1. ACHS Hospital Accreditation PART II Combined Endoscopy Unit
Ms Cecilia YEUNG
WM, CEU & SUR, CMC

2. ACESS TO CEU

3. Access prioritized Appointment booking waiting time and case loading
SOPD DATA 2010.xls

4. Patient safety Pre-procedure preparation checklist
Pre & intra & post-procedure assessment
Correct patient identification
Informed consent policy
Time out/ sign out policy
Checklist and assessment form
Evaluation of endoscopic complication
Complication report

5. Discharge Discharge advice note
Hotline and pathway of post procedure management
Call back alert
Education for carer on post procedure management

6. Infection Control Airflow & Workflow of environment floor plan
Disinfection & sterilization policy and working group
Tracking system : equipment and accessories
Training and audit on reprocessing
5 S policy

7. Follow up after ACHS Clinical Support
Compliance audit on
patient identification
biopsy taking
Compliance audit on clinical documentation
Review safety checklist
and Compliance audit on safety proceduce *
Patient satisfaction survey on provide information and post-procedure management*
Support
Introduction of image capturing system
Introduction of CGRS booking system
Corporate
Renovation on reprocessing room
Review report tracking system
Review transportation system