SAFP HSI Checklist

HSI Guide

(current as of May 98)

AREA: HCS.1.4 PHARMACEUTICAL MANAGEMENT

ELEMENT: HCS.1.4.1 PHARMACY MEDICATION SECURITY

EVALUATION CRITERIA:

- Medications were stored in controlled non-traffic areas under secure conditions

- There was limited access to bulk narcotic vault/safe storage

- Perpetual inventory was maintained for all scheduled drugs

- AF Forms 579 (or automated substitute) were issued and tracked by pharmacy and properly annotated for all controlled drugs stored outside the pharmacy

- Narcotic prescriptions were filled IAW federal law, AFIs, and state law

- Biennial inventory was completed on or about 1 May in odd years

- There was a mechanism to authenticate prescriber identification and DEA# for controlled drug prescriptions

- Provisions of AFI 31-209, controlled area security, were addressed

- Medical unit narcotic destruction was properly conducted, witnessed, and documented

- Narcotic inventory adjustments were documented and reviewed by oversight command authority (one year track record not required)

- There was a process to detect potential medication diversion/overuse/abuse by medical treatment facility staff or patients

SCORING:

1: Criteria met.

3: The organization had minor variations from standards and was at risk for a sentinel event.

5: The organization failed to meet the criteria and was at risk for loss of DEA license.

NA: Not scored.

PROTOCOL: HCS 5.

Reference(s): AFI 31-209, para 8.8.2 - 8.8.5; AFI 44-102, para 3.6, 3.9, 3.18, 3.19.

ELEMENT: HCS.1.4.2 FACILITY MEDICATION SECURITY

EVALUATION CRITERIA:

- Medications were stored in non-patient traffic areas under secure conditions

- Monthly medical treatment facility controlled medication inventories were completed

- Anesthesia narcotic controls were followed

-- One week supply of narcotics maintained

-- Narcotics limited and secured when unattended

-- Narcotics balanced daily (consistent with operating room schedule)

-- Anesthesia doses monitored monthly for appropriateness

- There was a process to detect potential medication diversion/overuse/abuse by medical treatment facility staff or patients to include witnessed destruction and documentation of unused controlled medications.

SCORING:

1: Criteria met.

3: The organization met some provisions of the criteria but was at potential risk for misuse or diversion.

5: The organization failed to meet the criteria and was potentially at risk for loss of DEA license.

NA: Not Scored.

PROTOCOL: HCS 5.

Reference(s): AFI 31-209, para 8.8.2 - 8.8.5; AFI 44-102, para 3.6, 3.18, 3.19, 3.21; USC 21, CFR 1307.21 (Disposal of Controlled Substances).

ELEMENT: HCS.1.4.3 THERAPY MONITORING

EVALUATION CRITERIA:

- Documentation existed that providers were contacted for questionable prescriptions

- There was a mechanism for direct pharmacist oversight of all outpatient dispensing areas, ensuring safe and effective use of medications (oversight includes any combination of the following; checking, filling, dispensing, monitoring interactions and medication profiles, retrospective prescription review, etc.)

- Overseas medical treatment facilities without a pharmacy officer and pharmacies without a pharmacist (TDY, leave, etc.) for greater than 24 hours were assigned a medical officer (physician) as the pharmacy officer for that period

SCORING:

1: Criteria met.

3: The organization met some provisions of the criteria and there may be an increased risk of adverse patient outcomes.

5: The organization failed to meet the criteria and there was potential for adverse outcomes.

NA: Not scored.

PROTOCOL: HCS 5.

Reference(s): AFI 44-102, para 3.5, 3.6.

ELEMENT: HCS.1.4.4 MEDICATION DISPENSING

EVALUATION CRITERIA:

- Medication profiles contained patient name, medications prescribed, directions for use, and allergies

- Outpatient profile contained all medication orders dispensed in the medical treatment facility (MOD, DOD, etc.)

- The pharmacy was the sole area for dispensing medications during normal pharmacy operating hours

-- Exceptions must comply with all applicable pharmacy practice standards

--- Dispensed by a physician

--- Counseling

--- Security

--- Patient medication profile (entry into CHCS)

--- Labeling

SCORING:

1: Criteria met.

3: Processes were in place for completed patient profiles; however, medication profiles were incomplete due to circumstances beyond human control, i.e., system failures, etc.

5: The organization failed to meet the criteria and the potential existed for significant adverse patient outcomes.

NA: Not scored.

PROTOCOL: HCS 5.

Reference(s): AFI 44-102, para 3.3, 3.4, 3.10, 3.11, 3.12.

ELEMENT: HCS.1.4.5 FORMULARY MANAGEMENT

EVALUATION CRITERIA:

- Tri-Service formulary was incorporated into local formulary

- All prescriptions for Tri-Service formulary medications were filled

- Evidence of compliance with applicable OASD(HA) and AFMOA policy regarding formulary management

- Civilian prescription service was not withdrawn or curtailed

- All eligible beneficiaries received a uniform standard of care to include the following

-- All formulary medications were available for dispensing to all patients

-- Nonformulary purchases were not used to provide special care to groups of patients (e.g. active duty)

- Multidisciplinary pharmacy and therapeutics committee/function met at least quarterly to ensure formulary oversight and meet responsibilities of AF guidance (i.e. IDMT oversight)

SCORING:

1: Criteria met.

2: The organization met most of the provisions of the criteria and only slight patient inconvenience may be encountered.

3: The organization met some provisions of the criteria and moderate patient inconvenience may be encountered. Patients may be placed at risk due to therapy changes

4: The organization met few provisions of the criteria and significant patient inconvenience may be encountered. Potential existed for adverse outcomes from therapy changes.

5: The organization failed to meet the criteria, with significant patient inconvenience and high potential risk of adverse outcome from therapy changes.

NA: Not scored.

