ESR Implementation Checklist

Region: ……………………………………………………………………………. Hospital Name: ………………………………………………………………..

Date of the visit: ………………………………………………………………. Assessor Name: ………………………………………………………………..

In case of Not Met or

All documented Partially Met
Standard Policy/Plan/List/Form Survey Tool evidences are Comments
completed? Is there any action have
been taken

All credentials (license, education, o Yes.

HR.5 o Yes.
training, certification and experience) in Personnel Files o No.
o No.
personnel files are verified o Partially Met.

All medical staff are having current clinical o Yes.

o Yes.
MS.7 privileges for their practices
Personnel Files o No.
o No.
o Partially Met.
There is a clear process to administer blood, o Yes.
o Yes.
PC. 25 Monitoring patients and good reporting system Staff Interview o No.
o No.
for blood reaction. o Partially Met.
There is implantation of risk assessment for All o Yes.
Medical record o Yes.
PC.26 Adult patients and prophylaxis is initiated
review
o No.
o No.
according to current evidence-based practice. o Partially Met.
Based on 3 to 5 staff interviews, correct o Yes.
o Yes.
QM.17 identification of patients is implemented.
Staff Interview o No.
o No.
o Partially Met.
Based on 3 to 5 staff interviews, process for o Yes.
o Yes.
QM.18 correct patient, site, and surgery/procedure Staff Interview o No.
o No.
during operations is implemented. o Partially Met.
 There is adequate number of Isolation room o Yes.
o Yes.
IPC.15 based on bed capacity and all procedures Observation o No.
o No.
required are followed. o Partially Met.
The plan for high-alert medications and o Yes.
o Yes.
MM.5 hazardous pharmaceutical chemicals is Observation o No.
o No.
implemented. o Partially Met.
The policy and procedure on handling look- o Yes.
o Yes.
MM.6 alike/sound-alike (LASA) medications is Observation o No.
o No.
implemented. o Partially Met.
- There is monthly/quarterly report of
Medication Errors.
- Medication errors are documented in the Documented o Yes.
o Yes.
MM.41 patient’s medical record. Evidence
o No.
o No.
- The hospital conducts intensive root-cause o Partially Met.
analysis for all significant or potentially
significant medication errors.
The donation area and tests are met the o Yes. Is there a contract
o Yes.
LB.51 Standards’ requirements. If no donation there Document Review o No.
o No.
o Yes.
must be a contract with accredited Lab. o Partially Met. o No.
Radiation safety in the hospital is properly Document Review o Yes.
o Yes.
FMS.9 managed in accordance with policy and & o No.
o No.
procedure. Observation o Partially Met.
Fire alarm system is functioning, regularly o Yes. o Yes.
Document Review
inspected, tested, and maintained. o No. o No.
FMS.21
o Yes. o Yes.
Elevators are connected to the fire alarm system Observation
o No. o No.
There is sprinkler system, clean agent, wet o Yes. o Yes.
FMS.22 chemical, stand pipes and hose system.
Observation
o No. o No.
Fire exits are available and are properly located
in the hospital
Not locked, Not obstructed, Having panic hard o Yes. o Yes.
FMS.23 ware
Observation
o No. o No.
Fire exits are fire resistant and clearly marked
with illuminated exit sign
 o Yes. o Yes.
No Smoking Policy is implemented Observation
o No. o No.
o Yes. o Yes.
FMS.24 Storage areas are properly and safely organized Observation
o No. o No.
Fire rated doors are available according to the o Yes. o Yes.
Observation
hospital zones and No Obstacles o No. o No.
The hospital has central medical gas system o Yes. o Yes.
Observation
which is regularly tested. o No. o No.
There is a policy and procedure that ensures o Yes. o Yes.
FMS.32 effective use of medical gas system
Document Review
o No. o No.
If no medical gas system, the current cylinders o Yes. o Yes.
Staff Interview
can fulfill the hospital need o No. o No.