JCI Internal Audit Checklist By-Dr.Mahboob Khan Phd

JCI Internal Audit Checklist N.A-Not Applicable N.T- Not Tested Assessed
(Tick as appropriate)
SN STANDARDS/MEASURABLE ELEMENTS MET? REMARKS
Y N N.A N.T
A SCOPE OF SERVICE
PASS/FAIL/N.A
(Circle one for this section)
A1 AFTER ENTERING THE WARD
Tell me about your ward
Staff should able to share the following:
a  No. of beds in the word/cubicle
 Are your wards usually full?/What the occupancy rate?
b  Nurse to patient ratio in the ward
 How many units are you responsible for?
c  Type of patients
 Common conditions of patients in the wards
 Average age of patients
d  Average length of safety
Staff doing the coordination is able to articulate
e  No. of working shifts for nurses
f  No. of staff at each shifts in the wards
g  The difference between Nurses and HCA
h  How patients are being assigned to the consultant
i
 specific core competency for for professional staff to
practice in this ward
j  What do you do if the patients does not speak English?
k  How the appointments are obtained /given
A2 AFTER RECEIVING PATIENT'S CASE NOTES
a Could you tell me more about this patients ? Staff should
be able to share the following
 Patient's diagnosis
 Time patient was seen
 How he was seen
 course of treatment
 Reasons for transfer/discharge, if any
b Is the patient on any clinical pathway?
A3
DOCUMENTATION - COMPLETENESS AND LEGIBILITY
(MCI)
a Legibility of patients clinical records is evidenced
b
 Every clinical record entry Identifies the data and name
of person who made the entry in the records
 Inpatients entries must also include time of entry
c Doctors use the SOAP format in writing case notes
d
Order forms and checklist are adequately filled in (e.g.
Radiology laboratory)

JCI Internal Audit Checklist (For Inpatient Only) N.A-Not Applicable N.T- Not Tested Assessed
Y N N.A N.T
f Standardizes symbols/abbreviations are used
g
No parts of the clerking sheet should be left blank "N.A"
should be written in those sections not deemed to be
clinically relevant
B INTRNATIONAL PATIENT SAFETY GOALS(IPSG)
B1 Identify patients correctly (IPSG1)
PASS/FAIL/N.A
a How do you identify patients
b
How do you identify unknown /unconscious
/uncommunicative patients (e.g. comalose)?
c When do you use 2 patient's identifiers?
B2 Improve Effective Communication (IPSG2)
PASS/FAIL/N.A
Verbal and Telephone orders -"Read Back"
a
What is the procedure of taking down verbal/telephonic
order for the doctor or receiving &reporting critical test
results?
b
b How do you do a verbal handover of your patients when
you go for a break ? What do you inform the nurse.
B3 Safety of High alert medications (HAM)(IPSG3)
PASS/FAIL/N.A
a
Are there any high concentrated electrolyte her? Where
should they be kept?
b why are the concentrated electrolytes kept in ICUs?
c
For places that can store concentrated electrolytes, they
are not stored in matrix drawer or omnicell shelves
d What HAM do you have in the clinic?
e where is the list of High Alert Medication?
f
Can high alert alert medications be stored with other
drugs?
g
Where are HAM placed/ stored &how do you ensure the
safety of HAM?
h refrigerated drugs are
 Kept under lock and key
 Fridges should be located in secure areas allowing only
medical/nursing staff access.
i
Drugs are not under lock and key in ED resuscitation rooms
and during surgery or procedure
j How do you know how long you can keep the medications?
Do you have discard dates for medications and
disinfectants once they are opened?
k
What are the examples of measures used to improve the
safety of high alert medications
l
when do you serve PRN (pro re nata or "as needed")
medication

