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 The clinical assessments are focused on identification of risk issues and opportunities
for improvement. The assessment process includes the use of evidence-based and consensus-based
approaches to improvement and best practices. The benefit of the assessment is to
help you prioritize the top areas and themes for implementation to control loss
and improve patient safety.
Assessment Options – Defined
Self assessment-consultant guided review
- Tools to assist you in auditing your own practice
- Looks at structure, practice and process
- The survey responses will be provided to PSRS and we will conduct
an analysis and provide feedback on the top areas to improve
- An action plan based on your results will be created for your
use
Accelerated review
- A questionnaire provided by PSRS is completed first
- A one day review will be conducted with a special focus on high
risk areas and outcomes
- A very brief review of a select number of these medical records
will be included
- Interviews will be conducted to determine practice
- An assessment report and action plan will be developed for your
use
Broad review
- A questionnaire provided by PSRS is completed first
- A two day on-site review will be conducted including limited
document review prior to on-site review, expanded interviews, observation and medical
record review.
- This assessment will focus more deeply on the high risk areas
and outcomes
- An assessment report, action plan with priority determination
will be provided
- Select resources/tools will be provided as may be applicable
to support your implementation of the action plan
Comprehensive evaluation
- A questionnaire provided by PSRS is completed first.
- A three to five day on-site review will be conducted including
full document review prior to on-site review, expanded interviews and staff surveys,
observation and expanded medical record review.
- This assessment will focus on the high risk areas and outcomes
- An assessment report, action plan with priority determination
will be provided
- Select resources/tools will be provided as may be applicable
to support your implementation of the action plan
- Consultants include nurse and physician experts on-site
Select an assessment category below for more detailed information.
Focus areas of review
- Claims trends and contributing factors based on national data
- Analysis of current practice in comparison with community and
national standards
- Risk management, loss prevention and control
- Clinical systems/high risk protocols/record review
- Induction of labor, shoulder dystocia, vacuum delivery, emergency
C-section, EFM, VBAC, neonatal resuscitation
- placental evaluation
- Staffing and competency
- Orientation and education
- Medical staff risk control/peer review
- Quality/compliance/risk integration
- Performance improvement
- Patient safety
- QI initiatives/indicators and process
- Patient satisfaction
Focus areas of review
- Claims trends and contributing factors based on national data
- Analysis of current practice in comparison with community and
national standards
- Risk management/loss prevention and control
- Practice management for the group
- ED group risk profile
- Clinical systems/high risk protocols
- Clinical systems/high risk protocols/record review
- Chest pain, headache, peds fever, lacerations/ wounds, stroke,
cauda equine, abdominal pain, fractures, trauma, pulmonary embolism
- Performance improvement
- QI initiatives/indicators and process
- On call availability
- Medical staff risk control/peer review
- Orientation and education
- Staffing and competency
- Technology use
- EMTALA
- Patient safety
- Complaint management
- Patient satisfaction
- Operations
- Boarding and throughput
- Waiting times /reassessments
- Triage
- Call back systems
- Discharge procedures
- Leadership, governance
- EKG over-read and x-ray discrepancy process
- Formal system to review adverse events
- Acuity/pt mix is in line with resources
- Staffing levels or per pt hour care is stable
Focus areas of review
- Claims trends and contributing factors based on national data
- Analysis of current practice in comparison with community and
national standards
- Risk management structure, process and outcomes
- Medical staff risk control/peer review
- Pain management/anesthesia
- Teamwork and communication
- QI initiatives/indicators and process
- Assessment and clearance
- Informed consent
- High risk surgeries and techniques
- Surgical site location
- Equipment safety and technology
- Infection control practices
- Patient identification
- Post-operative emergencies
- Orientation and education
- Staffing and competency
- Re-use of devices
- Vendors in the OR
Focus areas of review
- Claims trends and contributing factors based on national data
- Analysis of current practice in comparison with community and
national standards
- Cath lab
- Open heart surgery process
- Medication safety
- Re-use of devices
- Medical staff risk control/peer review
- Quality indicators
- Orientation and education
- Staffing and competency
- Equipment technology
Focus areas of review
- Transitions of care
- Sign out
- Shift to shift reporting
- Diagnostic information
- Referrals
- Critical test results
- Communication techniques
- Safety goals and communication
Focus areas of review
- Claims trends and contributing factors based on national data
- Analysis of current practice in comparison with community and
national standards
- Communication and information flow
- Imaging services and clinical information
- False positive reports
- Discrepancy and difficult diagnosis
- Interventional radiology-consent, complications
- QI initiatives/indicators and process
- Workload and scheduling
- Patient flow and handoffs
- Safety for high risk patients in the department
- Compliance with ACR standards
- Wet reads, provisional reports, critical result reporting
- Turn around times
- Critical results
- Equipment safety
- Medical staff policies
- Medication safety
- Patient identification
- Radiation safety
- Assessment and patient consent
- Orientation and education
- Staffing and competency
- Urgent/emergency response
Focus areas of review
- Claims trends and contributing factors based on national data
- Analysis of current practice in comparison with community and
national standards
- Wounds
- Documentation practices
- Advance directives and code status
- Diabetic management
- Behavior management
- Nutrition
- Restraints
- Communication
- Infection control
- Regulatory awareness
- Abuse and neglect
- Risk prevention and management
- Quality indicators
- Orientation and education
- Staffing and competency
- Equipment technology
- Physician services
- Environmental hazards
- Teamwork
- Medication management
- Transition of care
- Falls
- Wandering and elopement
- Medical staff risk control/peer review
- Safety and security
Focus areas of review
- Program infrastructure
- Ability to respond to clusters of healthcare associated infections
- Identification, surveillance and care of patients with MDROs
consistent with current national or state-based, scientific guidelines
- Surveillance plan program and cultures for patients with infections
or those at high risk
- Education needed for patients, family, visitors and the broader
community
- Sensitivity of surveillance, prevention and control of infection
program to detect and distinguish between HA-MRSA and community-associated MRSA
- Practices within the surveillance program are consistent with
the Centers for Disease Control & Prevention (CDC), National Healthcare Safety Network
(NHSN) – formerly National Nosocomial Infections Surveillance (NNIS) System, and
Association for Professionals in Infection Control & Epidemiology, Inc.
- Benchmarking of data
- Alignment of IC Program with overall performance improvement
& patient safety program
- Surveillance activities appropriate and consistent with best
practices
- Outcome indicators for surveillance program
- Opportunities for improvements in the IPC Program design and
infrastructure that would enhance effectiveness and patient safety
Focus areas of review
- Patient selection
- Informed consent
- Anesthesia and sedation
- Monitoring
- Emergency response
- Surgical site location
- Patient identification
- Risk management structure, process and outcomes
- Medical staff risk control/peer review
- Teamwork and communication
- Infection control practices
- Orientation and education
- Staffing and competency
Focus areas of review
- Staffing, resources and volume
- Guidelines for Unit Stock Medications
- Dangerous Abbreviations and Dose Design
- High Alert Medications
- Failure Analysis for Purchase
- Pharmacy and Therapeutics
- Limitations on Verbal Orders
- Triggers for Potential Medication Errors
- Safety Checklists for Infusion Pumps
- Computerized Prescriber Order Entry
Focus areas of review
- Falls
- Wounds
- Critical thinking
- Staffing and resources
- Clinical assessment skills
- Magnet preparation
- Orientation and education
- Competency evaluation
- Restraints
- High risk medications
- Equipment use
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