JCI Commonly Asked Questions

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What to do: When you see a surveyor?

• Don’t attempt to hide, ignore, avoid or run from them.

• Be certain to greet the surveyor (good morning/afternoon).

• Don’t be afraid and remain calm and friendly.

• Just remember they too are human beings and it is not as painful as you may think to tell them what you know.

• Just in case you do panic, it will still be okay if you don’t know the answer, and then tell them so.



What is The SGH Madinah mission

statement?

• Hospital Mission:To provide professional reliable, cost effective healthcare services that is safe to the patients well-being to all Madinah region.

• Hospital Vision:To be the center of excellence for state-of-art healthcare services in the middle east and Africa built on evidence-based practices and human values.



What does your hospital mission statement mean to you?

Or: what’s your role in supporting the hospital mission?

• Any of the following answers are good but you probably have a much better answer your self!!! BE PREPARED TO ANSWER IN YOUR OWN WORDS!– We serve a culturally diverse population.

Which means we treat patients from all walks of life, therefore, we must respect their differences and meet their special needs?

• (Examples: 1) elderly patients who have difficulty hearing, seeing, and may be frightened, alone, confused etc.

• 2) Young first time breast cancer diagnosed woman who may need more education and emotional support, etc.

– Our mission statement tells me how we define quality .which is providing friendly service to our customers by doing the right thing, the right way, the first time. I help deliver that quality by. (Give a simple example of what you do that is good.



Mission statement Cont.

• We work hard to be clinically effective and economically efficient. Which means we must do well and affordable

• Our mission statement tells me our vision of “serving the healthcare needs of people in our region as we have become the best regional healthcare facility.

• Our mission statement tells me that we value patients rights, involve our patients and families in decision making regarding their care and respect their ability to make choices including end of life decisions. We must inform them of the risks, benefits, alternatives & respect their decisions



What is your definition of quality?

• Any of the following: – Doing the right things right the first

time, and doing it better every time.

– To do the right things to the right patients at the right time by the right way in the right place.

– Compliance with the standards.



Who are your customers?

• Everybody! Patients, Families, Visitors, Physicians, Co-workers within my department and other departments– External Customers:

• Patients• Relatives• Visitors• Companies• Governments

– Internal Customers: our employee including doctors, nurses, technicians, etc



What is a “hospital wide patient plan of care” mean to you?

• It is a detailed document that describes the services offered in each department-(scope of services), description of department, location, hours of operation, staffing plans, etc.

• Be sure you know what is included under your department section of this plan - (scope of services of your department).



How do you make certain the same level of care is provided to

your patients throughout the hospital?

– Our staff and Management develop collaborative policies and procedures which allows various departments to work together to maintain consistency in processes done in different locations of the hospital. Ongoing communication and interaction with other departments is key to our success.

– (You need to be prepared for giving an example of how something done in your department that is also done by others is performed with consistency, could be as simple as our hospital wide hand washing techniques to minimize the spread of infections, transporting DNR information with all patients as they visit different departments/units, etc.)



Who is responsible for safety at our hospital?

• The Safety officer; Mr. Yaran Khan, and safety committee

But• Safety is an important part of every

employee responsibility



What does “Environment of care”

mean?

• It is our hospital wide safety program.

1) General Safety:– Visitor/Patient Incidents– Employee Accidents

2) Fire Safety3) Security: Theft, violence, etc. Workplace Violence4) Emergency Preparedness:- Disaster, Bomb Threat, etc.5) Hazardous Materials and Waste:

– Right to Know MSDS– Medical Wastes– Mercury– Cytotoxic, radioactive, chemicals.

6) Medical Equipment, Procurement and Maintenance.7) Utilities Management:

- Electric - AC

- Phones- Water- Sewage, etc.



What is the goal of the Safety Program?

The goal of the program is to promote a safe

environment for patients of all ages, visitors,

employees and all other people coming in contact

with our organization.



What should you do if you see smoke coming from a patient room, a fire in a Wastebasket or any other signs of a

fire?

• Follow the R-A-C-E protocol:– R = Rescue all persons from the

immediate area of the fire.– A = Activate the alarm and dial

88 to report the fire.– C = Contain the smoke or fire by

closing all doors.– E = Extinguish/Evacuate by

using the proper fire extinguisher.



Where are the fire alarm boxes and fire extinguishers located in

the department?

(Department-specific answer required.)

Know the locations of fire extinguishers and fire alarm boxes in your

area. (You should be able to point to them 20

feet from an exit.)



How do you use a fire extinguisher?

• P-A-S-S:– P = Pull the pin located

between the two handles.– A = Aim the base of the fire.– S = Squeeze the handles

together.– S = Sweep from side to side

at the base of the fire. Watch for re-flash and use extinguisher again if needed.



• Which extinguisher can be used for extinguishing fires involving burning cloth, paper, or wood?

– The red fire extinguisher (ABC)

• Which extinguisher can be used for electrical equipment motors, switches, and flammable liquids?

– The fire extinguisher contain (CO2)

• Which fire extinguisher should not be used on electrical equipment, motors, and flammable liquids?

– Fire extinguisher that contains water.



What is the hospital code for a Fire? And What to dial to call for fire?

• Code Red• Dial Number: 88



Which extinguisher can be used for extinguishing fires

involving burning cloth, paper, or wood?

• The red fire extinguisher (ABC)



Which extinguisher can be used for electrical equipment motors,

switches, and flammable liquids?

• The fire extinguisher contain (CO2)



Which fire extinguisher should not be used on electrical equipment, motors, and flammable liquids?

• Fire extinguisher that contains water.



Where is the nearest fire exit?

• (Department-specific answer required.) Know the fire exit route for your department. If you are a person who works in all areas of the hospital, know where all of the fire exits are located.



How would you respond if told, “A fire has broken

out?”

• Literally, respond as if there were a real fire, Initiate R-A-C-E Protocol.



How often do you have fire drills?

• Fire drills are held annually.



What is the hospital code for a Fire?

• Code Red



What to dial to call for fire?

• Dial Code Red Number – 88-



Emergency Preparedness:Where do you find information

regarding employee responsibilities during a

disaster?

• In the Emergency Disaster plan which is located in each department.



What does [YOUR HOSPITAL] consider a “disaster?”