Y N N.A N.T
B4 Ensure Correct site/Procedure/Patient surgery (IPSG4)
PASS/FAIL/N.A
a When do you Tme-out
b
Do you document the completed time-out
procedure?Where is it?
c What do you check before conducting the procedure?
d How is site making done?
e How do you involved patients during site making?
f when doyou do site making?
B5 Reduce risk of Healthcare Associated Infections(HAI)(IPSG5)
PASS/FAIL/N.A
a When do you practice hand hygiene
b
Staff practice correct hand washing and hand disinfection
techniques
c when do we hand wash and not handrub
d
hand hygiene items are available /Alcohl handrub at
cubicles are reasonably used
e
What kind of training is there for staff on infection control
practices?
f What do you teach patient regarding infection control?
B6
Reduce risk of patient Harm Reducing from Falls(Exclude
ICU &HDs) (IPSG6)
PASS/FAIL/N.A
a How do you determine the Score for falls risk?
b When is the initial fails risk assessment for all patients?
c
When and how often do you do conduct the fall risk
reassessment for all patients?
d
What interventions do you do those patients who are at fail
risk?
e How do we know which patients here are at fall risk?
f
How do you educate patients & families on falls prevention
?
g
What happens when a patient falls? How do you report
falls?
C ASSESSMENT OF PATIENTS (AOP)
C1 Initial Assessment (AOP1.2)
PASS/FAIL/N.A
a What are the main factors in the Initial Assessment?
b
How long do the doctor and nurses need to complete the
initial medical and nursing assessment of a patient?
C2 Re-assessments(AOP2)
PASS/FAIL/N.A
a How often do you re -assess patient

Y N N.A N.T
C3 Nutritional screening(AOP1.6)
PASS/FAIL/N.A
a Do you do nutritional screening ?
What do you do when patient has nutritional risk?
b who can refer patient to the dietician?
c How fast would the dietician see the patient?
For Speech Therapist ,Prosthelist & Ortholist Podiatrist,
Medical Social Worker ,Occupational Therapist and
Psychologist:
Physiotherapist:
Respiratory Therapist:
Acupuncturist:
Case Manager:
C4 Pain Assessment(AOP1.7)
PASS/FAIL/N.A
a Do you screen for pain the initial assessment?
How do you assess for pain /What do you measure?
b Pain score is documented
c
What happens to the patient when significant pain is
identified by screening criteria?
d(i) How often do you assess/re-assess for pain?
d(ii)
If pain score is ≥ 6, interventions and evaluation post pain
interventions are documented.
C5 Discharge planning (AOP1.11)
PASS/FAIL/N.A
a What's the time frame for discharge planning
D PATIENTS &FAMILY EDUCATION(PFE)
PASS/FAIL/N.A
a What are assessed and documented in the patient record?
b who initiates patient education
c
What have you been communicating to the patient about
education?
d PFE form is adequately filled up
E PATIENTS &FAMILY RIGHTS(PFR)
PASS/FAIL/N.A
E1 Consent Taking /Information Consent(PFR6)
a What is the process for obtaining consent
b Is the patient capable of give consent?
Who do you obtain consent from if patient is incapable of
giving consent?
c
What are some of the procedure and treatments that require
informed consent? Is the re a list of them?

Y N N.A N.T
d Do you use family members as interpreters for consent?
e No medical abbreviations and symbols are used.
f
For parts of the consent form that are not relevant, that
particular portion should be marked "not applicable"/"N.A"
g No alterations made in the consent form.
E2 Patient's Charter
PASS/FAIL/N.A
a
What relevant and available information do you have to
inform patients/family?
b
When the patients come to the ward, are they given the
patient's charter? What if they want to read?
c
What do you do if the patient who does not understand
English asks fo the patient's charter?
E3 Patient Privacy and confidentiality (PFR1)
PASS/FAIL/N.A
a
How do you ensure patients personal belongings are
protected?
b How are patients protected from physical assault?
c How do you ensure patients privacy and confidentiality ?
d
Privacy is povided to patients during the care and
treatment(Observation)
e
What is the process when patient or family request for a
second opinion?
f
Where can the patients carry out religious service or
worship?
g what if patient or family request for spirutual support?
E4 Care of high Risk Patients/ High risk Services(COP.3)
PASS/FAIL/N.A
a What is the timeframe to prepare patient's care plan?
b
The patient's plan of care is documented in the medical
record and masurable goals are indicated , when
appropriate.
c What are the High risk groups?
d What do you do when depressed patients become suicidal?
E5
Do Not Resuscitate Orders (DNR) (PER2.3) & Eternal of Care
at the End of Life (PFR 2.5)
PASS/FAIL/N.A
a How is a DNR order made?
Can the on cal doctor (register and above ) make the DNR
and EOC orders?
b How often to you review the DNR and EOC order?
c
If Patient (on DNR &EOC ) is not able to communicate , how
do you assist the family with decision on end of life case?
d How do you know if a patient has an AMD?

