# ATTACHMENT 6: TE 1.1 Locations and Hours of Operation 

+---------------------------+---------------------+-------------------+
| **Inpatient Units**       | **DAYS**            | **HOURS**         |
+---------------------------+---------------------+-------------------+
| 1NW (Pediatrics)          | Sunday - Saturday   | 24 hours          |
+---------------------------+---------------------+-------------------+
| 1SE (Adult Behavioral     | Sunday - Saturday   | 24 hours          |
| Health)                   |                     |                   |
+---------------------------+---------------------+-------------------+
| 1SW (Pediatric Behavioral | Sunday - Saturday   | 24 hours          |
| Health)                   |                     |                   |
+---------------------------+---------------------+-------------------+
| 3NE (Hematology-Oncology) | Sunday - Saturday   | 24 hours          |
+---------------------------+---------------------+-------------------+
| 3NW (Adult Oncology)      | Sunday - Saturday   | 24 hours          |
+---------------------------+---------------------+-------------------+
| 3SWS (Intensive Care)     | Sunday - Saturday   | 24 hours          |
+---------------------------+---------------------+-------------------+
| 5NW (General Medicine)    | Sunday - Saturday   | 24 hours          |
+---------------------------+---------------------+-------------------+
| 5SE (Medicine/Telemetry)  | Sunday - Saturday   | 24 hours          |
+---------------------------+---------------------+-------------------+
| 7SE (Adult Behavioral     | Sunday - Saturday   | 24 hours          |
| Health)                   |                     |                   |
+---------------------------+---------------------+-------------------+
| 7SWN (Neurology & Sleep   | Sunday - Saturday   | 24 hours          |
| Lab)                      |                     |                   |
+---------------------------+---------------------+-------------------+
| **Day Hospitals**         |                     |                   |
+---------------------------+---------------------+-------------------+
| 1NWDH (Pediatrics)        | Monday - Friday     | 7:00 am - 5:30 pm |
+---------------------------+---------------------+-------------------+
| 3SEDH (Hematology -       | Monday - Friday     | 7:00 am - 7:00 pm |
| Oncology)                 |                     |                   |
|                           | Saturday - Sunday   | 7:00 am - 6:30 pm |
|                           |                     |                   |
|                           | Holidays            | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| 5SWDH (Medical -          | Monday - Friday     | 7:00 am - 7:00 pm |
| Surgical)                 |                     |                   |
|                           | Saturday - Sunday   | 7:00 am - 3:30 pm |
|                           |                     |                   |
|                           | Holidays            | Closed            |
+---------------------------+---------------------+-------------------+
| **Diagnostic Testing**    |                     |                   |
+---------------------------+---------------------+-------------------+
| HS (Heart Station 1^st^   | Monday - Friday     | 6:30 am - 4:30 pm |
| floor)                    |                     |                   |
+---------------------------+---------------------+-------------------+
| 3SWN (Procedures)         | Monday - Friday     | 6:30 am - 6:00 pm |
+---------------------------+---------------------+-------------------+
| 5NEN (Cardio-pulmonary)   | Monday - Friday     | 6:30 am - 6:30 pm |
+---------------------------+---------------------+-------------------+
| 7SW (Neuro-testing)       | Monday - Friday     | 6:30 am - 6:00 pm |
+---------------------------+---------------------+-------------------+
| **Outpatient Clinics**    |                     |                   |
+---------------------------+---------------------+-------------------+
| OPRAD (Radiation          | Monday - Friday     | 8:00 am - 4:30 pm |
| Oncology)                 |                     |                   |
+---------------------------+---------------------+-------------------+
| 1HALC (Alcohol Clinic)    | Monday - Friday     | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| 1H-PED (Pediatric Clinic) | Monday - Friday     | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OPDEN                     | Monday - Friday     | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OP03                      | Monday - Friday     | 7:30 am - 5:30 pm |
+---------------------------+---------------------+-------------------+
| OP04                      | Monday - Friday     | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OP05                      | Monday - Friday     | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OP07                      | Monday - Friday     | 7:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OP08                      | Monday - Friday     | 7:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OP09                      | Monday - Friday     | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OP10                      | Monday - Friday     | 8:00 am - 5:30 pm |
+---------------------------+---------------------+-------------------+
| OP11                      | Monday - Friday     | 7:30 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| OP12                      | Monday - Friday     | 8:00 am - 6:00 pm |
+---------------------------+---------------------+-------------------+
| OP12W-VRC                 | Monday - Friday     | 6:00 am - 6:00 pm |
+---------------------------+---------------------+-------------------+
| OP13                      | Monday - Friday     | 8:00 am - 5:00 pm |
+---------------------------+---------------------+-------------------+
| **Imaging Services**      |                     |                   |
+---------------------------+---------------------+-------------------+
| IS R (Radiology)          | Monday-Friday       | 6:00 am - 9:15 pm |
+---------------------------+---------------------+-------------------+
| IS NM (Nuclear Medicine)  | Monday-Friday       | 7:00 am - 5:00 pm |
+---------------------------+---------------------+-------------------+
| IS B1 NMR                 | Monday-Friday       | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| IS LL (LDRR Lab)          | Monday-Friday       | 8:00 am - 4:30 pm |
+---------------------------+---------------------+-------------------+
| **Department of           |                     |                   |
| Anesthesia and Surgical   |                     |                   |
| Services**                |                     |                   |
+---------------------------+---------------------+-------------------+
| SS (Surgical Services)    | Monday - Friday     | 7:00 am - 3:30 pm |