PROTOCOL: HCS 5.

reference(s): AFI 44-102, para 2.5.3., 3.6, 3.8; AFI 90-501, criteria 6.1 - 6.3, 7.1 - 7.5; DoD HA Policy Letters 25 Jul 95 and 4 Apr 97.

Management/Leadership

REFERENCE	STANDARD / INTENT	CRITERIA	DOCUMENTATION / LOCATION	OPR:	COMPLIANCE / COMMENTS
LEADERSHIP	* Leaders--governing body, chief executive officer, nurse executive, department chairmen, and appointed staff in a position of leadership.	.	.	.	.
HR.1 (JCAHO)	The hospital's leaders define the qualifications and performance expectations for all staff positions (each department).	Leaders provide a job description for each position that defines the qualifications and performance expectations in measurable terms.	.	.	.
.	INTENT: Hospital's ability to fulfill its mission and provide for its patients' needs is directly related to its ability to provide qualified, competent staff.	As evidenced by: staff interviews, department-specific staffing plans, employee personnel files, job descriptions, CE records, orientations, etc.	.	.	.
HR.3.1 (JCAHO)	The hospital encourages and supports self-development and learning for all staff.	Performance Feedback: Performance Reports: Internal suggestion/questionnaires:	.	.	.
.	INTENT: Job performance is the result of both individual competence and the work environment.	Regular feed back from the staff helps the leaders create this kind of work environment.	.	.	.
LD.2 (JCAHO)	Each hospital department has effective leadership.	Department leaders clearly convey the hospital's mission to all staff.	.	.	.
.	* Leaders--governing body, chief executive officer, nurse executive, department chairmen, and appointed staff in a position of leadership.	.	.	.	.
LD.2.1 (JCAHO)	Directors integrate their department's services with hospital's primary function.	Directors are ultimately responsible for LD.2.1-LD.2.10	.	.	.
LD.2.2 (JCAHO)	Directors coordinate and integrate services within their department and with other departments.	.	.	.	.
LD.2.3 (JCAHO)	Directors develop and implement policies and procedures that guide and support the provision of services.	Directors delegate responsibilities in developing and implementing policies and procedures.	.	.	.
LD.2.4 (JCAHO)	Directors recommend a sufficient number of qualified and competent persons to provide care.	.	.	.	.
LD.2.5 (JCAHO)	Directors determine the qualifications and competence of department personnel who provide patient care services and who are not licensed independent practitioners.	Directors hold staff accountable for their performance.	,	.	.
LD.2.6 (JCAHO)	Directors continuously assess and improve their department's performance.	Directors delegate responsibility for gathering and analyzing continuous improvement data.	.	.	.
LD.2.7 (JCAHO)	Directors maintain appropriate quality control programs.	Directors delegate responsibility for maintaining quality control programs.	.	.	.
LD.2.8 (JCAHO)	Directors provide for orientation, in-service training, and continuing education of all persons in the department.	.	.	.	.
LD.2.9 (JCAHO)	Directors recommend space and other resources needed by the department.	.	.	.	.
LD.2.10 (JCAHO)	Directors participate in selecting outside sources for needed services.	.	.	.	.
LD.2.11 (JCAHO)	Departments that are not medical staff services that provide patient care are directed by one or more qualified professionals.	.	.	.	.
LD.2.11.1 (JCAHO)	Responsibility for administrative direction and clinical direction is defined in writing.	.	.	.	.
LD.2.11.2 (JCAHO)	A qualified professional with appropriate clinical training and experience is responsible for the clinical direction of patient care.	.	.	.	.
LD.3 (JCAHO)	Patient care services are integrated throughout the hospital.	Service directors are responsible for appropriate integration of each patient care service into the overall functioning of the hospital.	.	.	.
LD.3.4 (JCAHO)	All departments develop policies and procedures in collaboration with associated departments.	Policies and procedures are developed for processes that affect more than one department.	.	.	.
LD.4 (JCAHO)	The hospital's leaders set expectations, develop plans, and manage processes to measure, assess, and improve the quality of the hospital's governance, management, clinical, and support activities.	a. Processes are carried out by medical, nursing, and support personnel. b. Processes are coordinated and integrated, which requires the attention of managerial and clinical leaders.	.	.	.
LD.4.1 (JCAHO)	The leaders understand the approaches to and methods of performance improvement.	.	.	.	.
LD.4.2 (JCAHO)	The leaders adopt an approach to performance improvement.	Approach includes: planning, setting priorities for measurement and improvement, systematically measuring and assessing performance, implementing improvement activities based on assessment conclusions and maintaining achieved improvements.	.	.	.
LD.4.3 (JCAHO)	Leaders ensure that important processes and activities are measured, assessed, and improved systematically throughout the hospital.	.	.	.	.
LD.4.3.1 (JCAHO)	All leaders participate in interdisciplinary, interdepartmental performance improvement activities.	.	.	.	.