• Any situation which affect the normal operations in, i.e. fire, Earthquake, RTA



How do we test our emergency preparedness program?

• The Safety Committee had 2 mock disaster drills per year.



Where is your department’s Emergency Disaster Plan

located?

• Know where your department’s Emergency Disaster plan is located.



Can you describe your role in the emergency preparedness

plans?

• Discuss this with your department head and know the answer to this question! Or revise it through reading the disaster plan.



Who is trained to evacuate patients?

• Everyone is taught the principles of evacuation because all personnel might be asked to help.



What information should one attempt to obtain from

someone calling in a bomb threat?

• Exact Language used by the caller.

• Location of the bomb.• When explosion is to occur.• Type of speech of caller.• Background noise noted.• Gender of the caller.



Who should be contacted upon receiving a bomb threat?

• Administrator• Security• Safety Officer• Department Heads



What do you do if someone, whether a patient, visitor, or

employee becomes extremely agitated or violent?

• Remain calm, allow them to verbalize, keep distance, keep exit open, call code strong *66.



What is the hospital code for bomb threat?

• Code White *44



What is the hospital code for a Cardiac Arrest?

• Code blue 22



What is the hospital code for a chemicals spill?

• Code Grey *11



What is the hospital code for blood body fluid spill?

• Code Grey *11



What is the hospital code for radioactive spill?

• Code Grey *11



Medical Equipment:Can you show me where test sticker is located?

• Test sticker is located on side of equipment.



When new equipment is bought or loaned to

your unit you should?

• Call the biomedical engineer for a visual and electrical inspection before use.



How do you report an equipment malfunction?

• Put an out of order tag on it and takes it out of service! Call in a work order or send directly to Bio-med for service.



Whose responsibility is it to be certain the equipment you are using is functioning properly?

• It is your responsibility prior to using equipment that it is working properly. It is your responsibility to also adequately maintain equipment in addition to removing equipment from service and reporting it promptly!



where are the oxygen valves located in your patient care unit?

• (Answer will be unit specific.) Review all areas of department for location.



Who is authorized to shut off the oxygen valves in the event of a

fire or another emergency?

• Charge nurse on specific unit.



Utilities Management:What happens in the event of a utility

failure (i.e. electric, water, gas, medical gas, or telephone)?

- We have backup electrical generators that kick in within 9 seconds of a power failure. In this situation, but the equipment defined within the critical load list of equipments will be automatically work on UPS.

• In the event of a water outage, we have alternate water resource that can cover the hospital for almost one week, after that the external water resource will be contacted to supply water to hospital. All employees will make an effort to conserve as much water as possible.

• In the event there is a medical gas outage, call the Maintenance Department.

• In the event of a telephone outage, use mobiles, bleeper, paging



Hazardous Materials:Where can the details about

every chemical used be found?

• In the Material Safety Data Sheet (MSDS) Manual. Each chemical used in the department is in the department’s manual. The Master MSDS Manual is located in the Safety Office



Other than the Material Safety Data Sheet (MSDS), where can the hazardous material name and hazard warning for that

material be found?

• On the container label.



Do you use hazardous materials in your area?

• (Department-specific answer required.) However, all departments should have an MSDS Manual.



Can you name at least two hazardous materials that can be

found in your department?

• Ask your department head to review what hazardous materials are found in your department.



What first aid measures are necessary when working with

the hazardous chemicals found in your department?

• Check the MSDS for each specific chemical in the MSDS Manual located in your department.



How is your waste disposed of in your department?

• Medical waste is disposed of in covered containers with yellow bags. The bags are removed from the department by Housekeeping to storage area for final dispensing



What should you do if you have a hazardous spill in your area?

• Evacuate all personnel and seal off the area as best as possible. Pull material safety data sheet if aware of chemical. Call *11 and inform them about the location of spill



What by colures do you have for medical waste and for what

types?

• Yellow bags : infectious waste

• Red bags: body parts and human tissues waste

• Blue bags: cytotoxic waste

• Black bags: normal waste



Where do you dispense needles and sharps?

• In the sharps containers



Safety Management:What committee is responsible

for the management of the hospital’s safety management

program?

• The Safety Committee chaired by the administrative officer _______



Who is the Safety Officer at [YOUR HOSPITAL]?

• Engineer Yaran Khan



How are the safety activities reported to Administration and

the Board?

• The minutes of the Safety Committee are submitted to the CEO/SC members monthly.



Who is responsible for maintaining safe practices in the

hospital?

• Everyone is responsible for safe practice! Potential safety hazards should be reported to your immediate supervisor!!



What type of safety/environment of care training have you had

during the last twelve months?

• On a yearly basis, all employees attend mandatory retraining on Fire Safety, General Safety, Infection Control, Hazardous Waste, and Incident Reporting. In addition, patient care employees attend CPR training EVERY TWO YEARS



Describe your hospital-wide smoking policy

• Patients are not allowed to smoke in our hospital without a physicians order to do so. The criteria followed by our medical staff are patients that are terminally ill and the benefits of smoking outweigh the consequences.

• However, if the patient is unable to be escorted outside, then arrangements are made through security department.

• All smoker employees are required to smoke in the designated employee smoke area only which is located outside the hospital.



What type of incidents should you report?

• Any patient, visitor, employee, or physician incident or unusual happening. Fill out an Incident Report obtained from your supervisor.



How do you report an employee incident?

• Fill out an Incident Report immediately.

• Notify your supervisor immediately.



Security Management:What would you do if you are

suddenly involved in a potentially dangerous situation?

• Protect yourself and call for help as soon as possible call code strong *66. Remain calm.



How soon after witnessing a security incident should an

Incident Report be completed?

• As soon as the incident occurs.



What procedure do you follow when a theft has occurred in an area?

• Whether hospital or personal property, make sure the item has not been misplaced. Alert your supervisor. Fill out an Incident Report. (The supervisor will contact Security.)



Human Resources:How do you maintain your

competency/skills in order to perform your job?

• Educational Preparation, competency checklists, on the job training, certifications, licenses, etc.



How were you oriented to your job?

Talk about all orientation activities including: hospital, departmental, unit,

and job-specific orientation. General orientation includes:

• Mission statement/ Continuous Quality Improvement• Patient Rights• Infection Control issues like hand washing, infectious

waste disposal etc• Environment of Care issues such as: life safety,

utilities, medical equipment, general and safety, security issues.

