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JCIA Q & A
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JCIA Survey
Specially Trained Surveyors Will Visit & EvaluateEach Health
Care Organization s Compliance
And Identify Strengths And Weaknesses. TheSurveyor s Goal Is Not
Merely To FindProblems, But Also To Provide Education
AndConsultation So Health Care Organizations Can
Improve.
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Best Motto: Stay PreparedIt s very important that you have to be
ready for the
survey
Keep up-to-date & thorough with all thestandard procedures
involved in your assigned
job & related medical records procedures.
Seek your direct supervisors help & clarify your doubts
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Tips to get educated
Try to review your departmentalannouncements & policy /
guidelinesinformation from outlook public folder
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What do I say if I don t know the answer to a Joint Commission
surveyor s question?
Inform him/her where you would go tofind the answer (e.g., I
would ask my
supervisor, reference a specific policymanual, etc.).
NEVER RESPOND, "I DONT KNOW."
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ACCESS TO CARE& CONTINUITY OF CARE
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How do you provide for continuityof care throughout the patient
s hospital stay?
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How do you assure that onelevel of care is provided for
operative and other procedures
throughout the facility?
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Does the clinic provide thepatient and their family with
information about continuingcare, treatment or services andhow
to access the resources?
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Does the clinic/ambulatorysetting explain treatments
andfollow-up care to dischargedpatients?
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How do you provide for theexchange of appropriate patientcare
and clinical information whenpatients are admitted, referred,
transferred, or discharged?
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Do patients with alike healthcareproblems and needs receive
the
same quality of care throughoutthe hospital? How are you sureof
this?
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Do you have a Discharge planner?
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What is Nursing s role in thepatient admitting process?
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How are you sure that a patient s
discharge is based upon his/her assessed needs and that care
willcontinue as necessary in the
home environment?
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How do you arrange for home
care and/or home equipment for patients dischargedunexpectedly
during off hours?
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Who conducts dischargeplanning activities during theweekend?
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If a physician refused to respondto an emergent call from staff
regarding a patient, what is your process to arrange for care
for
the patient during off hours?
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Describe the process (es) for
referral, transfer, or discharge of a patient.
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How do you provide for theexchange of appropriate patient
care and clinical informationwhen patients are
admitted,referred, transferred, or discharged?
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What type of patients do you
routinely transfer to outsidefacilities? Why?
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What is done with mental healthpatients? How are they
managed if you do not have apsychiatric component of your
facility?
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What type of circumstances slow
the progress of ED patients?Why? What is being done toimprove in
these areas?
-
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How do you handle primary carereferral sources?
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Within what time frame arepatients seen and examined by
aphysician? What do your medical staff bylaws or ED rules
and regulations require?
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Has this unit ever transferred
one of your postoperativepatients to an ICU as anunplanned
event?
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What would PACU staff do if anunplanned admission to ICU fromthe
PACU was necessary and theICU was full to capacity?
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Can patients be dischargedwithout a physician s order? If this
center uses dischargecriteria, describe the elements of
the criteria
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What is the process if a patient
scheduled for an outpatientprocedure must be converted toan
inpatient?
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Tell me about your dischargeplanning?
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What has been done to
accommodate patients andvisitors with disabilities?
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What has been done toaccommodate culturallydiverse patients
andvisitors?
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PATIENT & FAMILY RIGHTS
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How is the patient s right to treatmentor service respected and
supported?How does your hospital respond torequests for care that
it cannotprovide based on its capacity, stated
mission and philosophy, and relevantlaws and regulations?
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How does your hospital demonstraterespect for the following
patientneeds in this setting:
Confidentiality;Privacy;Security;
Resolution of complaints; andCommunication?
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Describe how patients are involved in thefollowing
functions:
Giving informed consent;Participating in care decisions
(family
members);
Assessment and management of pain;Outcomes of care including
unanticipated
adverse outcomes;
Deciding to withhold resuscitative services;and
Deciding to forgo or withdraw life-
sustaining treatment;
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Describe the medical staff s rolein developing the hospital s
code of ethical behavior:
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Describe the medical staff s involvement in the
EthicsCommittee:
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Describe the medical staff s rolein developing and
implementingprocesses related to patientrights
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What was the medical staff sparticipation in the developmentof
policies regardingprocurement and donation of organs/tissues?
-
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What access is available to
knowledge-based information thatmay be required in patient
careactivities, research and other
clinical activities?
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When and how do you obtain consent?
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What happens if the patient isunable to sign the consent
form?
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What procedures needobtaining an informedconsent?
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What rights and responsibilitiesdo our patients have?
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How is the patient informedabout is/her rights?
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What is your role inobtaining informed consent?
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What structures are in place toaddress end of life decisions
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How do we evaluate the need for restrictions such as
telephones,visitors, etc.?
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How does the organizationensure patient s care is not
negatively affected if a staff member asks not to participate
inan aspect of care due to
personal, Ethical, cultural or religious values?
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If you have an ethical questionon any aspect of patient
caredelivery, what resources areavailable to discuss the
situation?
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How are you as a staff member made aware of theethical issues
surroundingpatient care and the hospital s
policies governing theseissues?
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What is your department s role in the development
andimplementation of themechanisms designed to
address patient rights?
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How is the patient complaintmanaged?
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How are patients (spiritual) needs met?
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7/27/2019 JCIA Q & A 2010
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How do inform other departments that a patientbeing
transportation to their area has valid DNR orders?
-
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What rights do patients haveregarding pain management?
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How do you involve the patientin participating in care
decisions? How do youinvolve the patient s family?
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What is the nurse s role inaddressing ethical issues inthe
patient care process?
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What is Nursing Service s involvement with the EthicsCommittee?
Are nursingpersonnel assigned as Ethics
Committee members?
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Do we have a ComplaintManagement Policy?
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What type of ethical issues doyou deal with in your
department?
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What is the mechanism your department follows if there is
aconflict between familymembers as to whether someone should be
made aNo Code?
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What are the patient s responsibilities and rightsrelated to
patient safety?
-
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How is confidentiality of patientinformation maintained at your
registration desk?
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Does housekeeping staff have
access to your department after hours? If so, how do you
maintainconfidentiality of patient information
-
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What does your staff do if thereis no informed consent for
aprocedure on the patient s record prior to the procedure?
-
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What mechanism does thepatient care unit staff have in
place to access the EthicsCommittee? How are patientsand their
families informed about
their right to access the EthicsCommittee?
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How does your hospital demonstraterespect for the following
patientneeds:
Response to patient and familyrequests for pastoral
services?Communication of information in a
way and language understood bythose making care decision?
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Describe the informed consentprocess on your unit. Who must
inform the patient about operativeand other procedures, and
whatmust the patient understand prior to signing an informed
consent?
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What process does your hospital
have in place to support thepatient s right for
DNRintraoperatively?