LD.4.3.2 (JCAHO)	Relevant information is forwarded to leaders and coordinators of hospitalwide performance-improvement activities.	.	.	.	.
LD.4.3.3 (JCAHO)	Responsibility for acting on recommendations generated through performance-improvement activities is assigned and defined in writing.	.	.	.	.
LD.4.4 (JCAHO)	The leaders allocate adequate resources for measuring, assessing, and improving the hospital's performance.	.	.	.	.
LD.4.4.1 (JCAHO)	The leaders assign personnel needed to participate in performance-improvement activities.	.	.	.	.
LD.4.4.2 (JCAHO)	The leaders provide adequate time for personnel to participate in performance-improvement activities.	.	.	.	.
LD.4.4.3 (JCAHO)	The leaders provide information systems and data management processes for ongoing performance improvement.	.	.	.	.
LD.4.4.4 (JCAHO)	The leaders provide for staff training in the basic approaches to and methods of performance improvement.	.	.	.	.
LD.4.5 (JCAHO)	The leaders measure and assess the effectiveness of their contributions to improving performance.	Leaders: set measurable objectives, gather information to assess their performance, draw conclusions based on findings, implement improvement in their activities, and evaluate their performance to support sustained performance.	.	.	.
MLM 2.2.2 (HSI)	FLIGHT LEADERSHIP	Planned, organized, operated, evaluated, and improved all aspects of system performance for flight	.	.	1: Criteria met 2. One criterion not met 3: Two criteria not met
.	.	Supported squadron CC and squadron's role in mission	.	.	4: Training programs not adequate to train personnel to support mission/taskings; mission accomplishment was potentially compromised 5: Little evidence of flight leader involvement or oversight of flight activities
.	.	Interacted with other flights to improve overall organizational performance	.	.	.
.	.	Collaborated with other flights to manage personnel and other resources	.	.	.
.	.	Provided oversight for education, training, and career management of flight personnel	.	.	.
.	.	Continuously developed knowledge and skill and assessed the effectiveness of contributions to flight performance	.	.	.
MANAGEMENT	.	.	.	.	.
EC.2.2 (JCAHO)	The safety management plan is implemented.	.	.	.	.
EC.2.3 (JCAHO)	The security management plan is implemented.	.	.	.	.
EC.2.4 (JCAHO)	The hazardous materials and waste management plan is implemented.	Includes proper documentation, handling of hazardous materials and waste, proper labeling, adequate space and equipment for managing hazardous materials and waste, and separates hazardous materials and waste storage and processing areas.	.	.	.
EC.2.5 (JCAHO)	The emergency preparedness management plan is implemented.	.	.	.	.
IC.1 (JCAHO)	The organization uses a coordinated process to reduce the risks of endemic and epidemic nosocomial infection in patients and health care workers.	Pharmacy services has at least one individual with appropriate background who attends or is consulted for pharmacy related issues discussed at the infection control committee.	.	.	.
INFORMATION MANAGEMENT	.	.	.	.	.
IM.5.1 (JCAHO)	The format and methods for disseminating data and information are standardized, whenever possible.	The use of abbreviations is discouraged and the use of the leading decimal point is avoided to minimize errors in the pharmacy.	.	.	.
IM.8 (JCAHO)	The hospital collects and analyzes aggregate data to support patient care and operations.	.	.	.	.
.	INTENT: The hospital is able to aggregate the following data and information: pharmacy transactions, as required by law and to control and account for all drugs; information about hazards and safety practices; records of radionuclides and radiopharmacy;	.	.	.	.
.	performance measures of processes and outcomes; financial information; patient information such as name, age and gender, etc.	.	.	.	.
IM.9.1 (JCAHO)	The hospital's knowledge-based information resources are available, authoritative and up to date.	Example: Poison-control and formulary information is quickly and easily available when needed.	.	.	.
HCS 1.4.5 (HSI)	FORMULARY MANAGEMENT	Triservice Formulary incorporated into local formulary.	.	.	1: Criteria met 2. Met most of the provisions-moderate patient inconvenience 3. Met some of the provisions-changes in therapy encountered
.	.	All prescriptions for Tri-Service formulary medications were filled.	.	.	4. Met few of the provisions-significant patient inconvenience 5. Failed to meet criteria-risk for adverse outcomes
.	.	Evidence of compliance with OASD (HA) and AFMOA policy regarding formulary management.	.	.	.
.	.	Civilian prescription service was not withdrawn or curtailed.	.	.	.
.	.	All eligible beneficiaries received a uniform standard of care to include the following: a. all formulary medications were available for dispensing to all patients.	.	.	.
.	.	b. nonformulary purchases were not used to provide special care to groups of patients (e.g. active duty).	.	.	.
.	.	Multidisciplinary P&T committee/function met at least quarterly to ensure formulary oversight and meet responsibility of AF guidance, for example: IDMT oversight.	.	.	.

