LD QM

1.
Leadership & Quality Management Surveyor (Closed Session)

Required Documents Related Standards
Policy on Policy
1. Policy for Development and Maintenance of Policies LD.20.1
Laws and Regulations

2. Laws and Regula ons Worksheet e.g. HR.5.5, ORT.2.1, LD.3.1
FMS.4.1, etc.)
3. Evidence of Hospital Compliance with Relevant Laws and LD.3.2, LD.2.3
Regulations
Hospital Leadership /Governing Body
4. governing body formation document LD.1.1
5. Governing Body Bylaws or Similar Document LD.1.2
6. Administrative Policies and Procedures Manual LD.6.3, LD.6.1
7. Policy for Delegation of Authority LD.1.3
8. Governing Body Meeting Minutes LD.1.4
9. Reports from Hospital Director to Governing Body LD.2.5
10. Evidence that the Leadership Supporting Hospital Safety LD.2.7
11. Hospital Executive Committee LD.2.8, LD.5.1, LD.5.4, LD.5.5, LD.5.6,
LD.14.2, LD.14.3, LD.24.2
12. Evidence of Hospital Director Response to the Authorities LD.2.9
13. Reports and Communications about Performance Quality LD.10.3
14. Evidence of Community Leaders Participation in Planning LD.11.2
15. Key Performance Indicator Report LD.15.8
16. Policy for Vertical and Horizontal Communication LD.18.1
17. Policy for Handling Incoming External Requests LD.18.5
18. Evidence on Response to any Incoming Requests LD.18.6
19. Contracts Oversight Process LB.1.4
Hospital Scope of Services
20. Hospital Scope of Services LD.4.1, LD.4.2, LD.4.3, LD.4.4, LD.4.5,
LD.4.6
Hospital Strategic Plan
21. Mission Statement LD.7.1, LD.7.4, LD.7.5
22. Hospital Code of Conduct LD.8.1, LD.8.2, LD.8.3, LD.8.4
23. Document Identifying Relevant Community Leaders LD.11.1
24. Hospital Strategic Plan LD.11.2, LD.11.3, LD.12.1, LD.12.2,
LD.12.3, LD.12.4, LD.12.5, LD.12.6,
LD.12.7, LD.15.1, LD.15.2, LD.15.3,
LD.15.4, LD.15.5, LD.15.6, LD.15.11
Hospital Budgeting Process
25. Hospital Budgeting Process LD.13.2, LD.13.3, LD.13.4, LD.13.5
Hospital Staffing Plan
26. Hospital Staffing Plan LD.16.1, LD.16.2, LD.16.3, LD.16.4,
LD.16.5
Hospital Committees
27. Policy for Committee Management LD.9.1, LD.9.2, LD.9.3
28. Committee Terms of Reference (Sample) LD.9.3
Page 58 of 134
Hospital Accreditation Guide Oct-2016
29. Terms of Reference of Patient Rights/Patient Advocacy PFR.1.1
Committee
30. Terms of Reference of Research Committee PFR.16.3
31. Medical Records/Forms Committee MR.16.2
Leadership & Quality Management Surveyor (Units Documents)