Y N N.A N.T
e If you are faced with unresolved ethical dilemmas, what do you do?
E6 Use of Restraints(COP3.7)
PASS/FAIL/N.A
(Circle one for this section
a Who can initiate restraint use for a patient?
b How often do you need to monitor patients on restraints?
c How long is each restraint order limited to?
F ACCESS OF CARE AND CONTINUTY OF CARE (ACC)
F1 Patient Transfer/Referral(ACC 3,4)
PASS/FAIL/N.A
Staff are able to articulate:
a
Patient transfer to ICU/ Specialized services is according to criteria,
and jointly agreed/ approved by primary team and ICU doctor
b When and how referrals for services(e.g. AHS) are made
c Who accompany patients during transfer
d
when a patient is transferred to another healthcare organization,
What relevant documents are required to handover to the staff of
the receiving institution?
F2 Patient Discharge and Follow Up (ACC 4)
PASS/FAIL/N.A
a
Staff able to articulate process & requirements for patient going on
home leave.
b
Staff/ Care Manager aware of the community healthcare providers/
organizations that patients can be discharged or referred to.
c
When do you have to complete the Hospital Inpatient Discharge
summery (EOSS)?
d Upon discharge , what documents will the patient take?
e
Who is allowed to give approval to patients who request for
discharge against medical advice (AMA)?
f
For an approved AMA, what do you need to give the patient/ legally
acceptable surrogate at the point of discharge?
G ANAESTHESIA AND SURGICAL CARE (ASC)
G1 Sedation (Moderate and Deep sedation) (ASC 3)
PASS/FAIL/N.A
a What do you have to do before administering sedation?
b What minimum monitoring is provided when performing sedation?
How often do you monitor patient when performing sedation?
c
What is the criteria for assessing the readiness for discharge to
ward from sedation monitoring?
d
How do you know if the doctor has been to perform moderate
sedation?

Y N N.A N.T
G2 Anaesthesia (ASC4,5,6)
PASS/FAIL/N.A
a Pre-anaesthesia assessment performed
b Anaesthesia care is planned and documented
c
Patient is reassessed prior to induction of anaesthesia by the
anaesthesiology team?
d When do you monitor patient's physiological status?
e What tol do you use to monitor the physiological status?
f What is the criteria for patient to be discharge from PACU?
g How long does the patient need to stay in the PACU post operation?
h What do you do when the PACU is full after surgery?
G3 Surgery (ASC 7)
PASS/FAIL/N.A
a Before surgery, what assessment is needed?
b Patient is re-evaluated before surgery . Date and time documented.
c
Documentation of the following are completed in the surgical
reports and brief operative notes:
d
Written surgical reports is completed and available before patient
leaves PACU
H EMERGENCY RESUSCITATION
H1 Emergency Medications (MMU3.2)
PASS/FAIL/N.A
a Where can I find emergency medications?
b
Emergency Medications are stored , maintained and protected from
loss o theft
c
Emergency medications are available, monitored , and replaced
after use.
d How do you replace the medications In the Emergency drug kit?
e No expired items in the E-kit /E-trolley.
Staff should know who checks for the expiry dates.
H2 Equipments (FMS 8)
PASS/FAIL/N.A
a
Check that emergency trolley is locked &checking is documented
daily.
b who checks the E-trolley
How often do you check the items in the E-trolley?
What do you checked for?
c Are all the E-trolleys the same in the hospital?
d
Check defibrillator is complete with defibrillation pads(in sealed
package and are not expired)
e Staff able to demonstrate proficient testing of:
f Demonstrate fixing of a functioning laryngoscope.

