Appalachian Regional Healthcare System 2018
EMPLOYEE REFERENCE GUIDE FOR JOINT COMMISSION - Hospital 2 TABLE OF CONTENTS
I. Leadership
II. Patient Rights and Organizational Ethics
III. Management of the Environment of Care Safety
IV. Surveillance, Prevention and Control of Infection
V. Management of Human Resources
VI. Management of Information
VII. Patient Safety
VIII. Improving Organizational Performance
The following sections are for Clinical Staff Only
IX. Provision of Care
X. National Patient Safety Goals
XI. Medication Management
Who is the Joint Commission?
The Joint Commission conducts evaluations and makes recommendations for hospital safety and quality of patient care. Surveys are conducted every three years. It is very important that we do well because the Joint Commission accreditation is closely linked with our ability to participate in managed care contracts and the Federal Medicare program. Obtaining Joint Commission accreditation is another way we communicate our dedication to quality, compassionate care to our community. Appalachian Regional Healthcare System hospitals will be surveyed sometime in 2018 and the survey will be completely unannounced. As a hospital, we are committed to meeting every standard, everyday, because it’s the right thing to do.
Any questions about the interpretation of Joint Commission standards should be directed to your manager or to Angie Hicks (262-4239 or [email protected]).
How will the survey be conducted?
In 2004, The Joint Commission began using what is referred to as “tracer” methodology. What this means is that surveyors will pick several patients and “trace” their care through the hospital, asking questions about things that happened to them along the way. For instance, if a patient came through Outpatient Surgery for a surgical procedure, they will go and interview staff about how they prepare a patient for surgery. They might then visit the OR and review issues with the OR staff about how they handle surgical procedures. Then they would go to a medical surgical floor and/or an ICU. They will also go to treating departments such as radiology or the cath lab. THE SURVEYORS WILL TALK TO STAFF MUCH MORE THAN TO MANAGERS AND ADMINISTRATORS. THEY WANT TO KNOW THAT YOU KNOW YOUR JOB AND ARE AWARE OF THE STANDARDS.
WHAT SHOULD YOU DO IF THE JOINT COMMISSION SURVEYOR ASKS YOU A QUESTION?
Stop…Smile…Take a deep breath…Think about the question and answer it.
If you don’t know the answer, tell the surveyor that you know where to find the answer and will get back to them. You have many resources to find the answer!
Helpful Hints 1. Don’t be intimidated! You know your job the best! 2. Review this handbook carefully so you feel prepared. 3. Talk about this information within your department. 4. “What if I am asked a question by a The Joint Commission surveyor?” Give the correct answer in your own words. If you don’t understand the question, ask for clarification. If you don’t know the answer, it is okay to admit it. You can tell or show them where you can find the answer. (e.g., Intranet resources, manuals, supervisors, policies) Be positive and friendly! DO NOT ARGUE WITH THE SURVEYOR! Graciously accept suggestions by the surveyor. 5. When the surveyor arrives, don’t scatter – it gives a surveyor a false impression you are not prepared, and we know you are prepared! 6. Wear your nametag so that it can be read! 7. Do not discuss patients while in public places. 8. Keep open charts away from public view. 9. Make sure protected information is not up on a computer where visitors can see it. 10. Always wash your hands prior to and after patient care.
11. Maintain privacy at all times for all patients. 12. Clean/clear hallways. 13. Cover all clean, unused linen. 14. Know your fire safety answers and responses. 15. Know the National Patient safety goals and how they relate to your department. 16. Document per policy and accurately; if you didn’t document it, you did not do it. 17. Be able to describe what your role is and how you are competent to perform your job. 18. Be able to answer a question about Performance Improvement, “How have you improved care on this unit/department?”
WHAT WILL THE JOINT COMMISSION BE SURVEYING?