• Hospital History and Structure• Human Resources Policies and Benefits

Department Specific Orientation:• Job Description• Policies• General Tour• Job Specific Orientation:• Competency assessment checklist • In services/Continuing Education Opportunities



Did you receive training during department orientation on

equipment used in your area?

• Medical equipment used in assigned areas was reviewed in department orientation. New equipment is in-serviced before used and additional review of equipment is periodically held.

• If I am ever unfamiliar with a piece of equipment I can go to a colleague with training on the equipment, the operator’s manual, our biomedical staff or my manager.



What age of patients do you care for? Have you received age-specific instructions and

care for all of these ages?

• If the ages of the patients you serve are from birth - death, you will need to give examples of age-specific competencies you have completed.

• Belen to prepare example



How is your competency measured?

• It is measured by performance evaluations, license where applicable, general orientation for new employees, competency based orientation as appropriate and continuing education.



Do you have access to educational materials

related to your profession?

• Materials are available on the unit (textbooks, journals, etc.), through Staff Development, the Internet, and other educational in-services and programs.



How are provisions made concerning assignments

that conflict with your personal beliefs?

• I would voice my concerns to my manager who would in turn, make arrangements for the patient to be cared for by other staff member as soon as possible.

• I would not abandon my patient until appropriate arrangements have been made. My patient of course, would continue to receive the proper care from me until I am relieved of those responsibilities.



How do you address your learning needs?

• Attendance to continuing education Programs

• Attendance to in-service programs, study packets etc. that provide me with input on areas to improve upon.

• Access to library and internet

• Request to attend special programs presented at outside agencies.

• Self learning



What are some examples of training offered as a result of a learning needs assessment?

• Computer Skills Classes on computer department

• JCI standards updates and issues which are ongoing to our staff

• Need more Examples



How is staffing decided and adjusted?

• Typically, for inpatient units, it is based on patient acuity level. In non-patient care areas, it depends on volume of work. (Your supervisor can give you more details)



Performance Improvement:How do you have input on what

should be improved in your area?

• Staff meetings, interviews, and questionnaires are used to provide input on our performance improvement initiatives. Department head also respond to concerns addressed in the patient satisfaction survey process and discuss these issues in department meetings.

• Each department has their own initiatives, based upon their core process and data identifying opportunities to improve. In addition, any employee may suggest quality opportunities

• Through measuring the performance of the department using certain indicators (give examples from your department)



How does the Hospital establish priorities for defining which

processes need to be improved?

• The Quality Improvement Committee establishes priorities based on input from staff, patients, doctors and administrators.

• The Quality Improvement Committee requires that teams to be chartered must involve 2 or more departments so that they are multi-disciplinary! Many good suggestions are submitted each year, they certainly can still be projects to work on among the departments involved!!

• Priorities are then determined based on criteria including but not limited to: high risk, high volume, high cost, problem prone, strategically important to the organization, in-line with the mission and values, multidisciplinary nature of the opportunity and the impact on customer service.



What are some of the teams and their priorities for 2008

e.g.;• Team 1: central line

device infection, Medical and nursing

• Team 2: bed ulcers, nursing department

• Team 3: turn around time /lab



What were some of the accomplishments in the past

year?

• Our PI teams have made changes, big and small, over the past year. Examples



What is everyone’s responsibility in data

collection?

• Everyone is accountable for information being accurate. It is our responsibility to call attention to apparent incorrect data for collection.



What quality initiatives are in place in your department?

• Check with your department head for specific quality efforts, measurements and also client relations improvements.



What is your responsibility in performance improvement?

• To ensure excellent personal performance; to share ideas about improvement in and streamlining of processes; to provide excellent customer service and to listen to internal and external customers

• To participate in basic performance improvement education; to participate in data collections as requested; and to participate on performance improvement teams when requested.



If our hospital should need to scale down its efforts for any of various reasons, what criteria would the

Quality Committee use to prioritize the minimal efforts to be continued?

As outlined in the Quality Management & Performance

Improvement Plan (QMP-01), the following 3 criterion is used to

select the efforts to be maintained: • Processes that affect large number

of our patient population• Processes that place patients at-

risk if not performed well• Processes that have been or are

likely to be problem-prone.



Are performance improvement activities carried out in a

collaborative fashion among departments and various

disciplines?

• Yes! (Be prepared to give examples of how your department has worked with one or more other departments to improve processes).

• Department managers plan and carry out improvement processes with other departments—be prepared to give 1-2 examples of quality teams from last year and their accomplishments as well as 1-2 examples of quality teams that have just gotten underway this year!

• Hint: Be sure to know about any team (s) from this year or last year that Impacts/improves work in your department



How is data systematically collected?

Collecting data helps us to assess outcomes or determine the performance of a function or

process (i.e.; specific work tasks. When data collection is systematic, the data can be used to:

• Establish a baseline when a new process is implemented

• Identify the performance or stability of existing processes

• Measure the dimensions of performance relevant to functions, processes and outcomes

• Identify areas for possible improvement• Determine whether changes improved the

processWe collect data on important processes and

outcomes related to patient care and organizational functions according to priorities

set by the quality improvement steering committee.



Can you tell me something that your department has improved from this time last year? In other words, why

would I want to be a patient or customer of in your department today

rather than this time last year?

• You and your co-workers need to tell the surveyors about any departmental improvements, quality initiatives and/or guest relations activities that have improved your department in the last year.

• Be sure you know of any PI teams that have involved your department last year as well as the new teams just underway for this coming year. Also, if our patient satisfaction survey has information pertaining to your department, you need to know what patients have viewed positively and areas that patients have shown less satisfaction and what you are doing as a department to improve satisfaction in the future!!



What model is used by CQI teams to improve performance

at your hospital?

FOCUS• F (Find an opportunity) • O (Organize a team) • C (Clarify current knowledge of process)• U (Uncover root problems)• S (Start the improvement cycle):

PDCA• P(lan): Identify the problem, develop a problem

statement, collect data to support solutions, use QI tools to narrow the problem and decide on a solution.

• D(o): Implement a plan, test using a trial run, identify costs, people and materials, educate staff.