+---------------------------+---------------------+-------------------+
| **Other Sections**        |                     |                   |
+---------------------------+---------------------+-------------------+
| ADM (Admissions)          | Sunday - Saturday   | 24 hours          |
+---------------------------+---------------------+-------------------+
| VO (Voucher Office)       | Monday - Friday     | 8:30 am - 5:00 pm |
+---------------------------+---------------------+-------------------+
| CSO (Central Staffing     | Monday - Friday     | 7:30 am - 4:00 pm |
| Office)                   |                     |                   |
+---------------------------+---------------------+-------------------+

# ATTACHMENT 9: C-5 PERFORMANCE STANDARDS FOR ALL PWS TASKS 

+-------------+------------------------------------------+------------+
| **PWS       | **Performance Standard/AQL**             | **Su       |
| ACTIVITY**  |                                          | rveillance |
|             |                                          | Method**   |
+=============+==========================================+============+
| **5.1       |                                          |            |
| Scheduling  |                                          |            |
| A           |                                          |            |
| ctivities** |                                          |            |
+-------------+------------------------------------------+------------+
| 5.1.1       | 1.  Appointment templates created and/or | Quarterly  |
| Create and  |     updated are complete and accurate -  | Planned    |
| Update      |     1%                                   | Sampling   |
| Clinical    |                                          |            |
| Resource    |                                          |            |
| Appointment |                                          |            |
| Templates   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 2.  Within 5 workdays of receipt of      |            |
|             |     resource schedule request form - 10% |            |
|             |     Max - 7 workdays                     |            |
+-------------+------------------------------------------+------------+
|             | 3.  Urgent requests completed            |            |
|             |     immediately - 0%                     |            |
+-------------+------------------------------------------+------------+
| 5.1.2       | 4.  Patient appointment schedules are    | Monthly    |
| Schedule    |     complete and accurate -- 1%          | Planned    |
| Patient     |                                          | Sampling   |
| A           |                                          |            |
| ppointments |                                          |            |
+-------------+------------------------------------------+------------+
|             | 5.  Patient appointments scheduled       |            |
|             |     within 5 minutes of request -- 10%   |            |
+-------------+------------------------------------------+------------+
|             | 6.  Appointment visits statused          |            |
|             |     accurately -- 2%                     |            |
+-------------+------------------------------------------+------------+
|             | 7.  Status by the end of the workday --  |            |
|             |     1%                                   |            |
+-------------+------------------------------------------+------------+
|             | 8.  OR appointment schedule is complete  | Monthly    |
|             |     and accurate -- 0%                   | Survey     |
+-------------+------------------------------------------+------------+
|             | 9.  OR schedule finalized within 4 hours |            |
|             |     of completion of operation -- 20%    |            |
+-------------+------------------------------------------+------------+
| 5.1.3 Enter | 10. Core staff schedule is complete and  | Quarterly  |
| Schedule    |     accurate -- 1% annually              | Planned    |
| for Core    |                                          | Sampling   |
| Staff       |                                          |            |
+-------------+------------------------------------------+------------+
|             | 11. \# of core staff schedules three     |            |
|             |     weeks prior to the start of core     |            |
|             |     staff schedule -- 50%                |            |
+-------------+------------------------------------------+------------+
| 5.1.4       | 12. Supplemental staff report is         | Monthly    |
| Assign      |     complete and accurate -- 0%          | Planned    |
| S           |                                          | Sampling   |
| upplemental |                                          | (focus on  |
| Staff and   |                                          | IP)        |
| Enter       |                                          |            |
| Schedule    |                                          |            |
+-------------+------------------------------------------+------------+
|             | 13. Calls placed between 11 am and noon  |            |
|             |     -- 20%                               |            |
+-------------+------------------------------------------+------------+
|             | 14. Supplemental staff schedule is       | Monthly    |
|             |     complete and accurate -- 0%          | Planned    |
|             |                                          | sampling   |
+-------------+------------------------------------------+------------+
|             | 15. Prior to COB each workday -- 50%     |            |
+-------------+------------------------------------------+------------+
| 5.1.5 Enter | 16. MRAP staff schedule is complete and  | Monthly    |
| MRAP Staff  |     accurate -- 2%                       | Random     |
| Assignments |                                          | Sampling   |
| in Staff    |                                          |            |
| Scheduling  |                                          |            |
| System      |                                          |            |
+-------------+------------------------------------------+------------+
|             | 17. Prior to COB same workday -- 50%     |            |
+-------------+------------------------------------------+------------+
|             | 18. MRAP folder complete and accurate -  | Quarterly  |
|             |     2%                                   | Random     |
|             |                                          | sampling   |
+-------------+------------------------------------------+------------+
|             | 19. New records filed within 1 workday   |            |
|             |     of record generation -- 20%          |            |