Medication Use

REFERENCE	STANDARD / INTENT	CRITERIA	DOCUMENTATION / LOCATION	OPR:	COMPLIANCE / COMMENTS
TX.3 (JCAHO)	Medication use processes are organized and systematic throughout the hospital.	.	.	.	.
TX.3.1 (JCAHO)	Organization identified an appropriate selection of medications available for prescribing.	P&T Committee Membership: Policies and procedures:	.	.	.
.	INTENT: List of medications that are always available. Selection is a collaborative process.	Selection criteria: Need (given the diseases and conditions treated)	.	.	.
.	.	Effectiveness: efficacy, toxicity, pharmacokinetcs, bioequivalence, pharmaceutical & therapeutic equivalence	.	.	.
.	.	Risks: Incidence of adverse effects, Potential for prescribing errors	.	.	.
.	.	Costs: Acquisition costs and cost impact	.	.	.
TX.3.2 (JCAHO)	Addresses prescribing or ordering and procuring medications not available in the organization.	P&T Committee Policy requiring: a. Justification for procurement of non-formulary drugs b. Sign-off by the chairperson prior to procurement	.	.	.
.	.	P&T Committee meets periodically to review and revise the formulary consistent with medical staff policy and procedure	.	.	.
.	.	.	.	.	.
TX.3.3 (JCAHO)	Policies and procedures support safe medication prescription or ordering.	.	.	.	.
.	INTENT: Procedures supporting safe medication prescription or ordering address a. through i.	a. Distribution and administration of controlled medications, including adequate documentation and record keeping required by law	.	.	.
.	.	b. Proper storage, distribution and control of investigational medications and those in clinical trial	.	.	.
.	.	c. Situations in which all or some of a patient's medication orders must be permanently or temporarily canceled, and mechanisms for reinstating them	.	.	.
.	.	d. "as needed" (PRN) prescriptions or orders and times of dose administration	.	.	.
.	.	e. Control of sample drugs	.	.	.
.	.	f. Distribution of medications to patients at discharge	.	.	.
.	.	g. Procurement, storage, control and distribution of prepackaged medications obtained from outside sources	.	.	.
.	.	h. Procurement, storage, control, distribution and administration of radioactive medications	.	.	.
.	.	i. Procurement, storage, control, distribution, administration and monitoring of all blood derivatives (pooled blood products, e.g. albumin, gamma globulin or immune globulins) and radiographic contrast media	.	.	.
HCS 1.4.1 (HSI)	Pharmacy medication security	Medications are stored in controlled non-traffic areas under secure conditions	.	.	1: Criteria met 3: Minor variations from standards and at risk 5: Failed to meet criteria
.	.	Limited access to bulk narcotic vault/storage	.	.	.
.	.	Perpetual inventory was maintained for all scheduled drugs	.	.	.
.	.	AF Forms 579 (or automated substitute) were issued and tracked by pharmacy and properly annotated for all controlled drugs stored outside pharmacy	.	.	.
.	.	Narcotic prescriptions filled IAW federal law, AFIs, and state law	.	.	.
.	.	Biennial inventory completed on or about 1 May in odd years	.	.	.
.	.	Mechanism in place ot authenticate prescriber identification and DEA# for controlled prescriptions	.	.	.
.	.	Provisions of AFI 31-209, controlled area security, were addressed	.	.	.
.	.	Medical unit narcotic destruction was properly conducted, witnessed, and documented	.	.	.
.	.	Narcotic Inventory adjustments were documented and reviewed by oversight command authority (one year track record not required)	.	.	.
.	.	There was a process to detect potential medication diversion/overuse/abuse by medical treatment facility staff or patients	.	.	.
HCS 1.4.2 (HSI)	Facility Medication Security	Medications were stored in non-patient traffic areas under secure conditions	.	.	1: Criteria Met 3: Met some provisions but increased risk for adverse patient outcomes 5: Failed to meet criteria and potential for adverse outcomes
.	.	Monthly MTF controlled medication inventories were completed	.	.	.
.	.	Anesthesia narcotic controls were followed: a. one week supply maintained b. narcotics limited and secured when unattended	.	.	.
.	.	c. narcotics balanced daily (consistent with OR schedule) d. anesthesia doses monitored monthly for appropriateness	.	.	.
.	.	There was a process to detect potential medication diversion/ overuse/abuse by medical treatment facility staff or patients to include witnessed destruction and documentation of unused controlled medications.	.	.	.
TX.3.4 (JCAHO)	Preparing and dispensing medication(s) adhere to law, regulation, licensure, and professional standards of practice.	On a monthly basis, pharmacy staff inspects and restocks expired medications in all preparation and dispensing areas throughout the organization including	.	.	***Compliance Issue
.	.	Nursing units, emergency medication carts, satellite pharmacies, anesthesia, emergency rooms, clinics, and radiology department.	.	.	.
.	.	Policies and procedures for control of expired, discontinued and recalled medications are developed and maintained. Drug defects are reported to the appropriate agency.	.	.	.
TX.3.5 - TX.3.5.2 (JCAHO)	Preparation and dispensing of medication(s) is appropriately controlled.	All medications dispensed to inpatients or outpatients are appropriately and safely labeled using a standardized method.	.	.	.
.	.	Procedures for the handling and preparation of hazardous medications, recommend no preparation outside of the pharmacy.	.	.	.
.	A patient medication dose system is implemented.	Medications are dispensed in the most ready-to-administer form possible to minimize opportunities for error.	.	.	.
.	Pharmacists review all prescriptions or orders.	Pharmacists review each prescription or order for medication before preparation and dispensing and contact the prescriber or orderer when questions arise.	.	.	.