• C(heck): Monitor the plan’s progress, obtain feedback, compare data with original, use QI tools to monitor, determine the success or failure of the plan/action.

• A(ct): Incorporate the improvement into policy, inform and educate all parties, distribute new information to all key players, look for new improvements.



What education have you had in Performance Improvement?

• Management and / or employee basic performance improvement in orientation; PI training for supervisors and managers; team leader and facilitator classes for selected groups of employees; advanced training for Committee of Quality Improvement. Staff education is provided through “Just in Time Training” when you participate on a hospital PI team.



How is Customer Satisfaction Monitored?

• Through the patient satisfaction surveys, which are done monthly using questionnaires for outpatients and inpatients, Results and actions are discussed in SC, QPS Committee, doctors meeting and Department Meetings.



How is the same level of care consistently assured?

• Through the Patient Bill of Rights, use of Clinical Care guidelines, policies and procedures, Quality Improvement activities.



What is the Performance Improvement Plan for the

hospital?

• It is our plan for organization-wide participation in continuously improving our work processes to meet and hopefully exceed customer needs and expectations. See QPS chapter, QPS.1



What are your key processes (important aspects of care or

service)?

• Discuss with your Department Director the specific work processes for your area



What training have you had on QI?

• All employees receive QI training as part of mandatory in-service as well as new employee orientation. Also, if I serve on a PI team, then I would receive training in my team meetings from our team facilitator



What are “Sentinel Events” and how should you respond?

A “Sentinel Event” is defined by policy QPS.5• An unanticipated occurrence involving death or

major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition or the event is one of the following:

• Suicide of a patient• Rape of a patient• Hemolytic transfusion reaction involving the

administration of blood or blood products having major blood group incompatibilities

• Surgery on the wrong patient or wrong body partWhen the event occurs, as applicable, first treat the

patient as directed by the physician. Second, notify the Department Director or your supervisor,

fill incident report send the report to QM office, QM office will call for team formation and

investigations.



What are clinical guidelines and how do they affect the outcome of the

patient?

Clinical guidelines/protocols are simply a documentation tool that is pre-printed, pre-

approved, outlining the course/plan of treatment for a given diagnosis.

• The use of clinical protocols can: • Reduce or eliminate system breakdown • Improve continuity of care • Improve liability management and outcomes • Improve quality, reduce lengths of stay, and

reduce cost• Improving resource utilization and promote quality

patient outcomes through reducing variation among healthcare practitioners.

Clinical protocols are not:• A substitution or replacement of any physician’s

professional judgment in the care and treatment of a patient



What are some examples of clinical protocols at our facility that have been

successfully implemented

• Pain management protocols, chemotherapy ordering, and disease specific protocols



What are some clinical protocols that we are working on and planning to implement within the coming year?

• Departmental specific answers



MANAGEMENT OF INFORMATION:What is your role in managing

information?

Protect Our Hospital Computer System by following proper procedures for protecting records and information from

tampering/damage, unauthorized access or use and theft.

• Make entries in a patient’s record only if you are authorized to do so.

• Never leave open files on your computer screen or reports from a printer unattended.

• Keep patient information confidential. • For example: Get written permission from the patient

before you share information with any unauthorized person or agency. Do not talk about patients in public areas such as the elevator or cafeteria. Never leave patient files open or unattended where unauthorized people could see them.

• Keep documentation up to date and accurate. All entries should be signed, dated and checked for accuracy.

• Anytime you see how a process can be improved, tell your supervisor!



What information do you need to do your job?

In general, information needs to be timely and accurate. For all departments, information is needed during staff meetings, mandatory in-services/orientation and ongoing educational

opportunities.For specific departments, basic examples include:• Housekeeping: timely and accurate patient

discharge time• Radiology: medical indication for a patient having

a procedure• Laboratory: precautions for sticking a patient• Nursing: results of labs or exams• Nutritional Services: patient medical history for

specific nutritional needs• Patient Accounting: specific information on the

patients insurance plan



What would you do if you were not getting the needed information to do

your job?

Staff and managers need to communicate effectively.

• Staff has the responsibility to let his/her supervisor know if there is a problem.

• Management has the responsibility to determine if the system can be improved to provide staff with more timely and accurate information.



From what sources do you get information?

Memos sent to your department • Bulletin boards and

communication books/logs• Staff meetings• Other employees• News letters, etc.• Email• Web Site and Internet.



What is knowledge-based information?

• Information that is used in problem solving can be found in clinical, scientific and management literature.

• On the patient floors are many reference books, text books, drug books, journals, etc.

• In the medical staff library there are journals, textbooks, reference materials and other resources.

• In the computer lab and various departments in the hospital, employees have access through their supervisor to access the internet world wide web with unlimited medical information.



One of your co-workers has forgotten her computer password and asks to use your password so she can get her work

complete. What do you do?

• Inform your coworker that you cannot share your password as you have agreed not to share your password with anyone else by signing a form stating you will keep your password confidential. You suggest she see her supervisor to get her password. If the supervisor is unavailable you assist your coworker with her work or find someone who can help her until the password is received.



You learn, as a result of your work, that a close friend is on the surgery schedule. Another friend asks you what you know about this patient. How do you handle

the situation?

• You do not discuss this patient with your friend.

• Our policy states any any Information that is contained in the patient’s chart, accessible by computer, or available through any other written or computerized source shall be considered confidential, and shall not be accessed, reviewed or discussed unless such information is necessary for completion of specific job duties.



What is the vision of our hospital as it relates to

Management of Information?

• Our hospital has a Management of Information Plan that outlines how we are obtaining information through networking in addition to the future plans for our hospital.

• See, Management Information Plan- PLN-MOI-01



Is comparative data available to assess

performance?

• Yes, for some areas, for others we compare our internal tends



Has your department or staff been provided with proper

equipment and training to use the equipment?

• Classes are offered in house on a regular basis Information Management can offer suggestions for training and equipment needs.



Are department and hospital policies and procedures

readily available?

• There should be a paper copy in every department.

• Current Policies are available electronically in server. All supervisors have access to this database.

• Hard copies /manuals available in each floor



How are you informed of policy and procedure

changes?

Through staff meetings, in-services and posting new policies.

• The latest policies on server. These can be viewed, searched, e-mail all staff about changes. Replace the old hard copies from the manuals



When are you given initial instruction and continue instruction

on how to access necessary data and instructed on the confidentiality

statement?