+-------------+------------------------------------------+------------+
| **5.2       |                                          |            |
| Admissions  |                                          |            |
| &           |                                          |            |
| Outpatient  |                                          |            |
| R           |                                          |            |
| egistration |                                          |            |
| A           |                                          |            |
| ctivities** |                                          |            |
+-------------+------------------------------------------+------------+
| 5.2.1       | 20. Patient admission request is         | Quarterly  |
| Transcribe  |     complete and accurate -- 2%          | Planned    |
| Requests    |                                          | Sampling   |
| for Patient |                                          |            |
| Admission   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 21. Requests submitted within 4 hours of |            |
|             |     identifying need -- 50%              |            |
+-------------+------------------------------------------+------------+
| 5.2.2       | 22. Data entered accurately - .5%        | Quarterly  |
| P           |                                          | Random     |
| re-Register |                                          | Sampling   |
| Patients    |                                          |            |
| for         |                                          |            |
| Admission   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 23. No later than 7:00 am morning        |            |
|             |     following request -- 1%              |            |
+-------------+------------------------------------------+------------+
| 5.2.3 Admit | 24. Admission information collected and  | Monthly    |
| Inpatients  |     entered is complete and accurate;    | Random     |
| and         |     patient name and date of birth       | Sampling   |
| Register    |     correct on all patient admission     |            |
| New         |     information -- 0%                    |            |
| Outpatients |                                          |            |
+-------------+------------------------------------------+------------+
|             | 25. Patients interviewed within 15       | Daily      |
|             |     minutes of signing in at Admissions  | O          |
|             |     desk - 5%                            | bservation |
+-------------+------------------------------------------+------------+
|             | 26. Prior to placement of wrist band on  |            |
|             |     patient -- 0%                        |            |
+-------------+------------------------------------------+------------+
|             | 27. Upon final completion of admission   |            |
|             |     paperwork -- 0%                      |            |
+-------------+------------------------------------------+------------+
| 5.2.4       | 28. Patient information entered          | Monthly    |
| Update      |     correctly -- 2%                      | Random     |
| Patient     |                                          | Sampling   |
| Information |                                          |            |
| in Database |                                          |            |
+-------------+------------------------------------------+------------+
|             | 29. Information updated within 4 hours   |            |
|             |     of identifying need -- 20%           |            |
+-------------+------------------------------------------+------------+
|             | 30. All urgent requests updated          | 100 %      |
|             |     immediately -- 0%                    | Inspection |
+-------------+------------------------------------------+------------+
| **5.3       |                                          |            |
| Reception   |                                          |            |
| A           |                                          |            |
| ctivities** |                                          |            |
+-------------+------------------------------------------+------------+
| 5.3.1 Open  | 31. Outpatient clinics are opened and    | Daily      |
| Outpatient  |     appropriately prepared for the       | O          |
| Clinics for |     workday -- 1%                        | bservation |
| Workday     |                                          |            |
+-------------+------------------------------------------+------------+
|             | 32. Preparations completed prior to the  |            |
|             |     start of clinic opening -- 1%        |            |
+-------------+------------------------------------------+------------+
| 5.3.2       | 33. Calls answered and handled           | Quarterly  |
| Receive and |     appropriately -- 2%                  | Ob         |
| Direct      |                                          | servation/ |
| Telephone   |                                          | Survey of  |
| Calls       |                                          | Pr         |
|             |                                          | ofessional |
|             |                                          | Staff      |
+-------------+------------------------------------------+------------+
|             | 34. Transferred within 30 seconds of     |            |
|             |     identifying location -- 5%           |            |
+-------------+------------------------------------------+------------+
| 5.3.3       | 35. Patients greeted in a courteous      | Monthly    |
| Provide     |     manner and information provided to   | Ob         |
| Reception   |     patients is clear and accurate -- 2% | servation/ |
|             |                                          | Survey of  |
|             |                                          | Pr         |
|             |                                          | ofessional |
|             |                                          | Staff      |
+-------------+------------------------------------------+------------+
|             | 36. (Greeted within) 5 minutes -- 2%     |            |
+-------------+------------------------------------------+------------+
| 5.3.4 Make  | 37. Interpreter services correctly       | Monthly    |
| A           |     arranged -- 10%                      | Ob         |
| rrangements |                                          | servation/ |
| for         |                                          | Survey of  |
| Interpreter |                                          | Pr         |
| Services    |                                          | ofessional |
|             |                                          | Staff      |