.	.	When not available, medication orders are reviewed by a pharmacist ideally within 24 hours, but no longer than 72 hours after distribution.	.	.	.
HCS 1.4.3 (HSI)	Therapy Monitoring	Providers contacted on questionable prescriptions	.	.	1: Criteria Met 3: Met some provisions but increased risk for adverse patient outcomes 5: Failed to meet criteria and potential for adverse outcomes
.	.	Direct pharmacist oversight of all outpatient dispensing areas; evidence of checking, filling, dispensing, monitoring interactions and profiles, retrospective review, etc.	.	.	.
TX.3.5.3 (JCAHO)	When preparing and dispensing a medication(s) for a patient, important patient medication information is considered.	Pharmacist contacts the practitioner to suggest modifications based on the patient's medical profile or new product availability.	.	.	.
.	INTENT: The pharmacist and appropriate staff receive important information about each patient's medication regimen to: (a-d)	a. facilitate continuity of care b. create an accurate medication history c. supplement monitoring of medication adverse events d. help provide safe administration of medication	.	.	.
.	.	Patient medication profiles include: the patient's name, birth date, and sex; problems or diagnosis(es); current therapy including prescription and nonprescription drugs; medication allergies or sensitivities; potential drug-food interactions.	.	.	.
.	.	Patient's medication profile may also include: patient's use of illegal drugs and misuse of medications; use of investigational medications; creatinine clearance for patients 65 yrs and older; height, weight or body surface area for dosage calculation.	.	.	.
.	.	Medical profiles must be accessible at all times to care providers.	.	.	.
HCS 1.4.4 (HSI)	Medication Dispensing	Medication profiles contain name, medications, directions for use, and allergies	.	.	1: Criteria Met 3: Met some provisions but increased risk for adverse patient outcomes 5: Failed to meet criteria and potential for adverse outcomes
.	.	Profiles contain all medication orders dispensed in facility (MOD, DOD)	.	.	.
.	.	Pharmacy is sole area for dispensing medications during normal operating hours. Exceptions must comply with all applicable pharmacy practice standards: dispensed by a physician, counseling, security, patient medication profile entry, labeling.	.	.	.
TX.3.5.4 (JCAHO)	Pharmacy services are available when the pharmacy department is closed or not available.	.	.	.	.
.	INTENT: To deliver consistent quality during all hours of service the organization has a means of providing pharmacy services when the pharmacy is closed or not available.	a. Regulation of after-hours drug carts and night cabinets b. Review of after-hours orders by pharmacist c. Policies are approved collaboratively by pharmacy, nursing, and medical staff (P&T)	.	.	.
TX.3.5.5 (JCAHO)	Emergency medications are consistently available, controlled and secure in the pharmacy and patient care areas.	Sealed emergency carts: Nursing staff member inspects and documents daily: Pharmacy inspects and documents contents monthly.	.	.	***Compliance Issue
OPS 2.2.4 (HSI)	Management of Animal Bites	Rabies immune globulin and vaccine were readily available	.	.	.
TX.3.5.6 (JCAHO)	A medication recall system provides for retrieval and safe disposition of discontinued and recalled medications.	The pharmacy department maintains records of the manufacturer and lot numbers of all medications stocked and in use throughout the organization to facilitate retrieval in the event of a recall.	.	.	.
TX.3.6 (JCAHO)	Prescriptions or orders are verified and patients are identified before medication is administered.	.	.	.	.
IM.7.7 (JCAHO)	Verbal orders of authorized individuals are accepted and transcribed by qualified personnel who are identified by title or category in the medical staff rules and regulations.	Pharmacy and nursing departments have policies and procedures for verbal orders.	.	.	.
TX.3.7 (JCAHO)	The organization has alternative medication administration systems.	Appropriate medication administration systems for the type of hospital: for example unit-dose distribution, self-administration, drug trials or research, outpatient pharmacy services.	.	.	.
.	INTENT: The hospital safely manages medications brought in by patients.	The hospital supports the patient's safe self-administration of such medications.	.	.	.
TX.3.8 (JCAHO)	Investigational medications are safely controlled, administered, and destroyed.	Investigational medication studies are safely conducted. Medications not administered are safely destroyed.	.	.	.
.	.	Policies and procedures address: a. Review and approval of participation in studies	.	.	.
.	.	b. Protocols for administering investigational drugs	.	.	.
.	.	c. How individuals are authorized to administer, and	.	.	.
.	.	d. IRB develops, maintains and enforces policies.	.	.	.
TX.3.9 (JCAHO)	Medication effects on patients are continually monitored.	a. Monitor therapeutic response to the medication regimen. b. Review the appropriateness of choice of medication(s)	.	.	.
.	INTENT: Medication monitoring is a collaborative effort. Input from the patient and various disciplines is used to evaluate, maintain, and improve the patient's medication regimen.	c. Attend to therapeutic duplication in the patient's medication regimen d. Consider patient-specific medication contraindications when prescribing or ordering	.	.	.
.	Assessment of the medications effects on the patient include the patient's own perceptions and information from the patient's medical record and medication profile.	e. Based on their expertise and familiarity with the medication profile, pharmacists alert practitioners to potential adverse events and situations warranting further consideration	.	.	.
.	.	f. Severe adverse events (death) are reported internally and externally to the FDA (FDA Problem Reporting Program, 1-800-638-6725 or fax 301-816-8532)	.	.	.