In general, the following are the major areas looked at:
Patient Care Issues
o Patient Rights and Ethics o Assessment of Patients o Patient and Family Education o Discharge Planning o National Patient Safety Goals o Communication o Equipment Use o Medication Management
Organizational issues
o Performance Improvement o Information Management o Environment of Care o Human Resources o Medical Records o Infection Control o Medical Staff Credentialing o Medication issues
Basically, The Joint Commission wants to see how well the hospital employees and physicians work together to care for patients. They review standards from the patient’s perspective. They expect the hospital should provide “seamless” care to the patient---this takes good team work from ALL departments.
IMPORTANT: Please note that there is a Joint Commission Standard that requires that any employee may contact The Joint Commission without fear of reprisal if they feel an important concern has not been addressed by their leadership. The chain of command should be exhausted prior to making a call to The Joint Commission, but you do have the right to contact The Joint Commission.
Findings During the Survey
In 2017, TJC transitioned to a different way of documenting findings identified during the survey. EVERY finding now will be captured using the SAFER matrix. Each finding will be evaluated to determine the risk based on the context of the situation as observed during the survey. Two components of risk will be assessed: 1) Likelihood to harm a patient, staff, or visitor and 2) Scope of the finding.
I. LEADERSHIP
MISSION STATEMENT
Q. What is the mission of Appalachian Regional Healthcare System?
A. To support the provision of high quality, compassionate healthcare for the High Country with a spirit of teamwork based on a set of operating values. VISION STATEMENT
Q. What is the vision of Appalachian Regional Healthcare System? A. Build a regional healthcare system that results in healthier individuals and enhanced quality of life. Organizational Values
Q. What are the values of Appalachian Regional Healthcare System? A. Compassion, Integrity, Excellence
Q. How does the job you perform support our mission? A. EVERY EMPLOYEE plays a critical role in fulfilling our Mission. So, ask yourself: How do I contribute? If you are not sure how WHAT YOU DO contributes to our Mission, please discuss with your department head or supervisor.
2018 Organizational Goals
II. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS PATIENT RIGHTS AND RESPONSBILITIES
Q. How do we support patient’s rights?
A. We support and advocate for the Patient Right and Responsibilities listed in the Patient Guide that is given to each of our patients when they are admitted.
Q. How are staff members made aware of procedures that maintain and support patient’s rights?
A. A review of patient’s rights, ethical issues, and advance directives are part of the new employee orientation as well as ongoing staff education.
Q. How are you involved in implementing the processes that support patient’s rights?
A. Each staff member is responsible to treat each patient with dignity and to see that the patient’s rights are protected. As part of the admission process, we review the contents of the Patient Rights and Responsibilities and Advance Directives with the patient and/or family/significant others. We protect confidentiality and make every effort to keep our patient informed.
Q. How do you ensure that a patient’s family/significant other participates in care decisions, when appropriate?
A. The patient’s family/significant others are included in the gathering of information, planning and evaluation of care as well as the implementation of patient education on admission and throughout the hospital stay. We have patient and family centered care. This involvement should be documented in the patient’s medical record by all disciplines as appropriate
Q. Who is the Patient Representative on your unit?
A. All health care providers act as patient advocates and representatives.
Q. What is our system if a patient needs translation services?
A. The hospital has access to interpretation services - Stratus Video Interpreting, which is provided via a tablet on a stand.
Q. What accommodations are available to meet the needs of our disabled customers/patients?
A. 1) We accommodate service animals.
2) Telephone amplifiers are available for patients who are hearing impaired.
3) All our hospital directional signs are in Braille. Large print educational materials are available.
4) The hospital provides wheelchair accessible bathrooms, as well as parking close to our entrances
5) We have availability of resources for patients who are deaf – via the Stratus Video Interpreting service.
Q. Can a patient change his/her Advance Directive once it is filled out?
A. YES, the patient may change his/her advance directive at ANY TIME! Please contact the Social Work department.
Q. If a patient has not designated a Healthcare Surrogate, but wishes to, what would you do?
A. Contact the Social Work department.
Q. Is a Living Will the same as a Last Will and Testament?
A. NO. A Living Will is a document that speaks to how patients would have health care provided for them when they are considered to be near death and can no longer speak for themselves. A Last Will and Testament addresses how the patient would like to have his/her assets disbursed upon his/her death.