-
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Can you list some of the rightsthat both the JCIA and thefederal
government requirehealthcare institutions to extend
to patients?
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What is meant by"informed consent?
-
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How are patients informedof their rights as apatient?
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Do you have access toother religious sects
-
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ASSESSMENT OF PATIENTS
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What is your process for nutrition screening?
-
7/27/2019 JCIA Q & A 2010
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What are the criteria you use
for identifying patients atnutritional risk?
-
7/27/2019 JCIA Q & A 2010
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What are the criteria for
developing a plan for nutritionaltherapy?
-
7/27/2019 JCIA Q & A 2010
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Is there a Nutritional Care
Manual? Who has copies? Isthere a copy available on eachpatient
care unit?
-
7/27/2019 JCIA Q & A 2010
85/674
Describe the functionalassessment process
-
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What elements are assessed
when a functional assessmentis performed?
-
7/27/2019 JCIA Q & A 2010
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Describe your interdisciplinaryapproach to nutritional care
-
7/27/2019 JCIA Q & A 2010
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When patients enter the sameday surgery area, does thenurse
perform the sameassessment as he/she would
on an inpatient?
-
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Does the initial patient assessmentinclude an evaluation of
physical,psychological, social, andeconomic factors, including,
aphysical examination and healthhistory?
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Describe the initial assessmentprocess, including which
disciplines are involved inassessing the patient, the scopeof
their assessment, and the time
frame to complete theassessment.
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In the initial assessment, how isthe patient s pain
identified?
-
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Are the initial assessment,medical history, and
physicalexamination competed in a timelyfashion, as defined by
hospital
policy or the standards?
-
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Do you periodically reassesspatients at appropriate intervals
todetermine their response totreatment and to plan for
continued treatment or discharge?
-
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How is a patient s painassessed and managed?
-
7/27/2019 JCIA Q & A 2010
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What waived testing proceduresare your nurses allowed to
perform? What type of treatmentis based on the results of
thewaived tests? What is your policyon this?
-
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Who evaluates or deals with thepsycho social needs.
-
7/27/2019 JCIA Q & A 2010
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How do you provide for services
not available at this facilityduring off hours (i.e.,
mobileMRI)?
-
7/27/2019 JCIA Q & A 2010
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-
7/27/2019 JCIA Q & A 2010
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What is your turn-around-time ondiagnostic radiology films
orderedSTAT during off hours? Can youprovide
documentationsupporting your answer?
-
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What do you do in the event of a reagent recall?
-
7/27/2019 JCIA Q & A 2010
102/674
What is the turn-around-time for STAT laboratory orders? Can
youprovide documentation to supportyour answer?
-
7/27/2019 JCIA Q & A 2010
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What types of tests are batched?
-
7/27/2019 JCIA Q & A 2010
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What percentage of collectedspecimens must be rerun dueto human
error? Due totechnical (equipment) error?
-
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What process is followed for providing STAT and urgent testingin
the event of laboratoryequipment failure?
-
7/27/2019 JCIA Q & A 2010
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How are medical and nursing
staff informed of critical or paniclaboratory values?
-
7/27/2019 JCIA Q & A 2010
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What is the Laboratory s processfor taking orders from
physiciansover the telephone? Where isthe documentation kept?
-
7/27/2019 JCIA Q & A 2010
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How does the Laboratory protectconfidential patient
information?
-
7/27/2019 JCIA Q & A 2010
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What type of staff safety
equipment is available in theLaboratory?
-
7/27/2019 JCIA Q & A 2010
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How are blood/blood productordering patterns established?
-
7/27/2019 JCIA Q & A 2010
111/674
How blood reactions are monitored?
-
7/27/2019 JCIA Q & A 2010
112/674
What is your process whenblood is not available?
-
7/27/2019 JCIA Q & A 2010
113/674
-
7/27/2019 JCIA Q & A 2010
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What is the role of the MedicalDirector of the
ClinicalLaboratory? Does he/shereview abnormal results prior
tofinal printing of result?
-
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What is the process used toevaluate and select
referencelaboratories and contractservices used by your
laboratory?
-
7/27/2019 JCIA Q & A 2010
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-
7/27/2019 JCIA Q & A 2010
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Who performs the tests onproficiency samples? Do thesepersonnel
also test patientsamples?
-
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Are there tests that are notincluded in a proficiency
testing program? If so, whatmeans do you have of verifying their
accuracy and
precision?
-
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What is your process for reviewing quality control and
patient results and where is thisreview process documented?Who
performs the review?
-
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What are your policies regardingunacceptable quality
controlresults, and how do youdocument remedial action whenthis
occurs?
-
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Describe how your hospitalprovides pathology and clinical
laboratory services andconsultation, whether on thepremises or
in a contact laboratory.
-
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Do you have set time frames for
communicating laboratoryresults to patient care staff?Please
provide an example?
-
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How do staff members
determine what is a normal range for a test?
-
7/27/2019 JCIA Q & A 2010
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Describe how your laboratorysafety program is coordinated
withthe organization s safetymanagement program.
-
7/27/2019 JCIA Q & A 2010
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How are reagents that are usedto provide laboratory
servicesperiodically evaluated for accuracy and results?
-
7/27/2019 JCIA Q & A 2010
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-
7/27/2019 JCIA Q & A 2010
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Who is responsible for reviewing
the quality control results for alloutside sources of
laboratoryservices?
-
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Does the organization haveaccess to experts in
specializeddiagnostic areas, such asparasitology or virology,
whennecessary?
-
7/27/2019 JCIA Q & A 2010
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Who draws blood besidesphlebotomists?
-
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How do you assure right
person is getting right blood atright time?
-
7/27/2019 JCIA Q & A 2010
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Describe the reassessmentprocess. What are thecomponents of a
reassessment?When are reassessmentsperformed? Do you have
criteria
for this?
-
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-
7/27/2019 JCIA Q & A 2010
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Have assessment activities beendefined in writing?
-
7/27/2019 JCIA Q & A 2010
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What are the time framesestablished by the organizationfor
initial assessmentsperformed by each discipline?
-
7/27/2019 JCIA Q & A 2010
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What process is in place t identify
those patients that need dischargeplanning?
-
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138/674
-
7/27/2019 JCIA Q & A 2010
139/674
-
7/27/2019 JCIA Q & A 2010
140/674
What is your triage process?
-
7/27/2019 JCIA Q & A 2010
141/674
Explain the difference betweentriage and medical screening
-
7/27/2019 JCIA Q & A 2010
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Who can perform triage activities?
Who conducts medical screeningexaminations?
-
7/27/2019 JCIA Q & A 2010
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How do you know you areassessing pain accurately?
-
7/27/2019 JCIA Q & A 2010
144/674
Is blood stored in the surgical
services environment? What isyour policy on this?