Human Resource Utilization and Development

REFERENCE	STANDARD/INTENT	CRITERIA	DOCUMENTATION / LOCATION	OPR:	COMPLIANCE / COMMENTS
RI.1 (JCAHO)	The hospital addresses ethical issues in providing patient care.	Assigned Patient Advocate: Patient questionnaires: Staff education/training:	.	.	.
.	INTENT: The hospital maintains structures to support patient rights, based on policies that address and educate staff about:	.	.	.	.
.	Access, personal beliefs, informed decisions, ethics, personal privacy & confidentiality, designating a decision maker.	.	.	.	.
HR.2 (JCAHO)	The hospital provides an adequate number of staff members whose qualifications are consistent with job responsibilities.	The department verifies the following elements for each employee:	.	.	.
.	INTENT: Departments provide an adequate number of staff members with the experience and training needed to serve and fulfill the hospital's mission.	a. Education and training are consistent with applicable legal and regulatory requirements and hospital policy b. The individual is licensed, certified or registered	.	.	.
.	.	c. The individual's knowledge and experience are appropriate for his or her assigned responsibilities (i.e. equipment training)	.	.	.
HR.3 (JCAHO)	The leaders ensure that the competence of all staff members is assessed, maintained, demonstrated, and improved continually.	Competence-assessment process meets the following criteria:	.	.	.
.	INTENT: Hospital measures performance regularly and expects employees to perform competently.	a. The hospital uses a combination of ongoing competence assessment and educational activities to maintain staff competence.	.	.	.
.	Departments encourage continual performance improvement by staff.	b. An objective, measurable system is used periodically to evaluate job performance, current competencies and skills.	.	.	.
HR.4 (JCAHO)	An orientation process provides initial job training and information and assesses the staff's ability to fulfill specified responsibilities.	Orientation policy and program in place. Performance feedback completed and documented.	.	.	.
.	INTENT: The orientation process assesses each staff member's abilities to fulfill specific responsibilities.	In-service training and continuing education program documented.	.	.	.
.	Volunteers are oriented to patient care, safety, infection control, and any other activities they are expected to perform competently.	Volunteer orientation program and training completed and documented.	.	.	.
HR.4.2 (JCAHO)	Ongoing in-service and other education and training maintain and improve staff competence.	Periodically review staff's ability to carry out job responsibilities, esp. new procedures.	.	.	.
.	INTENT: Hospital ensures that staff members participate in ongoing in-service education and other training to increase their knowledge of work-related issues.	ONGOING training and staff education, appropriate to patient age groups served by the hospital.	.	.	.
.	In-Service training/education to include - Age Specific Training; new procedures, equipment, technology; safety, security,etc.	In-Service education documentation to include: needs assessment, course or program outline and objectives, and copies of teaching aids and references,	.	.	.
.	.	and documentation of each staff member's participation. Completion in of training within established time frames.	.	.	.
HR.4.3 (JCAHO)	The hospital regularly collects aggregate data on competence patterns and trends to identify and respond to the staff's learning needs.	Reports at least annually on levels of competence, trends and competence activities.	.	.	.
.	INTENT: Collects and analyzes aggregate data from a variety of sources to assess staff competence and pinpoint training needs.	.	.	.	.
HR.5 (JCAHO)	The hospital assess each staff member's ability to meet the performance expectations stated in their job description.	.	.	.	.
.	INTENT: Hospital has a system to conduct periodic competence assessment and document findings for each staff member.	Assessment of professional competency: C.E., professional code of ethics, encouragement of staff development.	.	.	.
.	Competency assessments of individuals who do not have clinical privileges but who have regular clinical contact with patients (e.g.. technicians).	Assessment of such individuals addresses the ages of the patients they serve and the success with which employees produce the results expected from clinical interventions.	.	.	.
EC.2.1 (JCAHO)	Staff members have been oriented to and educated about the environment of care, and possess the knowledge and skills to perform their responsibilities under the environment of care management plans.	see attached list or INTENT of EC.2.1	.	.	.
OPS 3.4.1 (HSI)	Reproductive Health	Written plan for implementing HAZCOM requirements	.	.	1: Criteria Met 3: One or two criteria not met; potential for employees not to be aware of, or understand safety precautions; safety compromised
.	.	Work areas maintain a list of hazardous chemicals	.	.	5: Three or more criteria not met or basic program intent not met; high potential for employee health and safety compromised
.	.	Upon initial work assignment, workers receive training to provide them with a functional, lasting knowledge of the HAZCOM principles applicable to the chemical hazards in the work area	.	.	.
.	.	MSDSs were readily available for hazardous chemicals in the work area	.	.	.
.	.	Hazardous chemicals were properly labeled	.	.	.
.	.	Workers were knowledgeable of HAZCOM-related principles and method in their work area	.	.	.
IC.4 (JCAHO)	The hospital takes action to prevent or reduce the risk of nosocomial infections in patients, employees, and visitors.	Pharmacy staff are educated on hospital and pharmacy policies and procedures addressing infection prevention, such as medication preparation, hand-washing, control of traffic in medication preparation areas, etc.	.	.	.
OPS .3.4.2 (HSI)	Bloodborne Pathogens	All BBP training was documented and maintained IAW OSHA/AF guidelines	.	.	.
HCS 2.2.2 (HSI)	Basic Life Support	Medical service, civilian, and contract personnel maintain currency in BLS	.	.	1: BLS Currency 90-100% for last 12 mo. 2: BLS Currency 80-89% for last 12 mo. 3: BLS Currency 90-100% for last 6 mo. 5: BLS Currency < 80% for last 6 mo.
.	.	Personnel involved in direct patient care certified in AHA C course or ARC CPR/BLS course	.	.	.
.	.	Personnel not involved in direct patient care certified by AHA A course or ARC Adult CPR course	.	.	.
MRX 3.2.2 (HSI)	Clinical Support Team Training	Formalized programs to train contingency response teams/grps consistent with missions, plans, and concept of operations	.	.	1: Criteria Met 2: Training program adequate. Minor discrepancies 3: Training program adequate. Potential degradation of capabilities
.	.	Pharmacy team trng schedules and periodic update submitted to medical planner; lesson plans available	.	.	4: Training program not adequate to train personnel to support mission/taskings. Mission accomplishment was potentially compromised. 5: Training program not in place. Mission accomplishment compromised.
OPS .5.2.2 (HSI)	Preventive Health Services	Focused skills training (initial and recurring) were developed and targeted to primary care managers, nurses, technicians, clerical staff, medical records personnel, volunteers, and any other providers working with prevention clients	.	.	1: Criteria Met 3: One or two criteria not met; lack of appropriate training hampered prevention activities 5: Three or more criteria not met.
.	.	PPIP and prevention concepts were incorporated into basic curricula in facilities that have providers, nursing, and ancillary health training programs. Primary care residency programs provided ongoing, integrated training in PPIP	.	.	.
.	.	Principles and practice of prevention interventions were woven into all educational forums in the medical facility	.	.	.
.	.	PPIP information for patients was accomplished in may forums: informational handouts and video presentations in waiting areas, articles in base newspapers, public presentations, radio/TV spots, and referrals	.	.	..