Q. What educational resources are available to patients and families who would like information about Advance Directives?
A. The social workers are happy to talk to the family to explain advance directive documents.
Q. What are examples of an Advance Directive?
A. Living Will and Healthcare Power of Attorney.
Q. What hospital resource is available to address ethical concerns or dilemmas related to patient care?
A. The Ethics Committee.
Q. Who can access the Ethics Committee?
A. Patient, family, hospital staff and physicians. An ethical issue should first be addressed at the unit level, including the physician(s), nurse(s) and family involved. If unresolved, the Director or Supervisor would become involved. If the situation remains unresolved, contact any member of the committee. Name and contact information for all ARHS Ethics Committees are listed under “quick links” on the home page of the employee hub.
Q. How does ARHS protect and advocate for our patients who might be victims of abuse or neglect?
A. We screen all patients to identify those who may be victims of abuse or neglect, including physical or sexual abuse; elder abuse or neglect; and child abuse or neglect. Staff makes appropriate referrals based on assessments.
Q. How are patient complaints or grievances handled?
A. A minor non-care related issue regarding services in specific departments will be handled in those departments to resolve the concern at that time and by staff present. A significant concern related to patient care is reported through our occurrence reporting system (RiskWeb or the occurrence Hotline. The patient/ family will be notified in writing of the review and investigational findings and resolution.
III. MANAGEMENT OF THE ENVIRONMENT OF CARE
Q. Where is the Command Center located for disasters?
A. Watauga – New Education Classroom Cannon – Linville Room
Q. How can our hospital assure that each and every employee knows how to keep our patients and fellow employees safe?
A. Upon employment, ARHS personnel receive an orientation of the Environment of Care management program. Annual Review is part of the on line education process. Drills are conducted regularly to make sure we have the skills we need to keep everyone safe.
Q. What are the emergency codes? Make sure that you know what your responsibility is for each of the codes!!
A. Code Triage Disaster/Emergency Operations Plan Activation Code Red Fire Code Yellow Bomb Code Pink Abduction Infant/Child Code Blue Medical Emergency Code Gray Security Alert Code Silver Hostage Situation Code Orange Hazardous Materials Response Code Black Utilities Failure
Q. What number do we call for all emergencies in our Hospital?
A. CMH Emergency - #2911 WMC Emergency - #4400
Q. What is the purpose of the corridor doors that close when the fire alarm sounds?
A. When the fire alarm sounds, the smoke doors close to stop the spread of smoke and fire.
Q. Where is your nearest fire pull box? Fire extinguisher?
A. Fire pull box and fire extinguisher are located at intervals in each of the patient care units. Please take time right now to locate the fire pull box and fire extinguishers in your unit.
Q. If instructed to do so, how would you evacuate patients?
A. I would evacuate horizontally (beyond the fire doors) or vertically to a safe zone under the direction of the Administrator and/or Supervisor until the Fire Department arrives. Once the Fire Department arrives, they are in charge. Ambulatory patients are evacuated first, and then the most critical patients are moved to the safe zone. Equipment and emergency equipment are taken to the safe zone so that patients can be cared for.
Q. What would you use to evacuate the patients and visitors to the safe zone? Where are these items kept?
A. Wheelchairs, stretchers, bed covers, and bed linens all can be used to transport patients to the safe zone. These items are kept on the units. Evacuation SLED equipment is stored with hospital police
Q. What does “horizontal evacuation” mean?
A. This means moving from one zone to another safe zone on the same level or floor beyond the fire doors. We do not evacuate unless told to do so by the Administrator or Fire Department.
Q. What word should you think of to remind you of the steps to take in responding to a fire?
A. Race R for Rescue the patient. A for Alarm, (pull the fire alarm and call the emergency number). C for Contain the fire by closing doors, assure that smoke doors are closed E is for Extinguish the fire if it is safe to attempt this. Use the ABC extinguisher provided.
