Practice Certification and Benchmarks

Does the office have a designated medical director or quality assurance director responsible for patient safety issues?

Does the office have a policies and procedures manual?

Women’s health specific patient safety goals?

Procedures for office based surgery?

Does the office have a process to grant privileges for procedures based on adequate training and verified competency for all Providers?

Does the office have a system for ongoing monitoring of competency for all Providers that privileges are granted to?

Tier II?

Tier III?

Is ongoing monitoring of competency based on peer review data?

Does the office use a screening tool or other method to review intimate partner or domestic violence issues?

Is an intimate partner or domestic violence screening tool or other method used consistently in the office (ob, gyn, well woman)?

Does the office use a screening tool or other method to review depression and/or postpartum depression?

Is a depression and/or postpartum depression screening tool used consistently in the office (ob,gyn, well woman)?

Does the office have a written statement of patient rights including the office’s policy for reporting and managing violations of patient rights made available to patients and posted in areas that are accessible to patients and others?

If yes, is the statement posted in languages other than English that are pertinent to the practice?

Does the office train all clinical staff in basic life support (BLS) techniques?

Does the office have a policy or plan to ensure that BLS can be immediately provided to patients at all times patients are present in the office?

Does the office have a medical emergency management plan?

If the office actively manages obstetric patients, are there protocols specific to pregnancy related emergencies?

Does the reporting system allow all staff to report observed unsafe or potentially unsafe practices anonymously?

Does triage staff undergo formal training and have written procedures specific to women’s health that must be followed when providing medical advice by phone?

Do staff verify two patient identifiers (i.e. patient name and date of birth) for each patient upon arrival?

Does the office only use a paper system?

Does the office have a system that tracks imaging, laboratory orders and laboratory results?

Pap test results and necessary follow-up

Mammography referrals, results, and necessary follow-up

All laboratory tests and radiologic studies

Pathology reports

Routine as well as special obstetric testing, such as multiple marker studies

Follow- up education or referral if intimate partner violence, depression or other screening measures are found to be positive.

After-hours and on-call emergencies, including follow-up on laboratory and radiologic studies from the hospital and emergency department (relevant to the office practice)

Does the practice communicate with patients using e-mail?

Does the office use a patient portal for communication?

When communicating with patients using email or through a patient portal, is a secure network with provisions for authentication and encryption in accordance with HIPAA and other guidelines relevant to patient privacy issues used?

Does the office have a reminder system for notifying patients of upcoming appointments?

Does the office track patient referrals to health care providers?

Does the office note whether the referred health care provider’s report has been filed in the patient’s chart?

Does the office track referrals of patients from other health care providers tracked?

Does the office send notification and/or reports to the referring health care provider once the patient has been seen by a provider?

Does the office have a system for documenting all incoming patient phone calls?

Is there a system for documenting all incoming after-hours patient phone calls?

Does the office have a written policy and written list of “Do Not Use” abbreviations and symbols?

Do all patient records include a complete medication list of over-the-counter and prescribed medications taken, as well as vitamins and herbal supplements?

Is the medication list reviewed and, if necessary, updated with patients at each office visit?

Does the office use an e-prescribing or an auto-fax prescribing system?

Does the office have a system in place for reviewing the patient's known allergies to medication?

Does the office have a system of documenting identified medically-relevant allergies?

Are allergies reviewed at each office visit?

Does the office have a system to check for contraindications before prescribing medications?

Does the office have protocols or a decision support or protocols that support system to identify unique medication interactions in women?

Does the protocols or the decision support include hormonal contraceptives?

Does the protocols or the decision support system include medications prescribed to pregnant patients?

Name of Medication?

Lot Number?

Expiration Date?

Dose?

Injection Site?

Frequency?

Provider Name?

Date of Administration?

Are all medications (including samples, injectable medications, and emergency cart drugs) stored and secured properly?

Does the office have a system that ensures all outdated or recalled medications are replaced?

Does the office maintain a log of drug samples dispensed to patients?

Does the office have a policy that drug samples are given under a provider’s written or verbally confirmed order?

Does the office have a policy that all pharmacy orders, including refills, are approved by a provider and documented in the patient’s record?

Does the office have a policy that verbal medication orders shall be followed by a request that the person receiving the order repeat the order to the prescriber?

Are patients given ample opportunity to ask questions and reiterate, , their understanding of proper dosage and use of their medications, including a teach back technique for medications prescribed?

Does the office have a policy that only patients that fulfill the American Society of Anesthesiologists’ (ASA) classification for patient selection criteria as ASA Physical Status I (a normal, healthy patient) or medically controlled ASA Physical S

Does the office have a policy requiring that written preoperative and postoperative care instructions are discussed with and provided to all patients?

Do written postoperative care instructions that are discussed with and provided to all patients contain instructions for how to recognize an emergency situation, and the steps to follow in the event of an emergency?

Are preoperative and postoperative care instructions available in the most common languages used by patients in the office?

For procedures requiring more than minimal sedation according to ASA classification, does the office have a policy and procedures for health professionals trained and credentialed for more than minimal sedation?

Does the informed consent process, include a discussion of the risks, benefits, and alternatives to the office-based surgical procedure before the procedure occurs?