+-------------+------------------------------------------+------------+
|             | 38. Prior to patient arrival -- 5%       |            |
+-------------+------------------------------------------+------------+
| 5.3.5 Close | 39. Outpatient clinics are properly      | Daily      |
| Outpatient  |     closed at the end of each workday -- | O          |
| Clinics     |     2%                                   | bservation |
+-------------+------------------------------------------+------------+
|             | 40. Closing occurs at time of scheduled  |            |
|             |     clinic closing or within 30 minutes  |            |
|             |     following last patient departure     |            |
|             |     when clinic hours are exceeded -- 5% |            |
+-------------+------------------------------------------+------------+
| **5.4       |                                          |            |
| Patient     |                                          |            |
| Record      |                                          |            |
| A           |                                          |            |
| ctivities** |                                          |            |
+-------------+------------------------------------------+------------+
| 5.4.1       | 41. Medical records assembled correctly  | Monthly    |
| Assemble    |     -- 1%                                | Random     |
| New Patient |                                          | Sampling   |
| Medical     |                                          |            |
| Records     |                                          |            |
+-------------+------------------------------------------+------------+
|             | 42. Medical records prepared one workday |            |
|             |     prior to admission -- 1%             |            |
+-------------+------------------------------------------+------------+
|             | 43. Medical records for walk-ins are     |            |
|             |     assembled at time of admission -- 0% |            |
+-------------+------------------------------------------+------------+
| 5.4.2       | 44. Medical records are acquired for all | Monthly    |
| Acquire     |     outpatient visits -- 1%              | Planned    |
| Existing    |                                          | Sampling   |
| Medical     |                                          |            |
| Records and |                                          |            |
| Prepare for |                                          |            |
| Patient     |                                          |            |
| Visit       |                                          |            |
+-------------+------------------------------------------+------------+
|             | 45. Medical records acquired by time of  |            |
|             |     clinic / day hospital opening, the   |            |
|             |     day of the appointment -- 5%         |            |
+-------------+------------------------------------------+------------+
|             | 46. Medical records are acquired for all |            |
|             |     inpatient admissions -- 1%           |            |
+-------------+------------------------------------------+------------+
|             | 47. Medical records acquired by 7 am the |            |
|             |     day of the appointment -- 2%         |            |
+-------------+------------------------------------------+------------+
|             | 48. Medical records acquired at time of  |            |
|             |     admission for walk-in appointments   |            |
|             |     -- 0%                                |            |
+-------------+------------------------------------------+------------+
| 5.4.3       | 49. Patient charts are correctly         | Quarterly  |
| Assemble    |     assembled -- 0%                      | Planned    |
| Inpatient   |                                          | Sampling   |
| Chart       |                                          |            |
+-------------+------------------------------------------+------------+
|             | 50. 24 hours prior to patient admission  |            |
|             |     unless unplanned admission -- 10%    |            |
+-------------+------------------------------------------+------------+
| 5.4.4       | 51. Charts disassembled and appropriate  | Quarterly  |
| Disassemble |     forms filed in medical records -- 2% | Planned    |
| Inpatient   |                                          | Sampling   |
| Chart for   |                                          |            |
| Filing in   |                                          |            |
| Medical     |                                          |            |
| Record      |                                          |            |
+-------------+------------------------------------------+------------+
|             | 52. Within 48 hours of patient discharge |            |
|             |     -- 20%                               |            |
+-------------+------------------------------------------+------------+
| 5.4.5       | 53. Medical records prepared in          | Monthly    |
| Submit      |     accordance with Medical Record       | Random     |
| Patient     |     format guidelines for submission --  | Sampling   |
| Records to  |     2%                                   |            |
| Medical     |                                          |            |
| Record      |                                          |            |
| Department  |                                          |            |
+-------------+------------------------------------------+------------+
|             | 54. Medical records for inpatient units  | Ob         |
|             |     submitted at first pick up -- 50%    | servation/ |
|             |                                          | Survey     |
+-------------+------------------------------------------+------------+
|             | 55. Medical records for outpatient areas |            |
|             |     submitted once daily, COB -- 10%     |            |
+-------------+------------------------------------------+------------+
| 5.4.6       | 56. Film sorted and filed correctly in   | Monthly    |
| Prepare MRI |     patient\'s film jacket -- 1%         | Random     |
| Films for   |                                          | sampling   |
| Radiologist |                                          |            |
+-------------+------------------------------------------+------------+
|             | 57. Within 15 minutes of exam completion |            |
|             |     -- 2%                                |            |
+-------------+------------------------------------------+------------+
| **5.5       |                                          |            |