-
7/27/2019 JCIA Q & A 2010
145/674
Describe the preoperative and
intra-operative nursingassessment process
-
7/27/2019 JCIA Q & A 2010
146/674
-
7/27/2019 JCIA Q & A 2010
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Do you perform blood draws in thecenter? If so, how do you
knowstaff is competent? Do you monitor laboratory requests for
redraws? Do you monitor hematomas after
blood draw?
-
7/27/2019 JCIA Q & A 2010
148/674
What is the policy for pain
assessment in Adults(inpatient settings)?
-
7/27/2019 JCIA Q & A 2010
149/674
Are ambulatory clinics required
to conduct pain assessment onall patients?
-
7/27/2019 JCIA Q & A 2010
150/674
-
7/27/2019 JCIA Q & A 2010
151/674
CARE OF PATIENTS
-
7/27/2019 JCIA Q & A 2010
152/674
How do you know whether or
not your patients like the foodthey receive as inpatients?
-
7/27/2019 JCIA Q & A 2010
153/674
What is your policy on restraintand seclusion?
-
7/27/2019 JCIA Q & A 2010
154/674
How the staff members are
educated and trained onrestraint use?
-
7/27/2019 JCIA Q & A 2010
155/674
What are some of the alternative
measures you ve employed toreduce restraint use?
-
7/27/2019 JCIA Q & A 2010
156/674
How are patients assessedwhile in restraint/seclusion?
-
7/27/2019 JCIA Q & A 2010
157/674
What measures are in place to
assure all patients have accessto resuscitative measures?
-
7/27/2019 JCIA Q & A 2010
158/674
How do you monitor resuscitation outcomes?
-
7/27/2019 JCIA Q & A 2010
159/674
What processes are in place tooptimally manage patient pain?
-
7/27/2019 JCIA Q & A 2010
160/674
Have you addressed the specialneeds of patients who arepossible
victims of alleged or suspected abuse or neglect?
-
7/27/2019 JCIA Q & A 2010
161/674
How do you plan care to ensure
that it is appropriate to thepatient s needs?
-
7/27/2019 JCIA Q & A 2010
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How the same level of care isconsistently assured?
Explain the medical staff s role in theuse of restraint or
seclusion related to:
-
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use of restraint or seclusion related to:
Plans, policies, priorities: Assessment processes that
identify
and prevent, when appropriate,potential behavioral risk
factors:
Design and delivery of care:
Development and promotion of preventive strategies and use of
safeand effective alternatives to restraint:
-
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What type of performanceimprovement activities areconducted
related to restraints?
-
7/27/2019 JCIA Q & A 2010
165/674
How do you provide for special
nutritional requests of the patientwhen the kitchen is
closed?
-
7/27/2019 JCIA Q & A 2010
166/674
Who monitors food preparation,
safety and storage and how arethese processes monitored?
-
7/27/2019 JCIA Q & A 2010
167/674
-
7/27/2019 JCIA Q & A 2010
168/674
What has the Nutritional CareServices Department done to
improve the provision of food andnutrition to the patient
population?
-
7/27/2019 JCIA Q & A 2010
169/674
What has the Nutritional CareServices Department done toimprove
the meal serviceprovided?
-
7/27/2019 JCIA Q & A 2010
170/674
How do you ensure that members of the Nutritional Care
ServicesDepartment, Pharmacy, Nursing andthe medical staff find out
promptlywhen a patient is on a drug in which
there is a potential interaction withfood?
-
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Are dietitians available on weekends?
-
7/27/2019 JCIA Q & A 2010
172/674
Describe how patients areinvolved in the assessment
andmanagement of pain?
-
7/27/2019 JCIA Q & A 2010
173/674
Do you periodically evaluatepatient s progress against care
goals and the plan of care? Are theplans or goals revised
whenindicated?
-
7/27/2019 JCIA Q & A 2010
174/674
How do you provide for coordination among the
healthprofessional(s) and service(s) or setting(s) involved in
patient care?
-
7/27/2019 JCIA Q & A 2010
175/674
Describe the informed consentprocess on your unit. Who must
inform the patient about operativeand other procedures, and what
mustthe patient understand prior to
signing an informed consent?
-
7/27/2019 JCIA Q & A 2010
176/674
Is there a discharge planner available on the weekends
andholidays? If not, what education
has your staff received regardingordering of home health
supplies?How does the discharge processwork in this instance?
-
7/27/2019 JCIA Q & A 2010
177/674
Who on this patient care unit isapproved to take verbal or
telephone orders? When must theorder be signed by the
orderingphysician?
-
7/27/2019 JCIA Q & A 2010
178/674
What procedures are used to guidethe care of patients in
restraint and
seclusion? How do you know thatstaff members follow the
guidelines,when restraint and seclusion are
used in the care if a patient?
-
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Can restraints be initiated by an R.N?
-
7/27/2019 JCIA Q & A 2010
180/674
What must the physician order
include for the use of restraints?
-
7/27/2019 JCIA Q & A 2010
181/674
How long is an order for
Medical/Surgical restraint on apatient valid?
-
7/27/2019 JCIA Q & A 2010
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if a patient is restrained for suddenaggressive behavior, how
soonmust the patients is assessed face-to-face by the physician and
howlong is the restraint good for?
-
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Who is responsible for monitoring resuscitation (CodeBlue)
outcomes and how oftenis this performed?
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How can you be certain that acrash cart on a different unit
isstocked the same as the cart onyour unit?
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How often do the Nurses checkthe contents of all crash cart?
-
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What is your visitation policy?
-
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What is the process if you
suspect a patient is an abusevictim?
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Do you have access to nutritionfor patients after dietary
isclosed?
-
7/27/2019 JCIA Q & A 2010
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Describe what steps are taken in
the care of theimmunosuppressed patient
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Describe the process for performing a test or procedure ona
patient with a behavior management problem?
-
7/27/2019 JCIA Q & A 2010
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What is your hospital s policy
regarding organ donation? Whattissue bank do you report to?
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If your facility does not treatpatients suffering from
mentalillness/behavior problems, whatwould staff do if it
becameapparent that a patient with a
medical/surgical illness was inneed of mental health care?
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Can a physician write a PRNorder for restraints?
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How are patient rights, dignity
and well-being protectedduring an episode of restraint?
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Where are patientassessments/interventions relatedto restraints
documented?
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How staff are trained in theproper use of restraints?
-
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What is available for foodpreferences for patients of other
cultures/religions?
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ANESTHESIA & SURGICAL CARE
-
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What do you do if you discover thepatient does not have a
signed,
informed consent in the medicalrecord prior to surgical
procedure (ascenario where the patient is in the
surgical preoperative holding area):
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Where is IV conscious sedation
given? Are patients receivingconscious sedation recovered
thesame as surgical patients?
-
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Are medical staffs privileged togive conscious sedation? If
not,
how are you sure they arecompetent to provide thisservice?