Q. How can your remember the steps of how to use a fire extinguisher?
A. PASS P for Pull the Pin in the handle. A for Aim the extinguisher hose. S for Squeeze the handle. S for Sweep side to side at the base of the fire.
Q. How should you alert the hospital that there is a fire?
A. Pull the fire alarm pull station and dial the emergency number.
Q. What is the first thing that must be done in order to use any portable fire extinguisher?
A. Pull the pin by twisting the pin to break the plastic string. If this is not done, the fire extinguisher will not work.
Q. During a fire, if the medical gas valves need to be shut off, who is authorized to do so?
A. Medical gas valves can be shut off only when authorized by the Senior Clinical person within the affected area. This person must make sure all patients who require oxygen are taken care of first.
Q. What systems in your area are supplied by emergency backup generators?
A. All red plugs in every department are supplied by the emergency generator. Important patient care equipment is plugged into these outlets. Isolation rooms are also on emergency generator power.
Q. Patient bathroom doors lock for privacy, but are they able to be opened quickly in an emergency?
A. YES. In the event a patient has fallen, etc. in a locked bathroom, a key is located at each nurse’s station. Take the time to locate it today!
Q. What safety items are in patient use areas, toilets, and bathing areas that keep our patients safe?
A. Grab bars and emergency call lights are located within reach of the patient. Patients are taught how to use these bars and emergency call cords by the staff during orientation to their room on admission.
LIFE SAFETY:
Q. What training do you receive in life safety?
A. During orientation and at least annually formal education is provided in life safety. In addition, drills are conducted periodically for fire, bomb, infant abduction, medical emergencies and disasters.
Q. What should you do if you see unsafe conditions (example: wet floor, blocked fire door) or a maintenance problem that impacts safety (example: missing exit sign)?
A. Safety is everyone’s concern. If there is an unsafe condition, fix it or report to your supervisor. Make sure people are not hurt while you are trying to get the unsafe situation resolved.
Q. Can we store equipment in the corridors?
A. No. Only equipment actively being used can be in the corridors. Emergency carts are consider always in use.
EQUIPMENT SAFETY
Q. What do we do about maintaining safe equipment?
A. Our staff receives training on equipment safety at Orientation and yearly. Other means of assuring safe equipment are: Environmental Rounds Routine Equipment Inspections Equipment Safety Policy and Procedures In-services
Q. To avoid a critical piece of equipment from losing power during a power outage you want to make sure the critical equipment is plugged into:
A. A red outlet.
Q. What would you do if you have an electrical plug, which has a broken ground prong?
A. Take it out of service. Then place a work order to have it repaired and make sure that the piece of equipment is identified as broken.
Q. What should be done when a piece of patient care equipment is broken?
A. Take it out of service. Place it in the designated area on unit. Send a work order and make sure that the piece of equipment is identified as broken.
HAZARDOUS MATERIALS AND WASTE
Q. What is SDS (Formally MSDS)?
A. SDS (Safety Data Sheets) formally MSDS (Material Safety Data Sheet). It is a form provided by the manufacturers under the “Right to Know Law” that describes the health effects, flammability, reactivity, etc., of the product. You can request a copy of the SDS by calling a toll free number – there is an icon (MSDS online) on the hospital PCs. Look for it today!
Q. What training have you received regarding hazardous waste?
A. As new employees, we all learned about hazardous waste. Our supervisors instructed us on any department specific hazardous waste materials. Annually, we receive instruction on how to stay safe by completing the modules on line. Inservices are also given when there is a need such as a new or revised policy, product, or an identified learning need.
Hospital Police/Security Issues
Q. What security practices are in place to maintain and promote safety?
A. 1) Identification of personnel, and patients 2) Surveillance Systems (cameras). 3) Security Incident/Accident reporting forms. 4) Controlling access to special areas like ED, PACU, Pharmacy. 5) Police officers stationed in and around the campus.
