Tracer Tool

Adapted from Islamabad Health Regulatory

Authority (IHRA)
INSTRUCTIONS: Work on a copy of this template.
- Select Score from the dropdown list.
- Press "Delete" to erase a selection.
- RE-SAVE FILE after making selections

OVERALL RESULTS

# of items met: 0
# of items not met: 0
STRENGTHS

AREAS FOR IMPROVEMENT

PART E: SAFE AND APPROPRIATE ENVIRONMENT

19 HEALTH AND SAFETY
Standard 48: Promotion of health and safety and the avoidance of risk to human life as
well as to the property of the Hospital are integrated within the organisation and among
Indicator 477: The responsibility for health and safety of hospital management and other relevant
staff is included in their job descriptions and performance reviews.
Indicator 478: A Health and Safety Committee meets on a regular basis, includes representatives
of management and staff from different departments and enables two-way communication between
Indicator 479: Health and Safety Committee meetings follow a set agenda that includes follow-up
from the last meeting, minutes of each meeting are kept and the agendas and minutes are readily
Indicator 480: The Health and Safety Committee participates in the development of the Facility
Risk Management Plan.
Indicator 481: All new employees are trained in Health and Safety procedures relevant to their
duties within one month of taking up their post.
Indicator 482: All staff attend continuing training for health and safety and records are kept of the
trainings
Indicator 483: Each department uses a systematic process to:
- Regularly identify and record actual and potential hazards in a hazard register (at least
Indicator 484: Staff review significant hazards that have been isolated or minimised in accordance
with a set timetable appropriate for the identified hazards.
Indicator 485: All emergency telephone numbers concerned with Health and Safety are displayed
prominently.
Indicator 486: Health and Safety policies and procedures are followed by staff and include:
- Contamination incidents
Indicator 487: Organisation wide health and safety policies and procedures contain comprehensive
information, instruction and safety protocols for:
Indicator 488: Current health and safety notices, including hazard notices, and key extracts from
the Health and Safety manual are prominently displayed in relevant areas and brought to the
Indicator 489: There is a procedure for ensuring that all contractors are provided with relevant
information regarding health and safety issues within the hospital.
Indicator 490: A written policy and procedure on pest control including measures to prevent, detect
and remove pests is available and implemented.
Indicator 491: Security measures are taken in accordance with written policies and procedures to
protect:
Indicator 492: A procedure ensures that all hospital keys are available at all times to the relevant
staff on duty.
Indicator 493: An internal communication system connecting all units of the hospital enables a
continuous flow of communication and immediate reporting of any incident.
Indicator 494: The Hospital develops a disaster plan with all departments/services and is
reviewed and revised at least every two years.
Indicator 495: The plan outlines individual responsibilities, linkages with external institutions,
resources required in the case of a disaster and individuals within the hospital who must be
Indicator 496: Rehearsals of the disaster plan are carried out in association with the emergency
services and local authorities.
Unit:

Dept.: Quality Department

Date:
Tracer Team:

# of items completed: 0
% of applicable questions scored MET: #DIV/0!

Findings/ Recommendations