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Do you document informedconsent for anesthesia? How are
you sure the patient has beengiven information about all
risks,options and alternatives?
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How do you know which
procedures present a potentialfor blood transfusion?
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7/27/2019 JCIA Q & A 2010
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What are the criteria for discharge from the PACU?
-
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How are surgical casesreviewed? Who determinesthe criteria used
in the review?
-
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Are individuals administeringsedation and
anesthesiaqualified?
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Is pre anesthetic evaluationpreformed prior toadministering
sedation or anesthesia?
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Is anesthesia care of eachpatient planned anddocumented in the
patient
record before the patientreceives the anesthesia?
Whatinformation is included in theanesthesia plan of care?
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Are anesthesia risks, potentialcomplications, and options
discussed with patients andtheir families prior toadministering
anesthesia?
-
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Is each patient s psychologicalstatus during anesthesia
administration continuouslymonitored and documented inthe
patient s record?
-
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Describe the process for monitoring patients during
thepost-anesthesia recoveryarea?
If moderate and deep sedation
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considered a high-risk procedurein your organization? If so,
aredata collected and intensively
analyzed from a risk managementprospective, when
significantunexpected events andundesirable trends and
variationoccur?
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How do you recover patients if
they have received conscioussedation?
-
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Are all physicians allowed toorder and administer moderateto
deep sedation (conscioussedation)?
-
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What policies and procedureshave been established to guide
the
care of those patients undergoingmoderate or deep sedation, if
usedin the area?
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What are the qualifications of the individual responsible
for
monitoring the patientundergoing moderate or deepsedation?
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Why is it important to assess
reversal agent use?
-
7/27/2019 JCIA Q & A 2010
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How do you know the physicianperforming the endoscopy
procedure is privileged andcompetent?
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What processes are in place toprevent surgery on the wrong
body part or wrong side of thepatient s body?
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What is your policy on allowingrepresentatives from
equipmentmanufacturers into the Surgical
Services Department? Are theseindividuals allowed to
observeprocedures? Are they allowed toparticipate in
procedures?
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What are the minimal preoperative
testing requirements for all surgicalpatients?
-
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Is a plan of anesthesia careformulated and communicatedamong
care providers prior toadministering anesthesia?
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Are anesthesia options and risksdiscussed with patients and
their families prior to administeringanesthesia?
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Are patients discharged from thepost anesthetic recovery area
byan anesthesiologist or other
qualified individual or by aqualified individual who
appliescriteria and discharges thepatient?
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Describe how you monitor
patients during the post-procedure period.
-
7/27/2019 JCIA Q & A 2010
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How is pain managed for thePACU patient? How can staff
determine if the patient justemerging from anesthesia is
trulyhaving pain?
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Are patient family membersallowed in the PACU? Arethere ever any
specialcircumstances regarding this?
-
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MEDICATION MANAGEMENT & USE
-
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What has the medical staff
done with ADR reports toimprove the care of patients?
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What ADR trends have youidentified? What type of follow-up do
you do? What is your
ADR rate?
-
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How are medication errors reported?
-
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What is your medication error rate? How does this comparewith
other organizations?
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How are food-drug interactions
reported?
-
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How do you educate patientsabout food-drug interactions?When do
you provide theeducation?
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Are patient profiles from the
Pharmacy available to allcaregivers?
-
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How does nursing staff obtain
needed medications when thePharmacy is closed?
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What is your policy on self-administered drugs by patients?
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Describe how you monitor selection, ordering,
preparation,administration and medicationeffect on the patient as
part of your performance improvement
program:
-
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How do you knowyour Pharmacy issecure?
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Describe your controlled
substance protocol
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How are controlled substancesused by anesthesia tracked?
-
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Do storage, distribution,and control of medicationsreflect
policies andprocedures?
Has the organization planned for emergency medications to be
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located in ambulatory or outpatientclinics? When present, what
is the
procedure used to prevent abuse,theft, or loss of the
medication?What is the process to replaceemergency medications when
used,damaged, or out-of date?
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How do you determine if patients are usingalternative
medicines(herbals, etc.)?
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What do you do toobtain medicationsafter hours?
-
7/27/2019 JCIA Q & A 2010
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Do you as staff members feelcomfortable reportingmedication
errors?
-
7/27/2019 JCIA Q & A 2010
252/674
How do you managepediatric medicationdosing in an
emergencysituation?
-
7/27/2019 JCIA Q & A 2010
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How often is your resuscitation cart checked?
-
7/27/2019 JCIA Q & A 2010
254/674
How do you comply with therequirement that medicationorders are
to be reviewed by apharmacist prior to patientadministration when
the
Pharmacy is closed?
How do you assure that only medicationsthat are needed for
emergent or urgent
d b d d
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patient needs are obtained andadministered when the Pharmacy
isclosed (i.e., when a patient is admitted at2:00 AM. with orders
for medications andthe Nursing Supervisor fills these orders,how
are you sure only those medicationsthat are of urgent/emergent need
areobtained)?
Do you monitor illegible
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handwritten physicianorders? Have you identified
any problem areas? If so,have you been able toachieve
improvements in thisarea?
ib i i d d i
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Describe training and educationprovided regarding
cardiopulmonary resuscitation of patients and the Pharmacy staff
s involvement with this
-
7/27/2019 JCIA Q & A 2010
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Who is responsible for checking
medication refrigerators?
-
7/27/2019 JCIA Q & A 2010
259/674
What is the PharmacyDepartment s role in painmanagement?
-
7/27/2019 JCIA Q & A 2010
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-
7/27/2019 JCIA Q & A 2010
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How medication recalls are handled?
Wh i di i
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7/27/2019 JCIA Q & A 2010
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Who monitors medicationswasted in anesthesia? How
are controlled drugs managedin the Surgical Services area?
-
7/27/2019 JCIA Q & A 2010
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H di i
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7/27/2019 JCIA Q & A 2010
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How are medicationerrors being tracked
and does this processinclude prescribingerrors?
Wh t ti
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What are your narcoticdiscrepancies during the last sixto twelve
months? Have younoted any trends? What is thePharmacy Department
doing to
improve discrepancies?
H di ti
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How are medication useprocess organized throughoutthe
organization? What is theprocess for overseeingmedication use in
the
organization?
D h li t f
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Do you have a list of medications stocked in theorganization?
What is themethod for overseeing thelist?
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How do you obtain neededmedications not stocked or normally
available to theorganization?
Are written policies andd d id
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procedures used to guideprescribing, ordering,
administration, and monitoring of medications? Are the
uniformlyused throughout the organizationwhere medications are
used?
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Describe the hospital s use of verbal medicalorders?
-
7/27/2019 JCIA Q & A 2010
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Who is permitted toprescribe and order medications?
