Patient Rights and Organizational Ethics STANDARDS respect and support for patients rights and responsibilities opportunities

es for patients involvement in care provision confidentiality and security of patients information and communication feedback to patients staff code of ethics resolution of ethical issues patients outcomes by respecting patients rights and ethically relating with patients and other Goal: To improve patient outcomes by respecting patients rights and ethically relating with patients and other organizations. Patient Care ACCESS STANDARDS information about services access to services Goal: The organization is accessible to the community that it aims to serve. ENTRY STANDARDS prompt and timely attention efficient triaging unique patient identification informed consent planning for discharge and continuing care Goal: The entry processes meet patient needs and are supported by effective systems and a suitable environment.

ASSESSMENT STANDARDS physical, psychological, social assessment coordinated assessment by professionals regular assessments proper documentation of assessments appropriate diagnostics special needs assessments Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care.

CARE PLANNING STANDARDS relevant to patients needs evidence-based care plan clear and accessible information on care Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals. IMPLEMENTATION OF CARE STANDARDS timely, safe, appropriate and coordinated care delivery respect for patients needs and rights coordinated care delivery among professional patient education standardized drug administration standardized treatment procedures appropriate care for patients with special needs Goal: Care is delivered to ensure the best possible outcomes for the patient. EVALUATION OF CARE STANDARDS analysis of process and outcomes data actions for improvement activities Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of care delivered to patients. Discharge PLANNING STANDARDS discharge plan continuing management plan patient access to community health services patient understanding of discharge plan Goal: Care is coordinated between the organization and other health care providers in the community to ensure that the needs of the patient are continuously met.

Leadership and Management THE MANAGEMENT TEAM STANDARDS leadership effective working relationships committee meetings management performance assessment policies and procedures for operations Goal: The organization is effectively and efficiently governed and managed according to its values and goals to ensure that care produces the desired health outcomes, and is

responsive to patients and community needs.

EXTERNAL SERVICES STANDARDS agreements and contracts of the organization . Goal: The organization ensures that services provided by external contractors meet appropriate standards.

HUMAN RESOURCE MANAGEMENT

HUMAN RESOURCES PLANNING STANDARDS HR needs assessment workload monitoring

Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and external customers and to achieve its goals.

STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES STANDARDS procedures job descriptions staff accountabilities service provision by appropriate staff

Goal: Recruitment, selection and appointment of staff comply with statutory requirements and are consistent with the organizations human resource policies.

STAFF TRAINING & DEVELOPMENT STANDARDS

orientation, training and development programs supervision

Goal: A comprehensive program of staff training and development meets individual and organizational needs.

Information Management DATA COLLECTION, AGGREGATION AND USE STANDARDS timely and efficient data collection standardized information detailed medical charts coding and indexing of data Goal: Collection and aggregation of data are done for patient care, management of services, education and research.

RECORDS MANAGEMENT STANDARD accessible records of data are done for patient care, management of services, education and Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met.

Safe Practice and Environment PATIENT AND STAFF SAFETY STANDARDS plan of safe and eff ective environment of care provision of safe and eff ective environment of care routine evaluation of environment of care Goal: Patients, staff and other individuals within the organization are provided a safe,

functional and effective environment of care.

MAINTENANCE OF THE ENVIRONMENT OF CARE STANDARDS emergency light, power supply, water and ventilation regular maintenance of facilities and equipment maintenance of equipment by qualifi ed personnel current information on products are available Goal: A comprehensive maintenance program ensures a clean and safe environment.

INFECTION CONTROL STANDARDS infection control program risk reduction of nosocomial infection standardized cleaning and sterilization procedures internal and external reporting Goal: Risks of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. EQUIPMENT & SUPPLIES STANDARDS planning and acquisition of equipment and supplies specialized equipment operated by qualified staff safe reuse guidelines Goal: The provision of equipment and supplies supports the organizations role.

ENERGY & WASTE MANAGEMENT STANDARDS standardized waste handling and disposal program implementation of a waste disposal program demo Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability.

Improving Performance

STANDARDS organization-wide approach collaboration in new processes of care management responsibility service unit and staff responsibility evaluation of quality improvement program better service and care confidentiality of data Goal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and meeting the needs of its internal and external clients.