|
| Statement | Addressed in GRS-C yes/no? (SC) |
|
| (1) Informed consent | Yes |
| (2) Adoption of universal standards | Yes |
| (3) Appropriateness | Yes |
| (4) Technical and personnel resources | Yes |
| (5) Preprocedure information | Yes |
| (6) Intraprocedural policies to be implemented | Yes (refers to CAG auditable outcomes but does not specifically ask about each) |
| (7) Adherence to appropriate discharge policies | Yes (addressed but does not suggest need for documentation of standard discharge readiness score) |
| (8) Follow-up policy in place | Yes |
| (9) Provision of written discharge information | Yes (NB: does not include discussion of worrisome sx to watch for) |
| (10) Existence of formal QI program at facility | Yes |
| (11) Existence of a formal quality review committee | Yes |
| (12) Regular review of quality indicators with action plan | Yes |
| (13) Regular review of safety indicators with action plan | Yes |
| (14) Presence of education programs for staff | No |
| (15) Appropriate monitoring and evaluation of trainees | No |
| (16) Ensured competency of all trainees and staff (required documentation of procedures performed, direct observation) | No |
| (17) Regular review of individual practice/outcome data | Yes |
| (18) Privileges granted based on formal evaluation | No |
| (19) Privileges subject to formal regular review based on documented competence | No |
| (20) Standardized electronic endoscopic procedures | Yes |
| (21) Policies in place to ensure timeliness/completeness of procedure reporting | Yes |
| (22) Patient centered service | Yes |
| (23) Patient feedback and responsive action | Yes |
|