| Clinical    |                                          |            |
| Support     |                                          |            |
| A           |                                          |            |
| ctivities** |                                          |            |
+-------------+------------------------------------------+------------+
| 5.5.1a      | 58. Safety inspection conducted in       | Quarterly  |
| Perform     |     accordance with established          | Record     |
| Monthly     |     guidelines -- 0%                     | Review --  |
| Safety      |                                          | 100%       |
| Inspections |                                          |            |
+-------------+------------------------------------------+------------+
|             | 59. Prior to the 15th of each month --   |            |
|             |     50%                                  |            |
+-------------+------------------------------------------+------------+
| 5.5.1b      | 60. Medications are current and have not | Quarterly  |
| Inspections |     expired -- 0%                        | Random     |
| on          |                                          | Sampling   |
| Medication  |                                          | of OP      |
| Units       |                                          | clinics    |
+-------------+------------------------------------------+------------+
|             | 61. Prior to the 15th of each month --   |            |
|             |     50%                                  |            |
+-------------+------------------------------------------+------------+
| 5.5.2       | 62. BUN and Creatinine results are       | Monthly    |
| Prepare     |     available and match patient name --  | Random     |
| Patients    |     0%                                   | Sampling   |
| for         |                                          | (IS R)     |
| Diagnostic  |                                          |            |
| Exams under |                                          |            |
| the         |                                          |            |
| Supervision |                                          |            |
| of a LIP    |                                          |            |
+-------------+------------------------------------------+------------+
|             | 63. 1 day before scheduled test -- 20%   |            |
+-------------+------------------------------------------+------------+
|             | 64. Correct oral contrast is provided to |            |
|             |     patient -- 1%                        |            |
+-------------+------------------------------------------+------------+
|             | 65. Oral contrast is provided 1 hour     |            |
|             |     before test is performed -- 0%       |            |
+-------------+------------------------------------------+------------+
| 5.5.3       | 66. Order is present for every test      | Monthly    |
| Ensure      |     scheduled -- 0%                      | Random     |
| Patient     |                                          | Sampling   |
| Orders &    |                                          | (IS R)     |
| Laboratory  |                                          |            |
| Results are |                                          |            |
| Available   |                                          |            |
| for Imaging |                                          |            |
| Service     |                                          |            |
| A           |                                          |            |
| ppointments |                                          |            |
+-------------+------------------------------------------+------------+
|             | 67. Orders and lab results are available |            |
|             |     by 7 am morning of patient test --   |            |
|             |     30%                                  |            |
+-------------+------------------------------------------+------------+
|             | 68. Lab results are transcribed          |            |
|             |     accurately -- 0%                     |            |
+-------------+------------------------------------------+------------+
|             | 69. Lab results transcribed by 7 am      |            |
|             |     morning of patient test -- 30%       |            |
+-------------+------------------------------------------+------------+
| 5.5.4       | 70. Death certificate prepared           | Quarterly  |
| Prepare     |     accurately and completely -- 0%      | Record     |
| Death       |                                          | Review --  |
| C           |                                          | 100%       |
| ertificates |                                          |            |
| for         |                                          |            |
| Completion  |                                          |            |
| by          |                                          |            |
| Physician   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 71. Immediately upon notification of     |            |
|             |     death -- 0%                          |            |
+-------------+------------------------------------------+------------+
|             | 72. Patient expiration worksheet actions |            |
|             |     documented completely and accurately |            |
|             |     -- 0%                                |            |
+-------------+------------------------------------------+------------+
|             | 73. Expiration worksheet updated within  |            |
|             |     1 hour of completion of each action  |            |
|             |     -- 5%                                |            |
+-------------+------------------------------------------+------------+
| 5.5.5       | 74. Proper arrangements are made and     | Quarterly  |
| Coordinate  |     effectively coordinated without      | Record     |
| Funeral     |     error -- 3%                          | Rev        |
| Home &      |                                          | iew/Survey |
| Tra         |                                          |            |
| nsportation |                                          |            |
| A           |                                          |            |
| rrangements |                                          |            |
+-------------+------------------------------------------+------------+
|             | 75. Arrangements coordinated upon        |            |
|             |     request -- 3%                        |            |
+-------------+------------------------------------------+------------+
| 5.5.6       | 76. Forms are complete and accurate --   | Quarterly  |
| Disposition |     0%                                   | Record     |
