CBAHI non-clinical readiness check

Does each committee have terms of reference, minutes in one format that record decisions, and a register tracking every plan's actions?

Minutes that record who attended and a general discussion show nothing moving. The evidence is a decision, an owner and the follow-up at the next meeting, tracked on one register.

Is every policy on one register with its owner, approval date and review date, and none past its review date?

Policies carrying review dates that passed last year are a finding on their own. The register is what shows the whole set is current, rather than any single policy.

When a policy is revised, are old copies collected from every point of use, with the withdrawal signed and staff acknowledgement recorded?

A surveyor asks a member of staff where a policy is and reads the copy they are handed. An obsolete evacuation policy at the nursing station is a document control finding, not a nursing one.

Are there written plans for fire safety, hazardous materials, utilities, security, medical equipment and emergencies, each with an inspection and test schedule?

The facility standards ask you to plan, inspect, test and drill your building systems, and the evidence is mostly records. A plan without a schedule gives a surveyor nothing to sample.

Are the inspection and test records from your contractors and landlord in your own file, current and filed against your plan?

The generator is load-tested and the alarm serviced, but the records sit with the contractor in their format. A PDF that arrives by email two days after you ask is not a record the facility holds.

Have fire drills run on every shift, the night shift included, each followed by a short review and filed by shift?

A surveyor counts the drills on file. Drills recorded for the day shift only leave every other shift unevidenced, and a record with the same twelve names every time is a record of twelve people.

Can you produce the latest inspection record for the fire suppression system, and a record of the emergency lighting tested with the mains off?

A national study of essential safety requirement surveys in hospitals between 2016 and 2018 found fire suppression among the lowest-scoring requirements, in public and private hospitals alike. Its evidence is an inspection record, and in most buildings a contractor services it.

Is the hazardous materials inventory current, with safety data sheets kept where each chemical is used?

An inventory listing chemicals the store stopped buying two years ago shows nobody has checked it against the shelf. Safety data sheets in a binder in the manager's office are not at the point of use.

Are environmental cleaning schedules and waste segregation records kept, with containment sign-offs for any construction work, and agreed with your infection control lead?

Infection prevention and control is shared between clinical and non-clinical teams. The environmental side is evidenced by schedules and records, and the line between the two sides is best agreed in writing.

Does every staff file hold the current licence, orientation, competence and certification records that person's role requires, with every expiry date on one register that warns before it passes?

Staff files decay quietly. A renewal date passes during annual leave, a new starter works for weeks before orientation is recorded, and a competence assessed at hire is not assessed again.

Is there a working incident reporting flow, a risk register, and a routine for collecting and reviewing the indicators your clinicians choose?

The machinery is non-clinical and the indicators belong to your clinicians. The evidence is the flow in use: incidents reported, reviewed and closed, and indicator data reviewed on a schedule.

Do these records cover the period your programme's survey looks back over, rather than being assembled in the last few weeks?

Documents can be corrected in weeks, but a history of records cannot, because a record carries the date it was made. Check the look-back period in your programme's own accreditation guide.