Y N N.A N.T
H3 Emergency Resuscitation Activation (cop 3.2)
PASS/FAIL/N.A
a Staff able to recognize and assess cardiac arrest to activate CPR
Staff know the steps/ who to call for Emergency Resuscitation
at:
b Clinical area (ward)
c Non-clinical area(public)
d What number to call during emergency resuscitation ?
I MEDICATION MANAGEMENT AND USE (MMU)
I1 Storage (MMU 3)
PASS/FAIL/N.A
a How are the medications stored?
b Medications are stored using First-in-first-out principle.
c How do you label look-alike and sound-alike medications?
d There is segregation of look-alike and sound-alike medications?
e
Controlled drugs are checked each shift and kept locked in
safe?
f
The type of quality of controlled drugs physically available
tallies with the number recorded in the CD Book?
g Staff able to show log on drug wastage
h Staff able to show specimen signature for controlled drugs?
i Drug fridge temperature maintained at 2°C-8°C.
The medications fridge lights are working
j
Staff interviewed can explain what he/she is supposed to do
when the alarm for the medication fridge goes off.
k
medications are properly and safely stored according to
recommended storage conditions as specified by
manufacturers
l
What is the procedure for inpatients who bring their own
medication and for of patients own medication
m There is a procedure to stored and control sample medications.
n
Cartons are stacked in a "criss- cross" manner to improve
stability: will not topple when pushed gently and staff are able
to reach for the top carton without having to use a stepper.
o
There is no obstruction of firefighting equipment (e.g. Sprinkler,
fire hoses, fire extinguishers) In the medication storage area.
I2 Ordering and Transcribing (MMU 4)
PASS/FAIL/N.A
a
Who or where can you look for where you have doubts/
clarification on the medications prescribed?
b
Patients recorded contain a list of current medications taken
prior to admission and this information is made available to the
pharmacy and the patient's care providers.

Y N N.A N.T
c
The doctor screens through all the patient's existing medications
and documents in the clerking case notes, under "Present
Medicines".
d
The doctor reviews if the medicines are still required by the
patient and enters the drugs the drugs to be continued in the e-
IMR. These drugs should be indicated in brackets under the
Remarks column "patient's existing medication"
e
Initial medication orders are compared to the list of medications
taken prior to admission , according to the organization’s
established process.
f
There are special precautions or procedure for ordering drugs
with look-alike and sound-alike names?
I3 Preparing and Dispensing (MMU 5)
PASS/FAIL/N.A
a Injection trolleys are:
Clean and tidy
Assigned area for drug dilution
Aseptic techniques observed during dilution
b Medication cart is clean and tidy
c Stock medication is dated upon opening.
d there are no expired medications/ tubes.
e
How do you review medications prescriptions or orders for
appropriateness?
f
Staff is able to articulate how to dispense the medication for the
omnicell during omnicell downtime
I4 Administering Medications ( MMU 6)
PASS/FAIL/N.A
a what is process of administering medications to patients?
b Drug allergies are identified and indicated
c What are the 5 rights of medication administration?
d
medication prescribed and administered is written in the
patient's record.
e
What do you do with the leftover cytotoxic drug and
consumable used during administration of cytotoxic drugs?
f For multiple uses of the drug/mixture the following are recorded
g
For medication prepared in a syringe or burette for continuous
infusion, the following is labeled :
h
Are patients able to do self- administration of medication during
their hospital stay?
i eIMR and eMARS are logged off when not in use.
I5 Monitoring(MMU 7)
PASS/FAIL/N.A
a What do you do when adverse side effects are observed?

Y N N.A N.T
b What happens when there is a medication error/near miss?
c there is a medication recall system in place
J INJECTION CONTRO (PCI)
J1 Equipment (PCI 7.1)
PASS/FAIL/N.A
Staff have knowledge of:
a Who is supposed to clean equipments
b Devices which are reused in the hospital (None)
c
The process for the collection , analysis and use of infection
prevention and control data related to reused devices and
materials
J2 Laundry and linen Management (PCI 7.1, ME 3)
PASS/FAIL/N.A
a soiled linen is appropriately disposed
b Linen carrier is properly covered
J3 Waste Disposal (PCI 7.2)
PASS/FAIL/N.A
a Name some examples of biohazard waste
b How do you dispose biohazard materials?
J4 Sharps and needles (PCI 7.3)
PASS/FAIL/N.A
a Sharp boxes is less than 2/3 filled
b What is the process of disposing the sharp box?
c Staff's knowledge of needle-stick injury protocol
J5 Patients In Isolation (PCI 8)
PASS/FAIL/N.A
a
What do you need to observe before entering an isolation room/
ward?
b Signage for isolation precaution are available and appropriate
c Personal protection Equipment (PPE) is available for use
d
Staff educates patient's relatives to take precautions for patients
in isolation room
e
What happens when one bedded isolation rooms are
unavailable?
f
Patients with known/ suspected diseases are isolated
appropriately
J6 Personal Protective Equipment (PCI 9)
PASS/FAIL/N.A
a Staff know which situations to use different levels of PPE
b
Staff demonstrates correct techniques of pulling on and taking
of PPE and known what to do removal of PPE

