a debriefing takes place at the conclusion of a surgical procedure? VII. Operating Room (OR) Safety Practices and Equipment Hazards Yes No 1. Regarding Fire Safety: a. Does a surgical fire safety plan, policy, or guideline address fire education, prevention, and preparation? b. Are OR fire drills conducted on a regular basis?
2. Regarding Latex Allergies: a. Does the latex allergy policy address patient and employee sensitization or allergy to latex? b. Is a process in place to assess, plan for, and document the management of patients with a latex allergy? 3. Regarding Medication Safety: a. Is a process in place for medication reconciliation during the perioperative process? b. Is a policy or process in place to address proper medication labeling during the operative phase? 4. Regarding Laser Safety: a. Do policies, procedures, or protocols address fire and equipment safety with respect to the use of electrocautery units (ESUs) and lasers? b. Do the policies, procedures, or protocols address contraindications to laser use? VIII. Pre-Operative Patient Risk Assessment Yes No 1. Are policies, procedures, and/or guidelines in place addressing surgical and anesthesia pre-operative assessment requirements? 2. Does the medical record documentation demonstrate that pre-operative assessments are conducted by surgeons and anesthesia providers prior to surgery? 3. Is a process in place to address and communicate patient assessment findings, abnormal test results, and missing information to the surgeon and anesthesiologist? 4. Does the pre-operative nursing assessment include patient assessments for risk factors that are associated with patients developing a DVT and/or PE? 5. Have risk assessment criteria been developed which categorize patients who may require DVT/PE prophylaxis (e.g., low, moderate, or high risk)?
IX. Post Anesthesia Care Unit (PACU) Monitoring Yes No 1. Do patient assessment and discharge criteria include an evaluation of consciousness, activity, respiratory function, circulation status, and oxygen saturation? 2. Are the policy and procedures addressing post-operative assessment, monitoring, and objective discharge criteria requirements approved by the anesthesia department? 3. Do policy and procedures that direct the care of patients in the immediate postoperative phase require a complete systems assessment during the first few minutes of PACU care (e.g., vital signs, respiratory and cardiac stability, peripheral circulation, neurological status, level of consciousness, pain management, and a return of sensory and motor control in areas affected by local or regional anesthetics)? 4. Is a structured communication process for patient hand-offs utilized and documented in the medical record? X. Care of Obese Surgical Patients Yes No 1. Has the scope of surgical and anesthesia care that may be safely provided for obese patients been defined and include cardiac and respiratory management? 2. Has the weight capacity for surgical tables, gurneys, PACU beds, critical care beds, medical/surgical beds, and radiology and imaging equipment been evaluated? 3. Are weight capacity evaluations readily available for staff member reference? 4. Has a process been implemented to ensure that appropriately-sized equipment and supplies are available for obese surgical patients? 5. Has a formal program been developed to addresses the safe handling of obese patients? 6. Have surgeons, anesthesia providers, and staff members caring for obese surgical patients received sensitivity training?
XI. Care of Orthopedic Patients Yes No 1. Are formal documents in place that address assessing the circulation, sensation, and motor (CSM) assessments of orthopedic patients? 2. Have policies and procedures been developed to address assessments for acute compartment syndrome (ACS)? 3. Is acute compartment syndrome addressed in perioperative high-risk clinical presentation educational programs? 4. Have criteria been established to identify patient risk factors for acute compartment syndrome (e.g., long bone fracture, rigid cast, tight dressing)? 5. Has a mock drill that addresses acute compartment syndrome been performed? XII. Perioperative Anesthesia Yes No 1. Does a written policy require a pre-anesthesia evaluation for all patients who receive general, regional, or monitored anesthesia? 2. Is a policy in place that requires the physical presence of the attending surgeon and the first assistant (as needed) prior to anesthesia induction? 3. Is a policy in place that requires the presence of a qualified anesthesia provider throughout the administration of anesthesia? 4. Do policies require documentation of a post-operative anesthesia assessment, monitoring, and that PACU discharge criteria were met? 5. Does the medical record reflect documentation of a post-operative anesthesia assessment, monitoring, and that discharge criteria were met? XIII. Infection Control Yes No 1. Do perioperative infection prevention and control surveillance activities include the following: a. Appropriate attire? b. High-risk surgical procedures? c. Specimen labeling? d. Use of flash sterilization/immediate use steam sterilization (IUSS)?
XIII. Infection Control Yes No e. Traffic control in restricted areas? f. Post-operative surveillance? 2. Are surveillance data tracked and trended and actions are taken to address identified opportunities for improvement? 3. Are surgical team members required to report personal illnesses and comply with attire and scrub procedures that are consistent with infection control parameters? 4. Has the perioperative services department developed a formal document regarding the expectations for surgical attire, including, but not limited to the following: a. Use of cloth caps? b. Laundering of surgical scrubs/cloth hats? c. Cover gowns? d. Jewelry? 5. Have engineering and work practice controls been used to eliminate or minimize exposures to blood and other potentially infectious materials (OPIMs)? 6. Has a formal document been developed regarding the reuse of single-use devices (SUDs)? 7. Has a formal document been developed regarding flash sterilization/immediate use steam sterilization (IUSS)? 8. Has a formal document been developed regarding specimen labeling for surgical specimens? 9. Is access to the operative and post-anesthesia areas limited to authorized personnel? 10. Does the traffic flow control pattern reflect consideration of infection prevention, privacy, safety, and security?