Process Improvement

REFERENCE	STANDARD / INTENT	CRITERIA	DOCUMENTATION / LOCATION	OPR:	COMPLIANCE / COMMENTS
PI.1 (JCAHO)	The hospital has a planned, systematic hospitalwide approach to process design and performance measurement, assessment, and improvement.	.	.	.	.
PI.1.1 (JCAHO)	These activities are collaborative and interdisciplinary.	Performance-improvement activities are planned, systematic and organizationwide and appropriate professions work collaboratively to implement them.	.	.	.
PI.2 (JCAHO)	New processes are designed well.	.	.	.	.
.	INTENT: When processes are well designed, they draw upon a variety of information sources.	Good process design: a. is consistent with the hospital's mission, vision, values, and plans b. meets the needs and expectations of key constituents	.	.	.
.	.	c. is clinically sound & up-to-date d. is consistent with sound business practices e. establishes baseline performance expectations to guide measurement and assessment activities	.	.	.
PI.3 (JCAHO)	Data are systematically collected.	a. establish a baseline when a process is implemented or redesigned b. describe process performance or stability	.	.	.
.	.	c. describe the dimensions of performance relevant to functions, process, and outcomes d. identify areas for improvement e. determine whether changes in a process have met objectives.	.	.	.
PI.3.1 (JCAHO)	The hospital collects data on important processes or outcomes related to patient care and organization functions.	.	.	.	.
.	INTENT: selection process considers processes that affect a large percentage of patient, place patients at risk, and are problem prone; must include PI.3.2-PI.3.3.3.	Data may include: a. patients' needs, expectations, satisfactions b. results of infection-control activities	.	.	.
.	.	c. safety of care environment d. utilization management e. risk management.	.	.	.
PI.3.1.1 (JCAHO)	The hospital collects data for both improvement priorities and continuing measurement.	.	.	.	.
.	INTENT: Ongoing measurement enables the organization to judge the stability of processes and the predictability of outcomes. Priority issues are chosen for improvement.	a. Identify data which measures performance b. Routinely collect data to measure stability c. Adjust data collection for measurement of new processes and procedures.	.	.	.
PI.3.2 (JCAHO)	The important processes or outcomes on which the hospital collects data include at least:	.	.	.	.
PI.3.2.2 (JCAHO)	processes related to medication use.	.	.	.	.
.	INTENT: Medication is a common and important component in patient care, in some cases, it's the most important intervention. Because of both its risk and therapeutic benefit to the patient, medication use is measured on an ongoing basis.	Establish priorities for ongoing assessment based on: a. the number of patients taking a medication b. the balancing of risk with therapeutic potential	.	.	.
.	.	c. medications known or suspected to be problem prone d. therapeutic effectiveness (example antibiotics)	.	.	.
.	INTENT: Medication processes carried out by the organization are measured. Review of medication use focuses on these processes rather than primarily on individual knowledge, judgment, and skill.	Medication processes to be assessed: a. prescribing and ordering b. preparing and dispensing c. administrating d. monitoring effects on patients	.	.	.
PI.3.2.5 (JCAHO)	The needs, expectations, and satisfaction of patients and	.	.	.	.
PI.3.2.6 (JCAHO)	Staff views regarding performance and improvement opportunities.	Assess patient and staff: a. needs and expectations b. satisfaction with how well their needs and expectations are met	.	.	.
.	INTENT: In assessing how well processes are designed or operate, information from patient, families, staff members, and others is essential.	c. perceptions of how the hospital could improve d. perceptions of how well the hospital performs relative to the dimensions of performance	.	.	.
PI.3.3 (JCAHO)	Data on important processes and outcomes are also collected from:	Data on quality control activities include the following services and others as identified as appropriate by the hospital.	.	.	.
PI.3.3.2-PI.3.3.3 (JCAHO)	risk-management activities and quality control activities.	a. Equipment used in administering medications b. Pharmaceutical equipment used to prepare medications	.	.	.
PI.4 (JCAHO)	The hospital uses a systematic process to assess collected data.	.	.	.	.
.	INTENT: A systematic assessment framework collects and analyzes data to answer the following questions about important processes and outcomes.	Assessment includes: a. Current level of performance b. Stability of current processes c. Identify areas that could be improved	.	.	.
.	.	d. Prioritize areas of improvement e. Determine effectiveness of strategies to stabilize or improve performance f. Determine if specifications for new or redesigned processes have been met	.	.	.
PI.4.1 (JCAHO)	The assessment process uses appropriate quality control techniques.	.	.	.	.
.	INTENT: An understanding of statistical quality control techniques, including statistical process control, and variation is essential for an effective assessment process.	Use of statistical tools, such as run charts, control charts, and histograms with historical patterns and assessing variation and stability.	.	.	.
PI.4.2 (JCAHO)	The hospital makes internal comparisons of its performance of processes and outcomes over time.	.	.	.	.
.	INTENT: How are we doing compared to ourselves over time?	On going review of process	.	.	.
PI.4.3 (JCAHO)	The hospital compares performance data about its processes with information from up-to-date sources.	.	.	.	.
.	INTENT: How are we doing compared with external sources of scientific and other up-to-date information?	Comparisons to up-to-date external sources such as scientific, clinical, and management literature.	.	.	.
PI.4.4 (JCAHO)	The hospital compares performance data about its processes and outcomes to other hospitals, including through the use of reference data bases.	.	.	.	.
.	INTENT: How are we doing compared to like processes and outcomes in other hospitals?	Comparison to other like-size and patient population hospitals/clinics	.	.	.
PI.4.5 (JCAHO)	The hospital invites intensive assessment when statistical analysis detects undesirable variation in performance.	The hospital invites intensive assessment when statistical analysis shows: a. important single events, levels of performance and patterns or trends vary significantly and undesirably from those expected.	.	.	.
.	INTENT: When the hospital detects or suspects significant undesirable variation, it promptly initiates intensive assessment to return or bring performance to desired levels of stability.	b. performance varies significantly and undesirably from other organizations. c. performance varies significantly and undesirably from recognized standards.	.	.	.
PI.4.5.4 (JCAHO)	All significant adverse drug reactions are intensively assessed.	Significant adverse drug reactions, as defined by the hospital, always initiates intensive assessment.	.	.	.
PI.4.8 (JCAHO)	When assessment findings relate to the performance of an individual who is not a licensed independent practitioner, the department director determines the use of the findings in evaluating the competence of the individual.	Staff competence is reviewed and assessed.	.	.	.
PI.5 (JCAHO)	The hospital improves its performance.	Approach to improvement includes planning; testing; assessing results and redesigning if necessary; and implementing.	.	.	.
PI.5.1 (JCAHO)	When improvement activities lead to a determination that an individual with performance problems is unable or unwilling to improve, the hospital modifies the person's clinical privileges or job assignment or takes other appropriate action.	.	.	.	.