Q. What types of incidents/accidents should be reported to hospital police?
A. We should report to hospital police incidents/accidents that are not a part of the routine operation of the hospital. Examples are lost or stolen property, damaged property, missing patient, suspected crime or offense, and threat of violence. Any time we are feeling unsafe, hospital police would like us to call them.
IV. SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION
Q. What is the practice of Infection Control?
A. Infection Control is the means of preventing the transmission of organisms from person to person.
Q. What are Standard and Contact Precautions?
A. A principle of infection control in which we use personal protective equipment whenever we are potentially or actually exposed to any blood and body fluids even if the source is not identified to be infectious. Frequent hand hygiene is also part of Standard and Contact Precautions. In addition to consistent use of Standard Precautions, additional precautions (Transmission based precautions) may be warranted in certain situations such as MRSA (Contact Precautions), C- Difficle (Enteric Precautions), Respiratory Viruses (Droplet), and Tuberculosis (Airborne)
Q. What is Personal Protective Equipment?
A. Personnel Protective Equipment includes:
1) Gowns - used when there is anticipated soiling, splattering and/or splashing. 2) Gloves - used when touching a mucous membrane, dealing with blood, body fluids, and open or broken skin. 3) Goggles/Splatter shields - used to protect the eyes when there is anticipated splattering and/or splashing. 4) Masks - used when there is exposure to airborne or droplet particles pathogens and also in cases where there will be splattering and splashing of blood and body fluids. For TB patient’s, special N95 respirator masks are available for staff to protect themselves.
Q. What is a healthcare-acquired infection?
A. An infection acquired within the hospital.
Q. How do we prevent healthcare- acquired infections?
Proper practices and the use of personal protective equipment and devices Practicing hand hygiene consistently - the most effective method in preventing healthcare acquired infection. Annual In-service and training on principles and practices in infection control. Case Findings – Rapid identification/isolation and treatment of patients. Removal of artificial nails, gels, appliques for direct patient care providers, food handlers and laboratory technicians. Isolation/Precautions are initiated Airborne Isolation rooms are negative airflow (does not recirculate air into the air circulation of the hospital).
Regulated Medical Waste are those used medical supplies, devices or items that are contaminated with blood. Place empty vials and sharps such as needles and syringes in sharps containers designed to protect workers from injuries. Use of puncture resistant containers for sharps. Occupational Health Strategies: Pre-employment/annual physical evaluation Screening and Immunizations 1) Annual PPD skin testing or review of signs and symptoms. 2) Hepatitis B vaccine 3) Measles vaccine 4) Mumps vaccine 5) Rubella vaccine 6) Chicken Pox vaccine 7) Influenza vaccine
Q. What is your responsibility, if you are personally exposed to blood and/or body fluids or any potentially infectious disease like chicken pox, TB, meningitis, etc.?
A. 1. For blood and/or body fluids, wash the exposed area, with soap and water or rinse eyes for 20 minutes. Rinse mouth with large amounts of water and spit it out to not swallow the fluid. 2. Notify your supervisor or house supervisor immediately. 3. Go to AppUrgent or Baker Center walk-in clinic during normal operating hours. After hours, employees are to go to the nearest Emergency Department (CMH or WMC). 4. Register at one of the above ARHS facilities and fill out a packet. 5. Counseling and treatment options will be discussed. Occupational Health will follow up once other lab work is received for additional follow-up.
Q. How full can sharps containers get before they require exchange?
A. Sharps containers should only be filled to the manufacturer’s specifications, usually 2/3rds full. Once it is 2/3rds full the sharps container should be changed.
Q. How do you test if a negative pressure room is operational?
A. Check the gauge on the wall, it should read a NEGATIVE number. Also, if with the room door closed, place a piece of tissue at the bottom of the door. If the room is functioning properly, the tissue will be pulled inward. If the tissue isn’t pulled into the room, call engineering to check the room, BEFORE placing a patient in the room.
Q. Who tests negative pressure rooms and how often?
A. Plant Operations checks and records the pressure of each negative pressure room as part of their daily rounds at WMC. At CMH nursing personnel check on a daily basis. Each area has a log to mark the daily checks.