Is the self administration of
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7/27/2019 JCIA Q & A 2010
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Is the self-administration of medications permitted in the
organization? How do youensure that it is done safely,when
permitted?
-
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What is done with anymedications that are brought
into the organization for or bythe patient?
-
7/27/2019 JCIA Q & A 2010
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Who is responsible for supervising the storage,
preparation, and dispensingof medications?
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7/27/2019 JCIA Q & A 2010
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How do you ensure thatmedications are dispensed in
a form requiring minimalmanipulation?
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How do you identify patientsbefore medications
areadministered?
How are medication errorsreported? What time frame must
di ti i t d? Wh t
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medication errors is reported? Whathave you learned from the
aggregation and analysis of medication error data? What, if
anychanges have been made in themedication use processes from useof
this information?
Wh t ld d if
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What would you do if youfound that the emergency
box or crash cart wasunlocked?
-
7/27/2019 JCIA Q & A 2010
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Describe how the medicationorders are processed for your
hospital.
-
7/27/2019 JCIA Q & A 2010
281/674
How are drug storage areas checked?
-
7/27/2019 JCIA Q & A 2010
282/674
Is there an automaticstop policy at your
hospital? How does itwork?
Who is approved to mix Kcl?Who is approved to administer
-
7/27/2019 JCIA Q & A 2010
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Who is approved to administer this drug and monitor the
patient?
How do you know that staff member is competent to managethe type
of patient who requires
this medication?
-
7/27/2019 JCIA Q & A 2010
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What is your policy for use of multi-dose vialsof
medications?
-
7/27/2019 JCIA Q & A 2010
285/674
How do policies and procedures
support safe medicationprescription and ordering?
-
7/27/2019 JCIA Q & A 2010
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How are adverse
medication effects noted inthe patient s record?
-
7/27/2019 JCIA Q & A 2010
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U d h t i t
-
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Under what circumstances maythe inpatient nurse give a first
dose of medication to a patientprior to the pharmacist review of
the medication order?
-
7/27/2019 JCIA Q & A 2010
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PATIENT & FAMILY EDUCATION
H d h i
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7/27/2019 JCIA Q & A 2010
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How do you assess the patient s and familys education needs,
their ability and readiness tolearn?
When appropriate, are patientsgiven instruction on the safe
and
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given instruction on the safe andeffective use of
medications,including potential interactionsbetween medications and
food,nutritional guidance, safe use of
medical equipment, andrehabilitation techniques?
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-
7/27/2019 JCIA Q & A 2010
293/674
-
7/27/2019 JCIA Q & A 2010
294/674
-
7/27/2019 JCIA Q & A 2010
295/674
How do you identify thepatient/family need for education?
-
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7/27/2019 JCIA Q & A 2010
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How do pharmacy and nutritional
services work together in patientand family education?
-
7/27/2019 JCIA Q & A 2010
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How the family is educated on
how to assure compliance andcontinued care?
-
7/27/2019 JCIA Q & A 2010
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What questions can you ask your patients to determine their
level of understanding
-
7/27/2019 JCIA Q & A 2010
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When do you start to educatethe patient?
-
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How are patients educated about
Food Drug Interactions?
Are the patients given
-
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Are the patients giveninstructions on the safe and
effective use of medicalequipment, when required?
-
7/27/2019 JCIA Q & A 2010
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How do you educate thepatient s family about restraintuse?
-
7/27/2019 JCIA Q & A 2010
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How do you know
patient/family teaching hasbeen effective?
H i d d
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7/27/2019 JCIA Q & A 2010
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How are patients educatedregarding their responsibility insafety
issues pertinent to their care?
-
7/27/2019 JCIA Q & A 2010
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At time of patient discharge, whatis done in terms of educating
thepatient/family?
-
7/27/2019 JCIA Q & A 2010
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What type of pre-procedureeducation is provided to
thepatient?
-
7/27/2019 JCIA Q & A 2010
308/674
What type of post-procedure
education is provided to thepatient?
-
7/27/2019 JCIA Q & A 2010
309/674
Describe your patient educationprocesses, including
preoperativeand postoperative education
-
7/27/2019 JCIA Q & A 2010
310/674
How does staff on this unit assessthe learning needs and
barriers of the patient?
-
7/27/2019 JCIA Q & A 2010
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QUALITY IMPROVEMENT &PATIENT SAFETY
b h h l l
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Describe the hospital s sentinelevent policy and the procedure
for reporting events to the JCI.
H h d ti l t
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7/27/2019 JCIA Q & A 2010
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Have you had a sentinel event or near miss occurrence?
Whatprocedural changes have youinstituted following an event?
Does the unit get information back
-
7/27/2019 JCIA Q & A 2010
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gfrom indicators? If yes how do you
use the information? What impacthas the data had on your
operations?
-
7/27/2019 JCIA Q & A 2010
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What information is available
relative to patient satisfaction withthe services provided?
-
7/27/2019 JCIA Q & A 2010
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How have leaders
implemented a patient safetyprogram?
Does the organization have a
process to intensively assess datawhen significant
unexpected
-
7/27/2019 JCIA Q & A 2010
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p ywhen significant unexpectedevents and undesirable trendsand
variation occur?Describe which types of eventswould be included in
this intensiveanalysis.
How do the selected KPI
-
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measures focus on your
organization s mission, visionand improvement
planningstrategies?
How was your organization s staff
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y gtrained on the KPI initiative?(This question includes
collectionof data, analysis and use of data.)
-
7/27/2019 JCIA Q & A 2010
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How measure selections were
communicated to staff?
Outline your organizational
-
7/27/2019 JCIA Q & A 2010
321/674
Outline your organizationalperformance improvement
program (how program isimplemented and how it works)
-
7/27/2019 JCIA Q & A 2010
322/674
What is your method or model
of performance improvement?
-
7/27/2019 JCIA Q & A 2010
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Explain how your organization
plans and designs new or redesigns, existing processes
Explain the types and methods of
-
7/27/2019 JCIA Q & A 2010
324/674
Explain the types and methods of data collection you perform
for
performance improvementpurposes
-
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-
7/27/2019 JCIA Q & A 2010
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When does Leadership analyzecurrent performance? How is
thisconducted?
-
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Describe actual improvements
-
7/27/2019 JCIA Q & A 2010
328/674
Describe actual improvementswithin the facility or community asa
result of performanceimprovement activities
Are quality Improvement and
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7/27/2019 JCIA Q & A 2010
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q y ppatient safety activities carried out
in a collaborative fashion amongdepartments and disciplines?
-
7/27/2019 JCIA Q & A 2010
330/674
How do leaders prioritize the
-
7/27/2019 JCIA Q & A 2010
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processes to be monitored? How
do leaders prioritize thoseprocesses and activities to
beimproved?
-
7/27/2019 JCIA Q & A 2010
332/674
What data are collected about
the Patient assessment?
