QUALITY SELF-AUDIT
GENERIC CHECKLIST GUIDE FOR DEPARTMENTS/UNITS
DEPARTMENT: DATE OF AUDIT:
ITEM SC PC NC COMMENTS
GENERAL OVERVIEW FOR STAFF:
-ISO 9001:2000 ACREDITATION BY MSQH
ORGANIZATION & MANAGEMENT
1. Organization Chart
2. Vision
3. Mission
4. Objectives:
-Department/Unit
-Quality objectives of hospital
-Quality objectives of department/unit
5. Piagam Pelanggan
6. Patient orientation:
-Guide pamphlet
-Checklist
-Signature of staff & patient
7. Work flow charts
8. Fail Meja & Senarai Tugas, Carta aliran
9. Code of ethics
10. Facility layout plan & Signage
11. Disaster Plan & Fire Plan:
-Signage & floor plan
-Fire exits plan & doors/routes
-Staff training if hire handling & response,
drills at least once a year
-Fire fighting equipment-alarms, fire
extinguishers & hoses
-certification by BOMBA
Exit doors keys
-emergency lights
12. Meetings:
-call letters
-minutes
-attendance, distribution &
acknowledgements of notification
13. Files:
-Management meetings
-Clinical audits
-OSHA
-Incident reporting
-correspondence
14. Perintah Am, PKPA, CPGs, Circulars
15. Department/ Unit statistics-displayed
16. Budgeting:
-Program agreement
-Post
-Equipment
-Dasar Baru
17. Safety policy
-Fire
-Keys
-Office management
18. Water & energy:
-Storage & testing
-Conservation
FACILITIES & EQUIPMENT
1. HSIP & TRIP:
-Deduction formula awareness,
implementation
2. Equipment:
-Tagging
-Maintenance-PPM
-Calibration
-Update KEW 312,313 cards
3. Privileging of staff for specialized equipment
4. Clinical waste/Cleansing/Housekeeping:
-Segregation
-Spillage kits
-Collection schedule
-Toilet cleansing schedule displayed & proof of
execution
-Toilet floors dry after cleaning
-Railings in toilets
-Designated pathway for clinical waste
-Storage of cleansing equipment appropriate
-Review of nosocomial infections results
-Weekly joint inspection
5. Sluice room management
6. Chemical waste-storage & disposal
appropriate
7. Mortuary effluent management
8. Sharps bins-usage, limit for only ¾ full
9. Clinical bins for infectious cases, empty
injection vials
10. Medication-
-Indent, stock, expiry
-Charting & dispensing
-Dilution of injection & storage
-Labeling of iv infusions-time, date, medication
11. DDA:
-Storage
-Security
12. Food:
-Collection methods from kitchen
-Diet quantity & appropriateness
-Food trolley-cleanliness, war specific
-Food handlers hygiene, vaccinations
-Cutlery storage & cleanliness
-Dispensing of food in pantry under staff nurse
supervision
13. Clothes-no washing by patients
14. CSSD:
-FIFO
-Separation of sterile & unsterile, update
sterile storage
-Air conditioning
-Sampling
-Storage racks & bins
15. Fridges:
-Temperature monitoring & calibration daily
monitoring
-No specimens of foods in drug/vaccination
fridges
-Cold chain maintenance
16. Waiting areas:
-Adequate
-Reading & educational materials
17. Examinations rooms:
-Patient privacy
18. Meeting rooms
19. Signage:
-Toilets
-No smoking
-Telephones
-Facility locations
20. Traffic management:
-Vehicle flow
-Parking
-Security
21. Linen:
-HSIP schedule conformed
-TRIP adhered to verification
Rejection of poor conformance
-Adequacy for use
-Disposal of soiled linen by segregation:
-white, red, green bags
-Transport of soiled linen-Trolley SL4
-Linen record
22. Ambulances:
-Equipment checklist
-Maintenance PPM
-Log book
-Ambulance call protocol
23. Punch Clock:
-Monthly report
24. Emergency trolley
HUMAN RESOURCES DEVELOPMENT &
MANAGEMENT
1. Staff deployment
2. Personal files:
-Biodata, qualifications, APC, leave, MC, CME
reports, Surat Aku Janji, Profail Anggota
3. Training requirements:
-Year planner
-Records of training
-Department & hospital CME records
4. Roster of duties-call, daily work placement
5. Specimen signatures
6. Credentialing & Privileging
POLICEIS & PROCEDURES
1. Hospital Policy-update
2. Department Policy-update
3. ISO MK,PK,AK-
-Update
-Awareness
-Compliance
-Access & storage
4. PKPA, Perintah AM, Circulars, CPGs
5. Nursing Care Plans
6. Infection control-reporting, compliance,
circulars
QUALITY IMPROVEMENT
1. List of activities:
-Awareness of staff
2. Department CMEs:
-Program
-Attendance
-Notes
3. NIA, HAS, Piagam Pelanggan
4. KMK, QAP, Inovasi
5. MSQH Accreditation
6. ISO 9001:2000
7. POMR
8. Infection Control
9. Maternal Mortality
10. Lab –quality control
11. Corporate culture
12. Clinical audit
13. Incident reporting
14. Customer feedback & customer satisfaction
15. Research
Head of Departments Comments:
Signature of Head of Department: Date:
Name:
