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Accreditation Readiness Checklist

Accreditation Readiness Checklist

A quick self-assessment for pregnancy medical clinics & women’s health clinics

For each item below, circle the number that best describes your clinic’s current status.

As you circle a number, be honest — would you feel confident if a surveyor reviewed this today?

1. State-specific privacy & security policies reviewed and approved by the Board in the last 12 months

1 2 3 4 5

2. Medical Director has reviewed and approved the Medical Policies & Procedures in the last 12 months

1 2 3 4 5

3. Staff have signed an annual acknowledgment of policies, procedures, and plans based on job roles

1 2 3 4 5

4. Patients sign a Notice of Privacy Practices and Patients’ Rights & Respon. Acknowledgements

1 2 3 4 5

5. Allergies are asked about at every visit

1 2 3 4 5

6. Ultrasound reports returned to clinic within 72 hrs.

1 2 3 4 5

7. Informed consent documentation is complete, signed, and consistent across patient files

1 2 3 4 5

8. Annual Risk Assessments are completed (TB, State Privacy & Security, Medical Equipment, Sharps Injury Prevention, and Infection Control Risk Assessments)

1 2 3 4 5

9. Discharge Summary is given at every medical visit

1 2 3 4 5

10. Only medical professionals ask medical questions

1 2 3 4 5

11. Computers sleep within 10 minutes of non-use

1 2 3 4 5

12. Exit Surveys are kept separate from patient charts

1 2 3 4 5

13. Personnel files include current licenses, privileging, certifications, and background checks

1 2 3 4 5

14. Staff have annual training on Emergency/Disaster Preparedness, Patients’ Rights & Responsibilities, Privacy & Security of PHI, Handwashing, Workplace Violence

1 2 3 4 5

15. Clinical staff complete annual CEUs with documentation in their files

1 2 3 4 5

16. Documented competency/skills assessments for medical professionals are completed annually

1 2 3 4 5

17. Fire drills are conducted quarterly

1 2 3 4 5

18. Staff meeting minutes are kept

1 2 3 4 5

19. Meeting minutes reflect the day-to-day operations are delegated to the ED/CEO

1 2 3 4 5

20. Credentialing and privileging decisions are documented and current

1 2 3 4 5

21. A formal Quality Improvement Plan exists with measurable outcomes

1 2 3 4 5

22. Medical equipment is calibrated annually

1 2 3 4 5

23. Current OSHA compliance posters displayed

1 2 3 4 5

24. Fire extinguishers, exit signs, & safety equipment inspected/documented monthly

1 2 3 4 5

25. Safety walk-through of the facility conducted within the past 12 months

1 2 3 4 5

26. Medication refrigerator has a continuous monitoring thermometer, and is logged daily

1 2 3 4 5

27. Lab/ultrasound rooms are free of stored shipping boxes

1 2 3 4 5

28. Exit routes are posted throughout the clinic

1 2 3 4 5

Name

Clinic Name

City/State

Email

We’ll email your results along with a comparison to clinics across the industry.

360-200-8687

[email protected]

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