-
7/27/2019 JCIA Q & A 2010
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What data are collected
about the use of anesthesia?
-
7/27/2019 JCIA Q & A 2010
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Do you monitor the use of
blood and blood products?
-
7/27/2019 JCIA Q & A 2010
335/674
Do you monitor staff
expectations and satisfaction?
Have you identified any issuesform monitoring patient and
family
-
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g p yexpectations and satisfaction of
their care? What if anything, haveyou changed as a result of
thisinformation?
Wh if hi h l d
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7/27/2019 JCIA Q & A 2010
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What if anything, have you learned
from monitoring the use of antibiotics and other
medications?
d k h
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7/27/2019 JCIA Q & A 2010
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How do you know that
improvements in quality and safetyis achieved and sustained?
H d h i t h t
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7/27/2019 JCIA Q & A 2010
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How do you have input on whatshould be improved in your
area?
Wh t f th
-
7/27/2019 JCIA Q & A 2010
340/674
What were some of theaccomplishments in the pastyear?
-
7/27/2019 JCIA Q & A 2010
341/674
What is everyone s responsibility
in data collection?
If our hospital should need toscale down its efforts for any
of
i h i i
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7/27/2019 JCIA Q & A 2010
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various reasons, what criteria
would the performanceimprovement and patient safetycouncil use
to prioritize the
minimal efforts to be continued?
What are clinical guidelines and
-
7/27/2019 JCIA Q & A 2010
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What are clinical guidelines andhow do they affect the outcome
of the patient?
What are some examples of
-
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pclinical protocols at our facilitythat have been
successfullyimplemented?
What are some clinical protocols
-
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that we are working on and
planning to implement within thecoming year?
What types of outcome indicators
-
7/27/2019 JCIA Q & A 2010
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What types of outcome indicatorsare being monitored by
NursingServices?
How have departmental staffs
-
7/27/2019 JCIA Q & A 2010
347/674
How have departmental staffsbeen educated about
sentinelevents?
Wh t l d
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7/27/2019 JCIA Q & A 2010
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What role does your
department play in improvingpatient safety?
Do the members of your d f l f bl
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department feel comfortable
reporting medical/health careerrors?
H d h d
-
7/27/2019 JCIA Q & A 2010
350/674
How and when do you report
a medical/health care error?
-
7/27/2019 JCIA Q & A 2010
351/674
What is a sentinel event?
Who has responsibility for the
-
7/27/2019 JCIA Q & A 2010
352/674
Who has responsibility for theimplementation of the
QualityManagement System?
How often is the Quality Management
-
7/27/2019 JCIA Q & A 2010
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Q y gSystem reviewed and what were theresults of your last
review?
-
7/27/2019 JCIA Q & A 2010
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What is OVR?
-
7/27/2019 JCIA Q & A 2010
355/674
How do you report incidents?
-
7/27/2019 JCIA Q & A 2010
356/674
Who should fill out Incident Reports?
-
7/27/2019 JCIA Q & A 2010
357/674
To whom do you report incidents?
-
7/27/2019 JCIA Q & A 2010
358/674
What is a "Near Miss"
-
7/27/2019 JCIA Q & A 2010
359/674
PREVENTION & CONTROL OF
INFECTIONS
What procedures are in place to
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p preport infections when they havebeen identified?
What action has the hospital taken
-
7/27/2019 JCIA Q & A 2010
361/674
pto reduce the risk of or preventnosocomial infections?
-
7/27/2019 JCIA Q & A 2010
362/674
Is surgical site surveillance conducted?
-
7/27/2019 JCIA Q & A 2010
363/674
What has been improved as a
-
7/27/2019 JCIA Q & A 2010
364/674
result of your infection control andsurveillance program
efforts?
ff d d b
-
7/27/2019 JCIA Q & A 2010
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How are staffs educated about
categories of isolation?
What is the most common isolation
-
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category implemented in thisinstitution?
What type of education has beenprovided to staff regarding
the
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p ov ded to sta ega d g t eBlood borne PathogensStandards and
the Needle StickPrevention Act?
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What is your staff needle stick rate?
How infectious diseaseconsultations are managed? Ish ifi i i
i
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there a specific criterion or triggers,
or is the process dependent uponspecific request by the
InfectionControl Nurse?
What types of prevention activities
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What types of prevention activities
are currently in process?
What role does the InfectionControl Nurse, program and/or
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committee play in relationship topatient safety activities
conductedat this institution?
As the Infection Control
Nurse/Epidemiologist do you workfull time? If not, how many
hours
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, yper week do you work? How didyou arrive at this ratio of
hours?How do you know it is sufficient for
the facility?
Has this institution experienced
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pany outbreaks during the past 12months?
Have you treated any patients with
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Have you treated any patients with
tuberculosis?
How many negative airflow rooms
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How many negative airflow rooms
do you have?
How is Employee Health related
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p yto the Infection Control Program?
How do you prevent
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transmission of infections frompatients to staff?
Describe your waste managementprogram as it relates to the
handling
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program as it relates to the handling
of infectious waste?
Describe how your infectioncontrol activities are integrated
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control activities are integrated
with the hospital s performanceimprovement activities
Describe the resources availableto you, such as
professionaljournals related to infection
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journals related to infection
control, internal and externaldatabases, professional
library,CDC and APIC data
Why is there an infection control
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Why is there an infection control
program?
What single action is recognizedby the CDC (center of
diseasecontrol and prevention) as the
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control and prevention) as the
most effective means of preventing the spread of infection
within a facility
What does the term of Standard
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What does the term of Standard
Precaution mean?
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What is personal protectiveeq ipment? Name an e ample and
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equipment? Name an example and
when you should use.
If a patient has an infection whichrequires isolation where
would
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requires isolation, where would
you find information regarding thetype of isolation
required?
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What immunizations are available
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to our employees?
What precautions are taken for
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patients with known or suspectedTB?
D dl ?
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Do you recap needles?
H d di f h ?
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How do you dispose of sharps?
Who is on your infection controlcommittee? How do you
utilize
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committee? How do you utilize
these persons?
What types of surveillance, other
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than infections, are you doing?
Have there been any areas of concern for possible infectionsin
the last year such as
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in the last year such as
construction and what did youdo about it?
H IC P g d l d?
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How was your IC Program developed?
What is the most prevalent infectionseen in your hospital? How
is it
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seen in your hospital? How is it
addressed?
What do you do with theinformation (re infections) you
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information (re. infections) you
gather?
Where do you get the data (re:infections within the
hospital,
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nosocomial and communityacquired)?
What hand hygiene training is
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provided to staff and patients?
Is there a competency for handwashing/use of alcohol
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washing/use of alcohol
agents?
What preventive efforts ared i i l h l h?
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you doing in employee health?
What questions do you ask onyour employee medical
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your employee medical
assessment?
What is your program in preventinginfections in donated organs
and
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g
with organ procurement.