| of Deceased |                                          | Review --  |
| Patients    |                                          | 100%       |
+-------------+------------------------------------------+------------+
|             | 77. Within timeframe requested -- 0%     |            |
+-------------+------------------------------------------+------------+
|             | 78. Death certificate is obtained upon   |            |
|             |     acceptance of deceased patient       |            |
|             |     entering morgue -- 0%                |            |
+-------------+------------------------------------------+------------+
|             | 79. At time of acceptance of deceased    |            |
|             |     patient -- 0%                        |            |
+-------------+------------------------------------------+------------+
| 5.5.7       | 80. Service request is complete and      | Quarterly  |
| Arrange for |     accurate -- 0%                       | Record     |
| Courier     |                                          | Review --  |
| Service for |                                          | 100%       |
| Transport   |                                          |            |
| of          |                                          |            |
| Specimens   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 81. Within timeframe requested -- 1%     |            |
+-------------+------------------------------------------+------------+
| 5.5.8       | 82. Patient identification materials     | Monthly    |
| Provide     |     provided are complete and accurate   | Random     |
| Requested   |     -- 0%                                | Sampling   |
| Patient     |                                          |            |
| Ide         |                                          |            |
| ntification |                                          |            |
| Materials   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 83. Within 30 minutes of request -- 10%  | 100%       |
|             |                                          | Inspection |
+-------------+------------------------------------------+------------+
|             | 84. Urgent requests are completed        | 100%       |
|             |     immediately -- 0%                    | Inspection |
+-------------+------------------------------------------+------------+
| **5.6       |                                          |            |
| Equipment,  |                                          |            |
| Material &  |                                          |            |
| Supply      |                                          |            |
| Support     |                                          |            |
| A           |                                          |            |
| ctivities** |                                          |            |
+-------------+------------------------------------------+------------+
| 5.6.1       | 85. Correct materials requested to       | Survey of  |
| Request and |     replenish stock -- 10%               | Nurse      |
| Stock       |                                          | Managers   |
| Appropriate |                                          | --         |
| Medical/    |                                          | Bi-annual  |
| Pharm.      |                                          |            |
| Supplies &  |                                          |            |
| Forms       |                                          |            |
+-------------+------------------------------------------+------------+
|             | 86. Request within 5 minutes of          |            |
|             |     identified need -- 10%               |            |
+-------------+------------------------------------------+------------+
|             | 87. Materials stocked at adequate levels |            |
|             |     in the correct rooms -- 15%          |            |
+-------------+------------------------------------------+------------+
|             | 88. Materials stocked at the opening of  |            |
|             |     respective units and throughout the  |            |
|             |     workday within timeframe requested   |            |
|             |     -- 15%                               |            |
+-------------+------------------------------------------+------------+
| 5.6.2       | 89. Correct supplies and forms requested | Survey of  |
| Request and |     to replenish stock -- 20%            | Nurse      |
| Stock       |                                          | Managers   |
| Office      |                                          | --         |
| Supplies    |                                          | Bi-annual  |
| and Forms   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 90. 1 business day from completion of    |            |
|             |     inventory to submit request -- 20%   |            |
+-------------+------------------------------------------+------------+
|             | 91. Supplies and forms stocked at        |            |
|             |     adequate levels in the correct       |            |
|             |     locations -- 20%                     |            |
+-------------+------------------------------------------+------------+
|             | 92. Supplies and forms stocked at the    |            |
|             |     opening of respective units and      |            |
|             |     throughout the workday within        |            |
|             |     timeframe requested -- 20%           |            |
+-------------+------------------------------------------+------------+
| 5.6.3       | 93. Meal requests submitted to Nutrition | Quarterly  |
| Acquire     |     Department are complete and accurate | Random     |
| Meals and   |     -- 5%                                | Sampling   |
| Snacks for  |                                          |            |
| Patients    |                                          |            |
| (IP & OP)   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 94. Breakfast requests to Nutrition      |            |
|             |     Dept. by 8 am -- 2%                  |            |
+-------------+------------------------------------------+------------+
|             | 95. Lunch requests to Nutrition Dept. by |            |
|             |     10:30 am -- 2%                       |            |
+-------------+------------------------------------------+------------+
| 5.6.4       | 96. Temperatures are correctly monitored | Quarterly  |
| Monitor     |     and issues are appropriately         | Doc        |
| Patient     |     communicated -- 2%                   | umentation |
| Care        |                                          | Review     |
| R           |                                          |            |
