5.5 A record is maintained of staff % of sampled Triage staff who have completed the Document review IA+ED Onsite meeting mandatory annual online ETEK triage competency package competency/certification requirements for delivering scope in ED/UCC The ED/UCC 6.1 The conditions under which specific e.g. Organisation Acute Admission Policy e.g. Safe Document review Offsite IA+ED periodically reviews diagnostic groups will be transferred or Practice Framework the scope of services admitted from the ED/UCC have been or Emergency Department Admission Policy provided clearly defined in documentation Individual scope of 7.1 The scope of practice of individual Log of scope of practice or Document review IA + ED Onsite practice is defined staff in ED/UCC is documented and addendum to position description documenting approved and periodically there is evidence of regular review scope of practice such as: reviewed after recredentialling ultrasound procedural sedation X-ray Suturing Plastering 7.2 Orientation to and review of scope Evidence of training for new equipment or amendment to Document review Onsite IA +ED of practice occurs in relation to the scope of proactice implementation of new procedures or Staff interview equipment Appropriate levels 8.1 The rosters demonstrate ED – 24hr triage staff Document review IA +ED Onsite of staffing in the appropriate staffing in ED/UCC with 24 hour medical officers ED/UCC respect to medical, nursing, 24 hour on call access to designated senior doctor Staff interview administrative and other personnel. (emergency physician) UCC -24hr access to registered GP and Nurse
5.5 A record is maintained of staff meeting mandatory competency/certification requirements for delivering scope in ED/UCC % of sampled Triage staff who have completed the annual online ETEK triage competency package Document review Onsite IA+ED The ED/UCC periodically reviews the scope of services provided 6.1 The conditions under which specific diagnostic groups will be transferred or admitted from the ED/UCC have been clearly defined in documentation e.g. Organisation Acute Admission Policy e.g. Safe Practice Framework or Emergency Department Admission Policy Document review Offsite IA+ED Individual scope of practice is defined and periodically reviewed 7.1 The scope of practice of individual staff in ED/UCC is documented and there is evidence of regular review after recredentialling Log of scope of practice or addendum to position description documenting approved scope of practice such as: ultrasound procedural sedation X-ray Suturing Plastering Document review Onsite IA + ED 7.2 Orientation to and review of scope of practice occurs in relation to the implementation of new procedures or equipment Evidence of training for new equipment or amendment to scope of proactice Document review Staff interview Onsite IA +ED Appropriate levels of staffing in the ED/UCC 8.1 The rosters demonstrate appropriate staffing in ED/UCC with respect to medical, nursing, administrative and other personnel. ED – 24hr triage staff 24 hour medical officers 24 hour on call access to designated senior doctor (emergency physician) UCC -24hr access to registered GP and Nurse Document review Staff interview Onsite IA +ED
vmia_ecucc_internal_audit_tool_d17-63759.docx