Is there a process in place to address questions or concerns arising from the Yes No Unsure directive or delegation? Comments: Practice Setting Feasibility Are the necessary human and material resources available to support the Yes No Unsure practice? Is the practice sustainable? (For example can new staff readily adopt the practice? If intensive resources are required to support the practice over the Yes No Unsure longer-term, is this feasible?) Does the practice broadly support effective health care delivery? (For example, if implementers are responsible for implementing the directive or delegation or performing the proposed procedure, will other services only they Yes No Unsure can provide be disrupted? Will other team members or care delivery systems be negatively impacted? Can these effects be offset?) Can any billing, cost or liability considerations be appropriately managed? Yes No Unsure Are there any other situation-specific factors to consider? Yes No Unsure Comments: Risk/Benefit Analysis: Yes No Unsure Do the benefits of proceeding by way of the directive, delegation or practice outweigh the risks? Comments: Education and Performance Readiness Plan: Is there a plan for enabling implementers to attain the necessary Yes No Unsure competencies and achieve performance readiness? (Identify a basic plan here, or where the plan is more involved, refer to the Performance Readiness Plan.) Comments: Communication Plan: Yes No Unsure Is there a plan for informing stakeholders and for activating the directive, delegation or practice? Comments: References to Support Practice: Yes No Unsure Are there references to support practice? (References may be listed here or attached) Comments:
Is there a process in place to address questions or concerns arising from the directive or delegation? Yes No Unsure Comments: Practice Setting Feasibility Are the necessary human and material resources available to support the practice? Yes No Unsure Is the practice sustainable? (For example can new staff readily adopt the practice? If intensive resources are required to support the practice over the longer-term, is this feasible?) Yes No Unsure Does the practice broadly support effective health care delivery? (For example, if implementers are responsible for implementing the directive or delegation or performing the proposed procedure, will other services only they can provide be disrupted? Will other team members or care delivery systems be negatively impacted? Can these effects be offset?) Yes No Unsure Can any billing, cost or liability considerations be appropriately managed? Yes No Unsure Are there any other situation-specific factors to consider? Yes No Unsure Comments: Risk/Benefit Analysis: Do the benefits of proceeding by way of the directive, delegation or practice outweigh the risks? Yes No Unsure Comments: Education and Performance Readiness Plan: Is there a plan for enabling implementers to attain the necessary competencies and achieve performance readiness? (Identify a basic plan here, or where the plan is more involved, refer to the Performance Readiness Plan.) Yes No Unsure Comments: Communication Plan: Is there a plan for informing stakeholders and for activating the directive, delegation or practice? Yes No Unsure Comments: References to Support Practice: Are there references to support practice? (References may be listed here or attached) Yes No Unsure Comments:
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