Initial instruction is given during employment orientation program and yearly during in service/continuing education.



If you have access to confidential information via computer system, is it okay to leave it on this screen while you attend to another task

away from this system?

• The proper procedure is to sign off any screen that shows confidential information. This way an unauthorized person cannot access this information while the PC is unattended.



Information on hazardous material is

located where?

• In the Medical Safety Data Sheet book located at each work station.



Patent rights organizational/ Ethics:

What rights and responsibilities do our patients have?

• (Policy Patient and family Rights & responsibilities .ADT-11)

RIGHTS FOR TREATMENT: • Patients have the right to be treated without

discrimination. They cannot be denied appropriate and necessary services because of their race, religion, national origin, gender or ability to pay.

• Patients also have a right to care that is considerate and respectful of their personal values and beliefs.

• Patients have a right to appropriate assessment and management of pain.

• Patients have the right to review their medical record. They also have the right to have their questions about their condition answered.



continuation…

NFORMED CONSENT:• Patients have the right to know:• Treatment options including alternative options

and the option to refuse treatment• Risks, benefits and alternatives of each option

including the expected length of recovery• Possible side effects of treatments and

medications• Costs including what the patient’s insurance

may and may not coverINVOLVEMENT IN CARE DECISIONS:

• Patients have the right to be involved in making decisions which includes informed consent, withholding resuscitative services, care at the end of life and other options outlined in various documents known as “advance directives”.

• Patients also have the right to file a complaint and receive help in resolving any conflicts.



Continuation…

CONFIDENTIALITY:• Information about a patient (medical records, test

results, etc.) must be kept private. Anyone not directly involved in the patient’s care, including family members, must have the patient’s permission to get information.

CONFIDENTIALITY:• Staff must not needlessly talk about a patient’s

personal or medical details! Be cautious of where and how you discuss patient information! Remember you signed a confidentiality statement upon employment that must be taken seriously

PRIVACY:• All care (examinations, tests, etc.) should be given in

ways that respect the patient’s dignity. Some examples of how you do this should include:

• Knocking before entering the patient’s room• Keeping curtains drawn during examinations• Discussing sensitive issues in a private area• Asking the patient’s permission to speak about his or

her condition in front of visitors and/or family members.



Continuation…

ACCESS TO PROTECTIVE SERVICES:• Know our facility policy …….

addressing issues of suspected abuse and neglect. All healthcare workers are responsible for notifying our Social Workers ….when suspicion of abuse or neglect exists!

PATIENT RESPONSIBILITIES:• These include giving accurate

information, following instructions, asking questions when something isn’t clear, showing respect and consideration for other patients, hospital staff and visitors, and following hospital rules such as visiting hours and no smoking within the building).



How is the patient informed about his/her rights?

• The patient receives patient information through our admitting office ext.1542, which lists/explains patient’s services, rights, and responsibilities.

• During their hospitalization, if patients have any questions regarding their rights, please notify the supervisor, who can access the information for the patient. The patient rights and responsibility statements are also available in English.



How do you ensure the patient’s right to confidentiality?

• Do not share computer password.• Do not discuss patients in open areas

(i.e., elevators, cafeteria, and hallways).• Use caution when giving information

over the phone.• Share patient information only with

appropriate staff.• Tear up papers that contain patient

information and place in recycling bins to be confidentially shredded.

• Do not use patient’s name when voice paging.

• Employees, volunteers, students and affiliated care givers sign an agreement of confidentiality at time of employment.



Continuation…

• Only authorized individuals are permitted to access records (Paper or via computer)

• Job descriptions/evaluations address confidentiality.

• Boards or sign-in sheets with patient’s address or diagnosis should never be visible to the public.

• Also, reclose doors/curtains to maintain as much privacy as possible with the patient.

• We provide pen/paper to our patients if they seem embarrassed or uncomfortable to talk. We move to a more private area when possible. We assure patient gowns fit properly. We close bathroom doors when occupied, etc.



What is your role in obtaining informed consent? (Consent

policy, PFR-01)

- The staff’s role is to verify with the patient (by the patient’s signature on the consent form) that the patient has all the information needed regarding the risks, benefits, and alternatives of the procedure to make an informed choice.

• Risks, benefits, and alternatives of the procedure MUST BE ADDRESSED BY THE PATIENT’S PHYSICIAN.

• If the patient has questions, the nursing staff may choose to delay the consent process until the physician has satisfactorily answered all the patients’ questions and then proceed with the consent process.



What is an Advance Directive? (Patients & family rights and

responsibilities , consent policy-PFR- 01)

• A way for a patient to decide in advance how he or she wants to handle life-threatening situations. Examples



How are patients informed of their rights regarding Advance

Directives?

• Upon admission, registration personnel in the Admission office give patients a pamphlet on Advance Directives and ask patients if they have an Advance Directives. If they do not have an AD and want more information or assistance in formulating an Advance Directive, they are referred to Social Services, ext. …



. What structures are in place to address end of life decisions,

resuscitative measures or withholding life-sustaining

treatments? (DNR policy- ETC-01)

• The staff act as patient advocates and advise the attending physicians of patient/family concerns surrounding these issues. Refer ethical issues to Ethics committee.

• There is a hospital/medical staff policy on DNR and end of life decisions.



How is organ and tissue donation handled? (Donation

policy- PFR-02)

• Organ and tissue donation is discussed with the patient/family in appropriate cases. Refer to the Organ Donation policy…. If the donation is granted, consent is obtained on the Organ/Tissue Donation form.



How do you demonstrate family participation in care

decisions when appropriate?

• Participation is documented in the plan of care and in the nursing notes. Family involvement is part of being a patient advocate while maintaining the focus on the patient.



How do we evaluate the need for restrictions such as

telephones, visitors, etc.? (Visiting hours policy)

• Policies and procedures are in place to govern restrictions which are patient specific. When restriction of telephone calls or visitors is deemed appropriate, patients/families/friends are educated regarding this decision per policy on patient rights. Patient/family/friend education related to practice is performed on admission.



How does the organization ensure patients’ care is not negatively affected if a staff member asks not to participate in

an aspect of care due to personal, ethical, cultural, or religious values?