Does the informed consent process include a discussion about the risks and benefits of performing the procedure in the office versus an ambulatory surgery center or hospital?

Is the informed consent process documented in the patients’ medical record?

Does the office have a policy to require an evaluation of pregnancy status before performing a procedure that may interrupt or harm a pregnancy?

Are pregnancy status findings documented in the patient’s medical record?

Does the office notify patients in advance that they are required to have an escort, if they are having an office-based surgical procedure in which sedation is used?

A time-out to identify the patient?

Patient consent to have procedure confirmed?

If relevant, Surgical site marked?

Patient allergies confirmed?

If relevant, patient pregnancy status confirmed or reviewed?

Does the office have a system for ensuring postoperative follow-up telephone calls to all patients occur within 48 hours of a procedure?

Does the system address how to handle follow-up telephone calls when the 48 hour call window occurs over a weekend?

Does the office test and inspect its equipment for function and safety according to the equipment manufacturer’s current recommendations?

Are tests and inspections documented?

Does the office train appropriate staff on the proper cleansing and sterilization of reusable, non-disposable equipment according to the equipment manufacturer’s current recommendations (i.e, speculum, biopsy punch, and tenaculum)?

does the office train clinical staff to rapidly access and use emergency medical supplies and equipment?

Does the office have an emergency cart or box and cardiac and ventilator support equipment available?

Does the office currently participate in any quality improvement activities (i.e., outcome improvement tracking, peer review)?

Does the office routinely assess patient experience data?

Is patient experience data incorporated into the practice to improve quality of care?

Is patient experience data incorporated into ongoing credentialing?

Does the office require documentation of gestational age confirmed equal to or greater than 39 0/7 weeks at time of admission by ultrasound measurement at less than 20 weeks of gestation and/or fetal heart tones documented as present for 30 weeks

Does the office require documentation of indication for induction of labor or cesarean section?

If induction of labor is anticipated, is a Bishop score included in the scheduling document?

If induction of labor or cesarean delivery is on maternal request, are patients counseled on the risks, alternatives, and benefits of elective induction of labor or elective cesarean delivery?

Does the office require the patient sign an informed consent form to acknowledge that the patient received counseling on the risks, alternatives, and benefits of elective induction of labor or elective cesarean delivery?

Are there other practice standards or supports that you would like to share for this area?

Does the office provide educational information on a routine basis to pregnant patients regarding smoking?

Does the office provide training in the 5A’s of Smoking Cessation to clinical staff to aid in the counseling of pregnant patients who use products containing tobacco?

Does the office document supportive and ongoing counseling in smoking cessation during pregnancy prenatal visits and/or patient encounters for care?

Is the office smoke free, and does that extend to specific areas outside the building to discourage staff and patients from smoking at or near the entrance?

Is this the only office site in your practice?

Which best describes the location of this office site?

Is this office affiliated with a larger entity? (hospital, university, medical center, health plan, multispecialty group, etc.)

Trainning provided to clinical staff?

Trainning provided to non-clinical staff?

Drills conducted for clinical staff?

Drills conducted for non-clinical staff?

With clinical staff?

With non-clinical staff?

Does the office have a policy that drug samples are only given to patients currently enrolled in the practice?

Does the office have a policy that prescription medications are only given under a Provider’s written or verbally confirmed order?

Does the office have a policy that prescription medications are only prescribed to patients currently enrolled in the practice?

Clinical staff responses to patient calls?

Non-clinical staff responses to patient calls?

clinical staff responses to patient calls?

Non-clinical staff responses to patient calls?

Clinical staff responses to patient emails?

Non-clinical staff responses to patient emails?

Clinical staff responses to patient emails?

Non-clinical staff responses to patient emails?

Is there a system for documenting all patient emails?

Is there a system for documenting all after-hours patient emails?

If yes, does the office note whether the patient has visited with the referred health care provider?

If intimate partner violence, depression or other screening measures are found to be positive does the office follow-up with education or referral?

Does the office use uses an EMR system?

Electronically (EMR)?

Paper?

Combination of EMR and paper?

During office hours?

After office hours?

Clinical Staff?

Non-clinical Staff?

Clinical Staff?

Non-clinical Staff?

Does the office use a gestation age screening tool for obstetric patients?

Does the office hold regular team meetings to identify and discuss adverse events, and near-misses?

Does the process promote a blame-free environment?

Does this process address complaints?

Does this process address disruptive behaviors?

For Clinical Staff?

For Non-clinical Staff?

For Clinical Staff?

For Non-clinical Staff?

Clinical Staff?

Non-clinical Staff?

Clinical staff regularly trained?

Nonclinical staff regularly trained?

Medications

Anesthetics

Procedure complications, including a plan for transfer to a hospital if necessary?

Are unopened and opened vaccines stored in their original box with the lid in place until administration, with vaccines that require it protected from light?

Are calibrated thermometers with Certificates of Traceability and Calibration kept in both the refrigerator and freezer where vaccines are stored, and are temperatures read and documented in the morning AND at the end of the work day?

Does the office have a current emergency vaccine retrieval and storage plan in case of exposure of a vaccine to temperatures outside the recommended range that requires immediate corrective action?