How do you report to theHealth Department and
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Health Department andwhat/when etc.
How is infection data presented
-
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up and down in the institution?
What is your action if youprick yourself with a dirty
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prick yourself with a dirty
needle?
Have you had any sentinelevents related to infection
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events related to infection
control?
Where are your hot spots? Whatinterventions did you use toreduce
the risk of infections? Who
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was involved? Are you monitoringthe changes?
Tell me about your employeehealth program. Do you have
much TB in this area? Have youhad any conversions in the
lastyear? What percentage of your
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year? What percentage of your staff had their PPD last year?What
are the major issues inemployee health? Tell me aboutyour flu
vaccine initiative.
Do you re-sterilize any single used i ? Whi h i ?
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devices? Which items?
Asked staff about blood spill kits,yearly Infection Control
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yearly Infection Control
education
How do you get information backfrom the physicians
concerning
-
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p y g
post-op infections/SSIs?
Who do you network with locally?
-
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Who do you network with locally?
Where do you refer patients to or consult with concerning
infectious
-
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g
disease?
Asked about prophylactic pre-operative antibiotic usage and
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p g
trends.
With so much out-patient surgerybeing done, how do you find
out
h t t i f ti t
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what your post-op infection ratereally is?
In current literature, there has beennoted an increase of
cross-contamination due to computer
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p
hardware. Have you come acrossthat?
Speaking to operating roomrepresentative: What do you
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representative: What do you
decontaminate?
What plans do you have for d t i ti
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decontamination
For clinical personnel, whatare o doing abo t nails?
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are you doing about nails?
What information do your employees have about blood
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p y
exposures?
How often do you do infectioncontrol rounds and with whom?
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control rounds and with whom?
For HIV text, how quickly do youget the results back?How and
when do you start anexposed employee on prophylactic
di i ?
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medications?Going back to HIV, have you had toput exposed
employees on
drugs? How were they exposed?
What is IC's role in construction?
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Monitoring of air quality and water
quality---who did it, how often,where was it reported, what wasb
i d i thi d i
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being done in this area duringconstruction, did we have
backupplans for disruption of services, etc.
Explain your process for
sterilization of equipment /instruments, including flasht ili ti
Wh t t f
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sterilization. What type of documentation do you keepregarding
sterilization?
How do you manage an infectiouspatient in the OR?
Whatprecautions are undertaken to
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p
prevent spread of the infection inthe sterile environment?
What type of measures or policiesdo you have in place to
preventnosocomial infections as a result
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nosocomial infections as a resultof food or nutrition?
What type of orientationregarding food safety is providedto new
Nutritional Care Services
-
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to new Nutritional Care Servicesstaff?
How do you manage patients withinfections? How do you
preventnosocomial outbreaks within the
-
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nosocomial outbreaks within thedepartment and hospital wide?
Do you ever use non-disposablesuture kits? If so, what is thel i
d h d
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cleaning process and who doesthis?
Describe the following:
The process for reportinginformation about infections;and
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and Actions you have taken to reducethe risk of or prevent
nosocomial
infections.
How are instruments cleaned?
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What type of personal protectiveequipment is used when
cleaning
-
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equipment?
How are you sure the room wherecleaning is performed is safe for
personnel and that they are not
-
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personnel, and that they are notexposed to chemicals?
Describe the disposalprocess for anatomical
-
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remains
What types of infectious patientshas staff dealt with in the
PACU?What is the process for preventing
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nosocomial infection in thisenvironment?
Do risk reduction procedures and
processes address engineeringcontrols, such as
positiveventilation systems biological
-
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ventilation systems, biologicalhoods in laboratories,
andthermostats on water heaters?
What situations require the useof masks and gloves?
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g
Describe the processes for tracking nosocomial infection
risks,
-
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rates, and trends?
How do you dispose of infectiouswaste?
-
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waste?
When should you wash your hands?
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How do you handle soiled linen?
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GOVERNANCE, LEADERSHIP &DIRECTION
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How is the hospital s mission and
vision communicated to all hospitaland medical staff? How do
thehospital leaders know they have
-
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p yeffectively communicated themission/vision?
Describe your hospital s planningprocess and describe how
thisrelates to your mission and vision
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ystatement
What patient outcomes have youbeen able to improve based on
your
-
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KPI data measurements?
Describe how the hospital has
established processes that definethe qualifications,
responsibilities,competencies and staffing required
-
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p g qfor supporting and maintaining itsmission
Do you have a conflict of interestpolicy? Describe your process
for addressing conflict of interest in the
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gfacility
Describe how you are certain thatservices provided to patients
relates
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to their identified needs
Describe how you have planned tocoordinate administrative
withclinical decisions for patients that
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you may receive that are under legal or correctional
restrictions
Describe how departments haveestablished goals and scopes of
-
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service
How was your hospital-wide planfor providing patient
caredeveloped? Who was involved in
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the development? How did youimplement this plan?
Describe how hospital-wide policiesare developed and who is
involved
-
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in the development
Do patients with like healthcareproblems and needs receive
thesame quality of care throughout the
-
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q y ghospital? How are you sure of this?
How do you assure that patients
requiring tests, services or procedures not provided by your
hospital receive the necessary
-
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p ycare? Describe the medical staff s involvement in this
process
Describe how performanceimprovement priorities are
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established
Describe which individuals areinvolved in the planning process
for the operating budget and long term
-
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p g g gcapital budget
Describe your hospital s approach to
performance improvement. How areplanning the improvement
process,setting priorities and assessing
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g p gperformance in a systematic manner included?
Describe how your facility maintainsachieved improvements
-
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How were performanceimprovement expectations
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established?
What important internal processesand activities are continuously
andsystematically assessed and
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improved throughout your facility?
How were the leaders in theorganization educated
regardingperformance improvement
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p papproaches and methods?
Who establishes and evaluatesthe responsibilities of
department/service directors?
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pHow is this done?
What types of resources areallocated for assessing andimproving
the hospital s
-
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governance, managerial, clinicaland support activities?
Explain how the leaders assessthe effectiveness of their
contributions toward improving
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p gperformance
Describe your process thatassures that the competence of all
staff members is assessed,
-
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maintained, demonstrated andimproved on an ongoing basis
Describe your staffing plan, andexplain how you assess
actualstaff provided against projected
-
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staffing
Describe how your facilitypromotes personnel self-
-
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development and learning
-
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How are leaders involved inassuring that billing and
marketingpractices are conducted in an
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ethical manner?
How can you be sure your dischargeand transfer practices are
conducted
-
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in an ethical manner?
Have you started a new patientcare service recently?
Have there been any existingservices that have
undergonesignificant change recently?
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g g yDescribe the processes involved inimplementing this new
service/this
recent change in service
Describe your restraint policy.How do the leaders of the
facilityensure that only limited, justified
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restraint or seclusion use isconducted?