Y N N.A N.T
J7 MRSA(PCI 6)
PASS/FAIL/N.A
a Cases of MRSA infection are documented and reported
b What precautions do you have for MRSA patient?
K FACILITY MANAGEMENT AND SAFETY (FMS)
K1 Safety and Security (FMS 4)
PASS/FAIL/N.A
a All staff, visitors and venders are identified
K2 Hazardous Materials (FMS 5)
PASS/FAIL/N.A
a How do you handle a chemical spill?
b Show your Materials Safety Datasheet(MSDS)
c Give examples on the type of hazardous wastes.
d How is general waste disposed?
e How do you dispose cytotoxic wastes?
K3 Emergency Management (FMS 6)
PASS/FAIL/N.A
a The following information is posted?
Emergency instructions
Emergency phone numbers
Fire Emergency instructions
b
Staff has participated in Emergency Preparedness Exercise
(at least 1 per year)
K4 Fire Safety (FMS 7)
PASS/FAIL/N.A
Staff is able to articulate procedures related to:
a Fire safety R.A.C.E. relating to fire
b Location of Fire Extinguishers
c P.A.S.S. relating to fire
d Location of Fire hose reel
e P.O.R.T.S. relating hose reel
f Contact number for fire safety reporting center
g Clear passage way for all fire exits
h Fire exit doors closed completely
i Location of fire assembly area
j Staff has participated in fire drills (at least 1 per yr)
K5 Medical Equipment (FMS 8)
PASS/FAIL/N.A
a
Preventive Maintenance of equipment is updated &
documented

Y N N.A N.T
b
Oxygen cylinders are stored properly in holder in a
designated area
c Point of Care Testing Equipment:
-Urine lab-stick-not expired
-Hypo -count machine
 show Quality records
 expiry date time frame
K6 Utility Systems(FMS 9)
PASS/FAIL/N.A
a Show you uninterruptable power supply(UPS)
K7 Utility Room-Clean (FMS 11.2)
PASS/FAIL/N.A
a Items are labeled and placed in correct containers
b Stock items are arranged in first in first out order
c
No carton boxes on floor /All items are elevated from the
floor
d No contaminated or dirty items in utility room
e No patient care items under the sink
f CSSD items are stored in a clean and dry area
g Check integrity of items
h Pat- slide hung on the wall
i Utility room door is kept closed
K8 Utility Room-Dirty (Sluice Room) (FMS 11.2)
PASS/FAIL/N.A
a Room door is kept closed
b Separation of clean and dirty items
K9 Food and Pantry (COP 4.1)
PASS/FAIL/N.A
a
Food stored in the fridge are labeled with name date and
time
b Floor is clean and not littered
c No food related items placed under the sink
d Area clean: infection control measures implemented
L STAFF QUALIFICATIONS AND EDUCATION (SQE)
PASS/FAIL/N.A
a Department Staffing plan Staff schedule/roster in place

Y N N.A N.T
b
In the event of an emergency, what would your staffing
response plan be?
c Plan is in place for unexpected staff shortage
d Job description are current and available for all staff
e How do you ensure competency for your staff?
Does Nursing or Pharmacist do competency training?
f What groups staffs are BCLS certified?
g How does your Hospital carry out Privileging?
Do all departments have a list of specific privileges for
senior consultants / aside from common privileges?
h
All newly appointed , promoted and transferred staff (
including contract workers, students, volunteers, temp
staff) have attended department induction program.
All newly appointed staff have attended the hospital
orientation program and can articulate what they have
learnt during their orientation.
I
Each staff can articulate heor he or she is continuously (i.e.
knowledge, skills, competencies)
j All staff wear name tags or identification badges
k What quality improvement activities are you involved in?
M QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS)
PASS/FAIL/N.A
a
What are your quality data and measures / quality
improvement projects?
b
Are there any new /modified clinical pathways developed
in the last 12 months?
c What is a serious reportable event?
d What is medication error?
e What is a near miss?
f
What are steps to take in the event of a serious reportable
event / near miss?

Y N N.A N.T
Other Comments:
Prepared by Dr.Mahboob Khan Phd
Healthcare Quality Consultant
Copy right reserved c 2015

JCI Internal Audit Checklist By-Dr.Mahboob Khan Phd

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