| efrigerator |                                          | Survey of  |
| T           |                                          | Nurse      |
| emperatures |                                          | Managers   |
+-------------+------------------------------------------+------------+
|             | 97. Within 2 hours of patient care area  |            |
|             |     opening -- 50%                       |            |
+-------------+------------------------------------------+------------+
| **5.7       |                                          |            |
| Travel and  |                                          |            |
| Local       |                                          |            |
| Tra         |                                          |            |
| nsportation |                                          |            |
| Support     |                                          |            |
| Services**  |                                          |            |
+-------------+------------------------------------------+------------+
| 5.7.1       | 98. Patient travel request is complete   | Monthly    |
| Transcribe  |     and accurate -- 0%                   | planned    |
| Requests    |                                          | sampling   |
| for Patient |                                          |            |
| Travel      |                                          |            |
| Aut         |                                          |            |
| horizations |                                          |            |
| into ATV    |                                          |            |
+-------------+------------------------------------------+------------+
|             | 99. Requests submitted within 4 hours of |            |
|             |     identifying need -- 5%               |            |
+-------------+------------------------------------------+------------+
|             | 100. Urgent requests submitted           |            |
|             |      immediately upon identifying need   |            |
|             |      -- 0%                               |            |
+-------------+------------------------------------------+------------+
| 5.7.2 Issue | 101. Voucher is provided to correct      | Monthly    |
| Vouchers to |      patient or authorized guardian --   | Random     |
| Government  |      0%                                  | Sampling   |
| Approving   |                                          |            |
| Official    |                                          |            |
| for         |                                          |            |
| D           |                                          |            |
| isbursement |                                          |            |
| to Patient  |                                          |            |
| or          |                                          |            |
| Authorized  |                                          |            |
| Guardian    |                                          |            |
+-------------+------------------------------------------+------------+
|             | 102. Within 1 hour of request from       |            |
|             |      patient or authorized guardian --   |            |
|             |      10%                                 |            |
+-------------+------------------------------------------+------------+
|             | 103. Check mailed to correct patient or  |            |
|             |      guardian -- 0%                      |            |
+-------------+------------------------------------------+------------+
|             | 104. Within 5 workdays of request from   |            |
|             |      patient -- 25%                      |            |
+-------------+------------------------------------------+------------+
| 5.7.3 Issue | 105. Authorization created for patient   | Monthly    |
| Travel      |      travel office is complete and       | Random     |
| Aut         |      accurate -- 3%                      | Sampling   |
| horizations |                                          |            |
| to          |                                          |            |
| Government  |                                          |            |
| Approving   |                                          |            |
| Official    |                                          |            |
| for Patient |                                          |            |
| Travel      |                                          |            |
| Office      |                                          |            |
+-------------+------------------------------------------+------------+
|             | 106. Within timeframe negotiated with    |            |
|             |      requestor for routine request --    |            |
|             |      10%                                 |            |
+-------------+------------------------------------------+------------+
|             | 107. Urgent requests are processed       |            |
|             |      immediately -- 0%                   |            |
+-------------+------------------------------------------+------------+
| 5.7.4       | 108. Travel folders correctly maintained | Monthly    |
| Maintain    |      -- 0%                               |            |
| Travel      |                                          | Random     |
| Folders for |                                          | Sampling   |
| Authorized  |                                          |            |
| Patient     |                                          |            |
| Travel      |                                          |            |
+-------------+------------------------------------------+------------+
|             | 109. Travel records filed within 2       |            |
|             |      workdays of being generated -- 25%  |            |
+-------------+------------------------------------------+------------+
| 5.7.5       | 110. Lodging invoices are properly       | Quarterly  |
| Reconcile   |      reconciled -- 1%                    | Random     |
| Lodging     |                                          | Sampling   |
| Invoices    |                                          |            |
| against     |                                          |            |
| Travel      |                                          |            |
| Aut         |                                          |            |
| horizations |                                          |            |
+-------------+------------------------------------------+------------+
|             | 111. Invoices reconciled within 5        |            |
|             |      workdays of receipt -- 5%           |            |
+-------------+------------------------------------------+------------+
| 5.7.6       | 112. Taxi vouchers are complete and      | Quarterly  |