(DNR policy- ETC-01)

• There is a policy which defines conditions by which employees can refuse to participate in the care of a patient because of cultural, ethical or religious conflicts.

• The policy addresses the right that employees have to request a reassignment of work duties when conflict arises. The manager and employee evaluate this request .. an ad hock committee can be form, the care of the patient will continue the same until the issue solved



How do we help assure the hospital conducts its business and patient care

practices in an honest, decent and proper manner?

• The hospital has a Code of Ethical which addresses marketing, managed care, billing and admitting practices.

• Hospital staff has been involved in developing this policy that makes certain these issues are all handled in an ethical manner.

• Billing practices are monitored to ensure that patients are billed only for the services that were provided, patients are given an itemized statement and patient accounting staff is available to answer patient questions and resolve conflicts. The hospital mission statement and annual business plan care used as guides to provide a consistent, ethical framework for it’s business and patient care operations.



Who can look in a medical record?

• Health care professionals with a need to know and who are involved in the patient’s care.



What has been done to accommodate patients and visitors with disabilities?

• The hospital triage room entrance is designed for disability entrance, disability restrooms. Other needed materials can be enlarged on a copier or provided verbally..

• Barriers against education assist on admission (patient education policy)

• The current list of interpreters who can be called for deaf patients if the need arises is available.



What has been done to accommodate culturally diverse patients and

visitors?

• For non- Arabic or English speaking patients/visitors, arrangements are made through the Supervisor for a translator to be available. For patients with limited education, staff communicates various ways to make certain the patient understands to the best of their ability.

• For patients with certain religious or cultural beliefs that prevent them from seeking certain treatments, procedures, etc. we as healthcare workers respect their rights to refuse treatment. For elderly patients we communicate in various ways to make certain they see and hear what we’re saying..



If you have an ethical question on any aspect of patient care delivery, what resources are

available to discuss the situation?

• There is a hospital Ethics Committee. (Ethical consultation policy- ETC-02) chairman of ethics committee Dr. Khalil Ghandour



How are you as a staff member made aware of the ethical issues surrounding patient care and the

hospital’s policies governing these issues?

• A multidisciplinary ethics committee exists and staffs are made aware through hospital policies and procedures, mandatory in-service, orientation, supervisors, and communications through the hospital ethics committee. (Review our hospital ethics policies).



What is your department’s role in the development and implementation of the mechanisms designed to address

patient rights?

• All departments are responsible for making sure that patient’s rights have been respected and departmental input is needed in developing, implementing and abiding by policies.

• Departments represented on the Ethics Committee include: ICU, Nursing Administration, Social Services, administration, and medical staff.



How is the patient complaint managed?

• The employee should clarify the nature of the complaint before contacting their supervisor, department director, supervisor or administrator on call. That individual should promptly investigate and analyze the situation and notify the appropriate department director/manager for assistance. All in-house complaints must receive a verbal response within. 48 hours patient complain policy)

• Outpatient and emergency department complaints must be responded to within five days. A patient comment/complaint form must be completed by the individual responding to the patient complaint.

• Complaints come through suggestions boxes, process and reported by QMO



How are patients pastoral (spiritual) needs met?

• Staff recognizes that patients have spiritual needs and assess their desire for such services. Social workers may discuss spiritual care with the patient’s nurse.



How do we inform other departments that a patient being

transported to their area has valid DNR orders?

• We always send the patient’s chart with the patient. The code status sheet is located at the front of every chart and directly behind the code status sheet DNR notes kept if one exists.



What rights do patients have regarding pain management?

• The patient has the right to make decisions to manage pain effectively and to have an assessment of pain. Patients have a right to information about pain and pain relief measures. (Pain management policy)



How is a patient’s pain assessed and managed?

• The patient is asked about pain level, location, description on admission using a scale 0-5. Policy and Procedures are in place defining alternatives to help with pain management.



Surveillance, Prevention and Control of infection:

Why is there an Infection Control Program?

• To reduce the risk of infection between patients, visitors and our employees



What single action is recognized by the CDC

(centers for Disease Control and Prevention) as the most

effective means of preventing the spread of infection within a

facility

• HANDWASHING!!!!!



Who is responsible for Infection Control?

• ALL of us at PAC are responsible for preventing infections. The director of infection control program and Nurses : Infection Control Nurse Ms. Joy



What does the term “Standard Precautions” mean?

• [YOUR HOSPITAL] has adopted the 1996 CDC Isolation Precautions. Under these guidelines, standard precautions are used. Standard precautions mean that blood, non-intact skin, and all body fluids with the exception of sweat are treated as potentially infectious, so we must use personal protective equipment to protect ourselves from being exposed to these body fluids.



What would you do for an occupational exposure to blood borne pathogens (needle stick,

splash or spray to eyes, non-intact skin)?

• Go through the needle stick protocol. Report exposure to your supervisor, then contact the Employee Health Clinic), the Infection Control Coordinator or the House Supervisor to complete an exposure packet which is available from any of the above individuals. The details of the exposure will be reviewed with you and the risk of transmission of a blood borne pathogen will be determined. At this point you will be instructed further regarding any action needed. Employee clinic Dr. Yassar Qutaiba will follow up with you regarding the results of testing.



What isolation system do we use at [YOUR HOSPITAL] and what do the

signs mean?

• [YOUR HOSPITAL] uses the CDC Isolation Precautions which mandate standard precautions are to be used at all times with all patients. In addition to Standard Precautions there are three categories of transmission based precautions:

Three categories:• Airborne - for TB, chickenpox or other airborne

disease.• Droplet - for meningitis, pertussis, influenza or

certain other diseases. • Contact -used for patients with VRE, MRSA or

other drug resistant organisms. Signs instruct visitors and other persons to report

to the nursing station for information regarding precautions to be taken before entering the patient’s room. Standard precautions are

always used in addition to transmission based precautions.



What is personal protective equipment? Name an example and when you should use it.

• Personal protective equipment protects us from contact with blood or body fluids. Gloves, masks, goggles or face shields and gowns are personal protective equipment



If a patient has an infection which requires isolation,

where would you find information regarding the

type of isolation required?

• The Manual located in each department, or Isolation policies may be accessed



What are items that go in Red bags or Red

containers?