Clinical Pharmacy Services

REFERENCE	STANDARD / INTENT	CRITERIA	DOCUMENTATION / LOCATION	OPR:	COMPLIANCE / COMMENTS
TX.1.1 (JCAHO)	Settings and services required to meet patient care goals are identified, planned and provided if appropriate.	Hospital has a roster of on call personnel which is updated monthly and posted in the hospital's emergency care area.	.	.	.
TX.1.2 (JCAHO)	Care is planned and provided in an interdisciplinary, collaborative manner by qualified individuals.	.	.	.	.
.	INTENT: The mix of disciplines involved and the intensity of the collaboration will vary as appropriate to each patient.	.	.	.	.
PE.2 (JCAHO)	Each patient is reassessed at points designated in hospital policy.	.	.	.	.
PE.2.1-PE.2.4 (JCAHO)	Reassessment: (1) at regular intervals during care; (2) deter-mines patient's response; (3) result of significant change in patient's condition; and (4) result of change in diagnosis.	Patients are reassessed throughout the care process and at follow-up appts. Policy designates key reassessment points, including any specific time intervals. (i.e. pharmacist-run coumadin, diabetes, asthma clinics)	.	.	.
TX.4 (JCAHO)	Each patient's nutrition care is planned.	.	.	.	.
.	INTENT: Nutritional therapy is planned for patients determined to be at nutritional risk. Nutrients ordered can range from NPO, to regular diets, to parenteral or enteral nutrition.	Organization criteria guide development of the nutrition therapy plan. Patients at risk are identified.	.	.	.
TX.4.1 (JCAHO)	An interdisciplinary nutrition therapy plan is developed and periodically updated for patients at nutritional risk.	Based on the patient's condition, parenteral nutrition is prescribed for a specified period of time.	.	.	.
.	INTENT: A more intensive plan for nutrition therapy may be indicated for patients at high nutritional risk. Patient's physician, a dietitian, nursing, and pharmacy staff participate in developing the plan.	Nutrition therapy plan defines: the central goal; quantifiable measures to determine the patient's progress; strategies for achieving goals; time frames; and the roles of the physician, dietitian, nursing, and pharmacy.	.	.	.
TX.4.4 (JCAHO)	Food and nutrition products are distributed and administered to the patients for whom they were prescribed or ordered.	Procedures for safe labeling of enteral and parenteral nutrition, including accessory or cautionary statements and expiration dates.	.	.	.
TX.4.5 (JCAHO)	Each patient's response to nutrition care is monitored.	.	.	.	.
.	INTENT: Ongoing patient monitoring is essential to effective nutrition care. Nutrition care is a collaborative process that may involve a formal nutrition care team or communication between multiple disciplines.	Nutrition care monitoring includes: intake of nutrients, therapeutic regimen, reassessing and revising therapy, intense monitoring of patients not receiving adequate intake. Monitored by: practitioner, dietitian, nurse, pharmacist.	.	.	.
.	.	Pharmacist helps the practitioner and dietitian identify potential drug-nutrient interactions.	.	.	.
TX.4.7 (JCAHO)	Nutrition care practices are standardized throughout the organization.	.	.	.	.
.	INTENT: The medical staff, nutrition department, nursing, pharmacy collaborate in developing and maintaining standardized approaches to nutrition care. Approaches are communicated and used.	Nutrition manual developed by a multidisciplinary team. Manual is reviewed and revised at least every three years. Manual includes enteral and parenteral nutrition. It is available on patient care units.	.	.	.
PF.1.3 (JCAHO)	Patient Education: Patients are educated about the safe and effective use of medication, according to law and their needs.	Guidelines for educating patients on the safe and effective us of medication.	.	.	.
PF.1.5 (JCAHO)	Patient Education: Patients are educated about potential drug-food interactions, provided counseling on nutrition and modified diets.	Pharmacy department tracks all drugs prescribed during the patient's hospital stay and looks for interactions: drug-drug and drug-food. The needs of the patient for concrete information determine who is best qualified to provide the patient education.	.	.	***Compliance Issue
PF.2 (JCAHO)	Patient Education is interactive.	.	.	.	.
PF.4.2 (JCAHO)	Patient Education: The patient and family education process is collaborative and interdisciplinary, as appropriate to the plan of care.	Examples: Discharge planning: Diabetic teaching: Asthma Clinics: Pain Clinic:	.	.	.
CC.5 (JCAHO)	Continuum of Care: The hospital ensures coordination among the health professionals and services or settings involved in a patient's care.	.	.	.	.
.	INTENT: Care is coordinated throughout entry; assessment; diagnosis; planning; treatment; and transfer or discharge	An individual set of instructions is given to each patient upon discharge. Information is provided about follow-up appointments, pertinent medical supplies, and prescriptions.	.	.	.
IM.7.4 (JCAHO)	For patients receiving continuing ambulatory care services, the medical record contains a summary list of know significant diagnoses, conditions, procedures, drug allergies, and medications.	Patient information is documented in the Medical and Dental Record for KNOWN adverse and allergic drug reactions; and medications KNOWN to be prescribed for or used by the patient.	.	.	.
IM.7.4.1 (JCAHO)	The list is initiated for each patient by the third visit and maintained thereafter.	.	.	.	.
OPS 1.6.2 (HSI)	PROBLEM LIST	The medical records for ambulatory patients included listings of all: a. Significant diagnoses and conditions b. Significant surgical and invasive procedures	.	.	.
.	.	c. Hospitalizations d. Allergies and adverse drug reations, including the nature of the reaction if known e. Long term medications prescribed for and/or used by the patient, including current dose	.	.	.
OPS 6.2.3 (HSI)	TOBACCO USE PREVENTION	Nicotine replacement therapy was available whenever possible	.	.	.