| Arrange     |      accurate -- 0%                      | Random     |
| Authorized  |                                          | Sampling   |
| Patient     |                                          |            |
| Travel and  |                                          |            |
| Tra         |                                          |            |
| nsportation |                                          |            |
+-------------+------------------------------------------+------------+
|             | 113. Patient transportation arranged     |            |
|             |      upon request -- 1%                  |            |
+-------------+------------------------------------------+------------+
|             | 114. Air or train travel arrangements    |            |
|             |      are complete and accurate -- 0%     |            |
+-------------+------------------------------------------+------------+
|             | 115. Patient travel arranged upon        |            |
|             |      request -- 1%                       |            |
+-------------+------------------------------------------+------------+
| **5.8       |                                          |            |
| Statistics, |                                          |            |
| Reporting   |                                          |            |
| and Other   |                                          |            |
| Adm         |                                          |            |
| inistrative |                                          |            |
| A           |                                          |            |
| ctivities** |                                          |            |
+-------------+------------------------------------------+------------+
| 5.8.1 Enter | 116. Unstatused visit report is complete | Quarterly  |
| Data,       |      and provided to the appropriate     | Random     |
| Produce,    |      personnel -- 1%                     | sampling   |
| and/or      |                                          |            |
| Distribute  |                                          |            |
| Various     |                                          |            |
| Reports     |                                          |            |
+-------------+------------------------------------------+------------+
|             | 117. Report is provided prior to 9:00 am |            |
|             |      each business day -- 1%             |            |
+-------------+------------------------------------------+------------+
|             | 118. Outpatient visit activity report is | Survey of  |
|             |      complete and provided to the        | Nurse      |
|             |      appropriate personnel -- 8%         | Managers   |
+-------------+------------------------------------------+------------+
|             | 119. Report generated within 5 business  |            |
|             |      days after the end of the month --  |            |
|             |      8%                                  |            |
+-------------+------------------------------------------+------------+
|             | 120. Ad hoc outpatient visit activity    |            |
|             |      report is complete and provided to  |            |
|             |      the appropriate personnel -- 1%     |            |
+-------------+------------------------------------------+------------+
|             | 121. Report generated within 5 business  |            |
|             |      days of request or timeframe        |            |
|             |      negotiated with requestor -- 1%     |            |
+-------------+------------------------------------------+------------+
|             | 122. Urgent requests completed by COB    |            |
|             |      same business day -- 1%             |            |
+-------------+------------------------------------------+------------+
|             | 123. Operating Room report is complete   |            |
|             |      and provided to the appropriate     |            |
|             |      personnel -- 1%                     |            |
+-------------+------------------------------------------+------------+
|             | 124. Report generated by the 5th of the  | Survey of  |
|             |      month -- 1%                         | Nurse      |
|             |                                          | Managers   |
+-------------+------------------------------------------+------------+
|             | 125. MRAP status report is complete and  |            |
|             |      accurate -- 1%                      |            |
+-------------+------------------------------------------+------------+
|             | 126. Prior to noon every Friday -- 10%   |            |
+-------------+------------------------------------------+------------+
| 5.8.2       | 127. Patient wait and processing time    | Quarterly  |
| Collect and |      entries are complete and accurate   | Random     |
| Enter       |      -- 4%                               | Sampling   |
| Patient     |                                          |            |
| Wait and    |                                          |            |
| Processing  |                                          |            |
| Time        |                                          |            |
| Statistics  |                                          |            |
+-------------+------------------------------------------+------------+
|             | 128. Statistics entered within 3         |            |
|             |      workdays after the end of the month |            |
|             |      -- 5%                               |            |
+-------------+------------------------------------------+------------+
| 5.8.3 Issue | 129. Key issued to approved personnel    | Annual     |
| Keys and    |      and log information is complete and | Planned    |
| Control Key |      accurate -- 1%                      | Sampling   |
| Inventory   |                                          |            |
+-------------+------------------------------------------+------------+
|             | 130. Key issued within 5 minutes of      |            |
|             |      request -- 10%                      |            |
+-------------+------------------------------------------+------------+
| 5.8.4       | 131. Mail distributed correctly -- 2%    | Complaints |
| Distribute  |                                          |            |
| Mail        |                                          |            |
+-------------+------------------------------------------+------------+
|             | 132. Collected by 11 am each workday --  |            |
|             |      40%                                 |            |
+-------------+------------------------------------------+------------+