• Items that are full of blood or have the potential to break or splash blood go into the red bagged waste containers. Nursing staff assign to monitor the flows needles and sharp items which may puncture bags go into the sharps disposal boxes. This is called Biohazardous waste.



Who monitors refrigerator temperatures in our facility and what action should be taken to

correct an out of range reading?

• In the main facility temperatures are checked daily and logged by our Security personnel. Any variance is reported to Plant Operations. Nursing staff a sign to monitor the floors refrigerator temperature



What immunizations are available to our

employees?

• All of our employees are offered the Hepatitis B vaccine. All employees are offered the flu vaccine yearly.



What precautions are taken for patients with known or

suspected TB?

• The patient is placed in a private room with negative air pressure, outside ventilation and an isolation sign is placed on the door.

• An employee who has been fit tested for an approved mask is assigned to care for the patient. Patients should not leave the room unless required for testing or treatment and then they must wear a mask the entire time they are out of the room. Only employees fit tested with an approved mask may enter the room.



Do you recap needles?

• Generally needles are never recapped, but if there should be a situation where recapping is necessary then you must use a one handed scoop method or a mechanical device designed for needle recapping.



How do you dispose of sharps?

• Needle/sharps boxes are where all contaminated sharp items are disposed of.



Care of Patient:Can restraints be initiated by

an R.N.?

• Yes, if the physician is not available, with the approval of the House Supervisor based on appropriate assessment of the patient and sound clinical judgment. The physician must be contacted for a written or verbal order as soon as possible but within 12 hours of the restraint application.



What must the

physician order include for the use of

restraints?

The condition present that warrants the use of restraints.

• Type of restraint• Time of the order• Date• Physician's signature



How long is a Med / Surg restraint order good

for?

• No longer than 24 hours.



If a patient is restrained for sudden aggressive behavior, how soon must the patient be assessed face-to-face by the physician and how long is the restraint good for?

• If a patient exhibits sudden aggressive behavior and poses an imminent danger to himself or others and restraints are applied, a physician must see and evaluate the need for restraint within ONE hour after the intervention.

• Each written order for a physical restraint for aggressive behavior is limited to four (4) hours for adults, two (2) hours for children and adolescents age 9-17 and one (1) hour for children under the age of 9.

• When the time span for the original order is close to expiring, a nurse is to telephone the physician, report the results of his/her most recent assessment and request that the original order be renewed for another period of time.....not to exceed the time limits set by the original order. The physician does not have to perform another face-to-face assessment until the 24hr. maximum is reached.



Name alternative interventions to

restraint application

• Sitters• Bed check system• Family staying with

patient• Frequent toileting• Ambulation• Leaving lights on



Who is responsible for monitoring resuscitation

(Code blue) outcomes and how often is this

performed?

The house supervisor conducts a review of all Code blue after the code has ended. Completed sheets are forwarded to CPR committee with reports presented quarterly at Medical board meeting



How can you be certain that a crash cart on a

different unit is stocked the same as the crash cart

on your unit?

• All crash carts are restocked by the pharmacy using the same criteria for each and every crash cart



How often does the pharmacy check the contents of all crash

carts?

• The pharmacy checks the content of all crash carts on a monthly basis for completeness and expiration dates.



Conscious Sedation:What is conscious

sedation?

• A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patient airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.



What is the difference between “conscious sedation” and ? other types of sedation

• Minimal sedation is defined as a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.(such as medication given for pain or pre-operative medication).

• Deep sedation/analgesia is defined as a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.(these patients will have an anesthetist in attendance)



What equipment is to be readily available in monitoring

the patient for conscious sedation?

• The following equipment and supplies must be available for the administration of intravenous conscious sedation:

• Continuous monitoring non-invasive blood pressure and pulse oximetry; and cardiac monitoring (only if known cardiac patient) during and immediately following in the recovery period of the procedure. In case cardiac monitoring is not available, at least pulse oximetry should be available

• Continuous intravenous infusion of an appropriate solution functional suction apparatus with appropriate suction catheters.Telephone or some other system so as to be able to activate the emergency medical system if required Duct number 8060

Conscious Sedation• An emergency crash cart which includes

respiratory emergency equipment.• Reversal agents/medications.• Sedation and analgesia medications as ordered

by M.D.



Who is responsible for assessing and/or reassessing the patient

immediately prior to administering anesthesia when

a nurse anesthetist is not involved in the procedure?

• The RN



How do you know if a

physician or other licensed independent practitioner

has privileges to do a certain procedure in your

area?

• There is policy number ANT02



How do you ensure emergency meds are

consistently available, controlled & secure?

• Every shift, during normal hours the department is open, the staff verifies that the red numbered lock is intact and that the lock number matches that recorded on the orange sticker affixed to the cart. This shows that the cart is complete.



What would you do if you found that the emergency

box or crash cart was unlocked ?

• During pharmacy hours (8a-8p M-F, 8a-6p SS) call pharmacy. After pharmacy hours, call house supervisor to obtain emergency replacement cart from night cabinet. Red Box is to be returned to Pharmacy via dumbwaiter when they re-open (8am).



How are medications distributed, stored,

secured?

Inpatient Areas:• Pharmacy uses unit dose distribution

system. Deliver a 24hr supply of meds and IV products every day. Medications are locked in carts. DEA scheduled meds (Controlled substances) are kept double locked in carts or cabinets.

Outpatient Areas:• Drugs routinely used are kept as floor

stock. Once used, the charges are sent to Pharmacy for replacement and billing. Meds are kept locked; controlled substances are kept double locked. Doses are signed out on control sheets as used.



Describe how the medication orders are processed for

your hospital.

• Practitioners write orders in patient chart. Nurse verifies order and order is copied onto med administration record (medix). Copy or order goes to pharmacy via dumbwaiter. Pharmacy sends up enough doses until time of cart exchange, when a new 24hr supply is delivered. Pharmacy and nursing reconcile drugs being delivered at cart exchange against nursing medix.Use chart to clarify discrepancies.



How are pharmacy services provided when

pharmacy is closed? Who has keys to pharmacy?

• only pharmacists may have keys to pharmacy. After pharmacy closes, night cabinet is available to nursing supervisors for new orders/admits



How are drug storage areas checked?

• Pharmacy staff checks all areas monthly for expiration dates.



How do you monitor the effects of medications on

patients?