Required Documents Related Standards
Human Resources
1. Human Resources Manual HR.1.3
2. Laboratory/facility policy on job description and samples HR.3.1
of job descriptions (lab staff)
3. Policy for Delegation of Authority LD.17.1, LD.17.2
4. Policy for Management of Personnel Files HR.4.1
5. Policy for Credentialing and Privileging HR.5.1
6. Departmental and Job Orientation Program HR.7.1
7. Policy for Probationary Period Evaluation HR.8.1
8. Policy for Regular Performance Evaluation HR.9.1
9. Policy for Staff Complaint HR.14.1
10. Evidence of Staff Complaints Management HR.14.3
11. Evidence for Exit Interview HR.15.4
12. General Hospital Orientation Program / Employee PFR.2.1
Handbook
Education and Training Department
13. Training Needs Assessment HR.10.1, HR.10.2
14. Policy for Continuing Education HR.11.1
15. Evidences of support of Staff Education HR.11.2
16. Continuing Education Program HR.11.3
Quality Management Department
17. Hospital Organization Chart QM.3.4
18. Departmental Scope of Services QM.1.1
19. Quality Improvement Plan/Program QM.4.1, QM.4.2, QM.4.3, QM.4.4,
QM.2.1, QM.2.2
20. Risk Management Program QM.13.1, QM.13.2, QM.13.4, QM.13.5,
QM.13.9, QM.13.10, QM.13.11,
QM.13.13
21. Terms of Reference of Patient Safety Committee QM.16.4, QM.16.9
22. Patient Safety Culture Assessment Report and Actions QM.16.5
23. Leadership Patient Safety Rounds QM.16.6
24. Policy for Incidents Reporting QM.14.1, QM.14.2
25. Terms of Reference for Quality Improvement QM.14.4, QM.14.6
Committee/Council
26. Policy for Sentinel Events QM.15.1, QM.15.2
27. Reports of Sentinel Events QM.15.3, QM.15.4, QM.15.5, QM.15.6
28. Data Management Education/Training Program MOI.5.1, MOI.5.2, MOI.5.3
29. Performance Improvement Projects/Reports QM.12.1, QM.12.2, QM.12.3
30. Hospital Indicators Reports MOI.4.2, QM.10.1, QM.10.2, QM.10.3
Page 59 of 134
31. Evidence on Systematic Approach of New or Modified LD.19.1
Processes
32. List of Identified Customers and their Needs LD.19.2
33. Risk Assessment LD.19.4
34. Pilot Testing Report LD.19.5
35. New Process Indicators LD.19.6
36. Staff Training Records for New Processes LD.19.7
Patient Affairs
37. Patient and Family Rights Statement PFR.1.3, PFR.4.2, PFR.8.1, PFR.8.2,
PFR.8.3
38. Policy for Patient and Family Rights PFR.1.4, PFR.8.1, PFR.8.2, PFR.8.3,
PFR.8.4, PFR.17.5
39. General Hospital Orientation Program / Employee PFR.2.1
Handbook
40. Policy for the Protection of Patient Belongings PFR.4.1, PFR.4.3
41. Policy for Information Confidentiality, Security and PFR.7.1, PFR.7.2
Integrity
42. Terms of Reference of Research Committee PFR.7.2
43. Patient's Booklet/Handbook PFR.8.6
44. Policy for Patient Complaint PFR.14.1
45. Evidence of Patient Complaints Management PFR.14.3
46. Patient Satisfaction Program PFR.15.1, PFR.15.2
Social Services
Policy For Refusal of Treatment PFR.11.1, PFR.11.2, PFR.11.3 PFR.11.4,
47.
PFR.11.5
48. Policy on "No Code" PFR.12.1
49. Policy for Experimental Research PFR.16.1, PFR.16.2,
Sample of patient's informed consent for participating in
50.
research. PFR.16.4, PFR.16.5
Medical Records
51. Departmental Staffing Plan MR.1.3
52. Policy for Medical Records Documentation MR.5.1, MR.5.6
53. Policy for Medical Records Protection MR.6.3, MR.13.1, MR.13.3
54. Policy for Access to Medical Records MR.9.1
55. Medical Records Management Process MR.11.3, MR.15.1, MR.15.2
56. Policy for Medical Records Retention MR.12.1, MR.12.2
57. Policy for Release of Medical Records MR.14.1, MR.14.2, MR.14.3
58. Medical Records Review Reports MR.17.1, MR.17.2, MR.17.3, MR.17.4,
MR.17.5
IT
59. Policy for Data and Information Retention MOI.2.5, MOI.8.1, MOI.8.2, MOI.8.3
60. Policy for Information Confidentiality, Security and MOI.6.1, MOI.6.2, MOI.6.3, MOI.6.4,
Integrity MOI.6.9
Property Control
61. Evidence for Qualification of Medical Suppliers LD.23.2
62. Documents Reflecting Implementation of Safe LD.23.4, LD.23.9
Management of Medical Supplies and Devices Process
63. Medical Supplies and Devices Inspection Reports LD.23.5
64. Evidence for Reporting Medical Supplies Adverse Effects LD.23.6
Page 60 of 134
65. Risk Assessment QM.24.6
Hospital-wide
66. Departmental Organization Chart LD.26.1, LD.26.2
67. Departmental Mission Statement LD.27.1, LD.28.2
68. Departmental Scope of Services LD.28. 2
69. Annual Departmental Plan LD.15.9
70. Departmental Staffing Plan LD.30.2, LD.30.3, HR.2.1, HR.2.3, HR.2.4
71. Departmental Meeting Minutes LD.18.2
72. Policy for Development and Maintenance of Policies LD.20.1, LD.20.2
73. Policies and Procedures LD.20.3, LD.20.4
74. Interdepartmental Agreement LD.27.2
75. Departmental Manual LD.29.1
76. Multidisciplinary Policies and Procedures (Sample) LD.29.2
77. Departmental Request for Resources and Staffing LD.30.1
78. Performance Improvement Projects/Reports LD.31.1, LD.31.2, LD.31.4
79. Departmental Indicators Report LD.31.3
80. Evidences of rewarding recognized staff HR.15.1
81. Information System Downtime Procedures and Forms MOI.9.1
Page 61 of 134

LD QM

Uploaded by

Copyright:

Available Formats

LD QM

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

LD QM

Uploaded by

Copyright:

Available Formats

1.

Leadership & Quality Management Surveyor (Closed Session)

Laws and Regulations

Leadership & Quality Management Surveyor (Units Documents)

You might also like