Describe the patient and familyeducation processes in place
in
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your institution
Explain the process you as leadersuse to approve the policies
andplans used to operate your
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organization.
What is a recent example of howthe governance of
thisorganization has supported and
-
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promoted quality managementand improvement efforts?
How do you monitor the servicesoffered by an outside
organizationwith which you have a contract to
-
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provide services?
What is your process for identifying in writing the
servicesprovided by each department?
-
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How do you know the documentsare current?
When did the organization last testits community-wide disaster
plan?What changes, if any, did you
-
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make in the plan as a result of testing?
Discuss the processes for staff recruitment, retention and staff
development and continuing
-
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education.
How do leaders support theoversight of professional ethical
-
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issues?
What is mission statement?
-
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What does your hospital missionstatement mean to you?
-
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What is your definition of quality?
-
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Who are your customers?
-
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How do you decide on Boardmembers?
-
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How do you evaluate Boardmembers? Do you have a formal
-
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process to evaluate the Board?
What have you done concerningergonomics?
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How do you protect the integrityof clinical decisions?
-
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Tell me about your organdonation program
-
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How does the community let youknow their needs?
-
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How do you measure if you aremeeting community needs?
-
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Tell me about your population?
-
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What are the job requirements of the medical director?
-
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Asked medical director about performance
-
7/27/2019 JCIA Q & A 2010
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improvement activities
What type of feedback do youget from patients?
-
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What barriers make it difficult toobtain needed staff?
-
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Does the hospital have an effectivemechanism to ensure that
licensedindependent practitioners function
i hi h f d
-
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within the scope of grantedprivileges?
-
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How are recommendations toappoint or reappoint practitioners
d h G i B d ?
-
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made to the Governing Body?
What is the criteria for initialappointment and how was this
i i d l d?
-
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criteria developed?
What are the criteria for granting,renewing and/or revising
clinical
i il ?
-
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privileges?
How are you sure that individualswith clinical privileges
provideservices within the scope of thoseprivileges? Are privilege
lists
d d fl h i
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updated to reflect changes inprivileges, technology or
clinicalpractice?
Do decisions on reappointmentor revisions or renewal of
clinicalprivileges consider criteria that
di tl l t d t lit f
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are directly related to quality of care? Explain
Describe your peer reviewprocess and how this impacts
th d ti li f ti
-
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the credentialing function
What is the process if theGoverning Body declines amedical staff
recommendation for
i t t i t t?
-
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appointment or reappointment?
Does the competency review attime of reappointment include
thepractitioner s ethical behavior
tt ?
-
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patterns?
What mechanism does your medical staff have in place toassure
all practitioners are treatedf i l ?
-
7/27/2019 JCIA Q & A 2010
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fairly?
How do you know the members of the Credentials Committee
arecompetent and knowledgeable to
f th i d ti itt
-
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perform their duties as a committeemember?
How often your privilege listsare revised?
-
7/27/2019 JCIA Q & A 2010
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What process does your medicalstaff have in place to
accurately
assess outcomes from a statisticalstandpoint? (i.e., for
thoserequesting surgical privileges, attime of reappointment do o
list
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time of reappointment do you listnumber of procedures
performedversus number of complications)
How you are sure informationregarding any medicalmalpractice
judgments iscommunicated at time of
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appointment or reappointment?
What does a department director doif he/she has no
personalknowledge of an applicant for reappointment and there are
nomembers with knowledge of the
practitioner on the committee
-
7/27/2019 JCIA Q & A 2010
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practitioner on the committeereviewing privilege requests,
tomake a determination regarding thepractitioner s competence?
How is Nursing Leadershipinvolved in the budget process?
-
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How is Nursing Leadershipinvolved in improving patient
satisfaction?
-
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satisfaction?
How much input does NursingServices have in hospital wide
decision making processes?
-
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decision-making processes?
How do you contain and controldepartmental costs?
-
7/27/2019 JCIA Q & A 2010
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How is peer review for theMedical Director of the Clinical
Laboratory performed?
-
7/27/2019 JCIA Q & A 2010
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Laboratory performed?
How do your leaders define thefollowing:
The qualifications andresponsibilities of staff working in
this setting;
A system to evaluate how well
-
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A system to evaluate how wellstaff responsibilities are met;
andThe number of staff needed to fill
the setting s mission?
How does the departmentmanager determine if staff iscompetent to
perform assignedduties, and when appropriate,
provide care for the special needs
-
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provide care for the special needsand behaviors of specific
agegroups?
FACILITY MANAGEMENT &SAFETY
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Have staff educated and trainedabout their roles in providing
asafe and effective patient carefacility, including their roles in
theorganization s plans for fire safety,
it h d t i l d
-
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security, hazardous materials, andemergencies?
Have you maintained, tested, andinspected medical equipment
in
this setting?
-
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this setting?
How have the ambulatorycare/outpatient clinics been involvedin
the risk assessment and planningactivities for utility systems,
includingthe identification of areas and
services at greatest risk when powerf l d
-
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services at greatest risk when power fails or water is
contaminated or interrupted? How have the risks of
such events been reduced?
Information on hazardous materialis located where?
-
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What has the Safety Officer s rolebeen in developing
departmentand organization safety policies,
procedures and performance?
-
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procedures and performancemeasures?
Has the safety officer worked withappropriate staff to
implementrecommendations and monitor
their effectiveness?
-
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their effectiveness?
What performance measure hasbeen prioritized by the
SafetyCommittee for recommendation
to the Performance ImprovementC itt ?
-
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to the Performance ImprovementCommittee?
How does the Safety Committeeinteract with other hospital
committees?
-
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committees?
How is information on incidentshandled? How does informationget
to the Administrator/CEO?How does information get to theGoverning
Body?
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Governing Body?
Describe how the organizationprovides for the security of
patients and personnel
-
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patients and personnel
Describe your most challengingsecurity issue: How are you
meeting this challenge?
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meeting this challenge?
What is the process for selectionof hazardous materials for use
inthe organization? Who approvesthese materials?
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these materials?
What are the hazardous
chemicals used in the hospital?Who is responsible for
trainingthe employees? How do you
know training has occurred and
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know training has occurred andis effective?
Where is the master list of
MSDSs kept? Are unit specificMSDSs kept on individual
units?(Surveyor may request specificMSDS and time staff s
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MSDS and time staff s response.)
What is the hospital s role incommunitywide emergency
preparedness/management?
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preparedness/management?
What is the procedure youfollow when a bomb threat
isreceived?
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538/674
How are physicians oriented andeducated about life
safety?(Surveyor may ask for
documentation verifying physician
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documentation verifying physicianeducation.)
Describe the emergencyprocedures that are in place inthe event
of a utility systemdisruption or failure
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disruption or failure
What are the PM completion rates?
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What is your