Depends on the drug. If analgesic, go back and ask patient to rate their pain, using pain scale. If anti-hypertensive, take blood pressure. If antibiotic, check WBC, temp, confirm C&S for bug and drug. Etc. Overall there is a Multidisciplinary approach

Multidisciplinary• Pharmacy screens for drug-drug

interactions, drug-food interactions. • Lab reports sub therapeutic or toxic

levels/labs.• Everyone evaluates patient for

suspected adverse reactions. • Nursing documents SE, effects.• Physician, monitor outcomes.



Describe how you are addressing the patient’s right

to pain management.

• First of all, the patient is informed of the right to pain management in the admission brochure. Upon admission, the nursing assessment is used to assess pain. A standard pain scale (0 pain free-5 worst ever pain) is used to document the pain..

• Medications are ordered by the physician and administered according to the instructions. Appropriate selection and dose of drugs are monitored by pharmacists. When doses are administered, the nurse re-checks the patient and documents pain after the analgesic dose (or non-pharmacologic) intervention

• Care plans include the pain scale. The physician is informed if the pain regimen prescribed is not effective at managing the patients pain. In addition, PCA pumps are now available at PAC. This allows the patient to assist in their pain management. Patients are educated about their pain meds by the nurse when given the med and before being discharged home on a pain med.



Are there any therapeutic interchanges/drug

substitutions in place at PAC?

Yes. Pharmacy & Therapeutics committee has approved several

automatic substitutions. • H2 blocker (po)= Zantac 150 bid

(for any oral H2 ; Axid, Pepcid, Tagamet)

• H2 blocker (iv)= Pepcid 20mg iv q 12h ( for any inj H2)

• Proton pump inhibitor= Prevacid 15mg qd (for Prilosec 20mg)

• Antacid= Maalox Plus (for Mylanta)

• Maalox Plus XS (for Mylanta II) • Multivitamins= Theragran M qd



How are those substitutions documented?

• Pharmacy sends up sticker noting interchange to be placed in chart (with order)Nursing unit staff is to note drug patient actually receiving on med administration record.



How long is a multiple dose drug good for?

• Multiple dose vial for injection 30 days from date opened, as long as not visibly contaminated. Staff is to write date and initials on vial when opened.

• Bulk or multi use container liquid, etc

• Up to manufacturer’s expiration date as long as no visible signs of contamination and proper dispensing/administration techniques are used



Where do you get the red numbered locks for

crash carts?

• Pharmacy controls locks. They sign them out in Pharmacy. Issue with new sticker for cart/box (with new lock number).



How are samples used at PAC?

- Pharmacy does not keep samples for inpatients. If a doctor supplies samples for a patient, they are delivered to pharmacy and pharmacy will distribute via normal cartfill procedure.



How are herbal products used at PAC?

• Pharmacy & Therapeutics committee approved a policy that states the PAC pharmacy will not stock/dispense herbal products for inpatients. Nursing assessments do include a question for the patient about use of herbal, food supplements or OTC products at home.



What has been done at PAC to minimize risk of

medication errors?

• Re-implemented cartfill exchange reconciliation. Developed an IV potassium protocol -removed undiluted Kcl vials from floor stock and crash carts.

• Standardized iv drip Concentrations• Use of routine orders (annually review &

revise)• Converted from heparin to saline lock

(flushes)• Reduced drugs available in night cabinet • Focus articles in Pharmacy newsletters on

steps to reduce med errors. • Held CE program, “How to avoid the

Headlines: Medication Error Prevention.”• Review of P&P for safety related to med

distribution, administration, dispensing• Performance improvement looking at

prescribing (completeness of orders)• Evaluating house wide computerized charting

software • Analyze and trend medication errors



Is there an automatic stop policy at PAC? How does

it work?

• Yes. It requires the practitioner to re-evaluate the use of certain types of drugs every 5 days and either re-order (to continue therapy) or discontinue . Anti-infective agents, inj. corticosteroids, controlled substances. Pharmacy sends notice to unit secretaries about drugs which are reaching the 5 day limit and they write note in chart asking Dr to renew or d/c the drug.



What MUE (medication use evaluations) have been

done this year?

• Allergy reporting, CHF, B blocker+ ASA in post MI patients, Epogen, Pain management



Nutritional Services:nutritional needs

assessed and monitored?

• Patients are screened and if needed assessed. The assessment includes a plan of care, documented in the chart in the multi-dis. plan of care. This plan of care is undated and redefined dependent on each individual patient and their individual needs. Therapies are monitored by nutrition services, nursing, pharmacy and other disciplines. These may include: intake, weight change, lab values, wound healing



How is nutrition services triggered to see patients?

• Each inpatient has a screening tool completed by nursing staff to identify problems on admission. The tool has 4 copies, one for the chart, one for nutrition, one for social services, and one for PT. This alters these disciplines to review the charts. Nutrition can also be consulted via physician, nursing, pharmacy, other disc. or via discharge planning group.



What happens to patients needing trays between meals of in off hours?

• Nursing may call down for trays anytime during operating hours. The trays are filled and placed on the dumb-waiter.

• During off hours there are a variety of food stuffs available on the floors, juices, soups, Jell-O, frozen dinners, milk, crackers, nabs, fruit.



What are you doing to comply with Food guidelines for

enteral support?

• We use a closed system, with RTH ( ready to hang) formula when ever possible. This allows the formula to be hung for a 24 hour period.

• There are several formulas not available in the RTH , these are poured into containers, with enough for only 8 hours at a time, the containers are then rinsed before new formula is added.

• We do not manipulate our formulas with dye, but have color pelled systems which allow the formula to be colored without manipulation.

• Formula is dated and timed by nursing. We also have an enteral feeding form which alerts nutrition to assess patients on enteral support.



Are dietitians available on weekends?

• Yes, our dietitians rotate weekends



How are you sure patients get the correct diet?

• Nursing services verify the trays/ diet orders with food service staff prior to trays being passed. This is repeated for each meal.



EACH OF US HAS THE RESPONSIBILITY OF MAKING SURE THAT

WE ARE KNOWLEDGEABLE

ABOUT THE INFORMATION THAT HAS BEEN SHARED

TODAY“LET’S BE

PREPARED”



Documents

JCI Commonly Asked Questions