Q. What is the #1 preventative measure for transmission of disease?
A. Hand-hygiene: You can use antiseptic soap and water when hands are visibly soiled with blood or body fluids or you are caring for a patient who has C-difficile. You can use an alcohol based product if hands are not visibly soiled with blood or body fluids.
Q. How long do I wash my hands when I use soap and water?
A. For at least 15-20 seconds (sing Happy Birthday 2 times)
Q. How long do I rub my hands with hand sanitizer?
A. Until dry.
V. MANAGEMENT OF HUMAN RESOURCES
Q. What are your qualifications for your job?
A. When asked this question, you should state your credentials (licensure, any degree or educational preparation; specific training that make you qualified for your job. Describe any age specific training or special training that you received to help you be qualified for the job you hold. Mention BLS, ACLS, PALS, etc as well as other specialty training you have completed.
Q. How is orientation provided for new employees?
A. All employees receive a New Employee Orientation including a hospital and a system wide orientation; in addition a department role specific orientation is provided. Your general orientation and department specific orientation will provide each employee with the essential information for Appalachian Regional Healthcare System requirements. Department specific orientation includes both didactic and competency-based clinical orientation. A mentor/preceptor is assigned to facilitate the clinical orientation of a new employee. The duration of orientation varies with each role and the new employees needs.
Competency
Q. How can you demonstrate your competencies?
A. Here’s a list of some of the ways to demonstrate your competence: Having an educational background and degree appropriate to your position. Receiving orientation and training to your job. Being supervised and mentored by senior staff. Having your competency evaluated by a supervisor. Attending continuing education classes, online programs, seminars,etc. Completing environment of care and all other required annual training courses or in the classroom. Attending in-services on new equipment. Having ready access to all policies and procedures.
Q. How is competence assessed at ARHS?
A. ARHS has job descriptions for every job. These descriptions list the qualifications required for each job and the skills necessary to perform it competently. At 90 days post-hire and periodically thereafter, every employee is evaluated by a supervisor to make sure he/she is performing at the appropriate level.
Staff participate in ongoing education and training to maintain competence. Staff participate in ongoing education and training whenever staff responsibilities change. Staff participate in ongoing education and training that is specific to the needs of the patient population. Staff participate in ongoing education and training that incorporates the skills of team communication, collaboration and coordination of care.
This training is documented through: Employee’s continuing education Written tests Direct observation Assessment of employee’s ability to verbalize steps in a process or procedure Evaluation of employee’s written work Peer evaluation Netlearning and/or Learning on Demand/TEDS
Q. How does the hospital address staffs request not to participate in an aspect of care because of cultural, religious, or value/beliefs conflicts?
A. A request not to be assigned on a service or unit where he/she may have religious, cultural, or value conflicts may be approved if it will not negatively affect the standard of patient care and/ or treatment. See the Staff Rights policy located in the Human Resources Policy and Procedure Manual.
VI. MANAGEMENT OF INFORMATION
Q. Who can authorize the release of medical records?
A. Only patients or their legal representatives can authorize the release of information from their medical record. All other releases are controlled either by law, subpoena, and court order.
Q. If patient information or copies of medical records are requested, what should you do?
A. Refer all requestors to the Health Information Management (HIM) department for proper release of information.
Q. Who has access to patient records?
A. Patients, or their legal representative (i.e.: Healthcare Power of Attorney) may review their own medical record upon request. Medical personnel also have access to patient records for continued treatment.
Q. Who is authorized to access medical records?
A. Clinicians involved in the patient’s care and Health Information Management staff is authorized to access medical records.
Q. What happens if a staff member breaches confidentiality or security requirements?
A. Staff who breach confidentiality or security requirements are subject to the hospital and healthcare system’s disciplinary policy, up to and including termination.
Q. When and with whom is it ethical to discuss patients’ diagnosis and treatment?
A. Patient diagnosis and treatment should only be discussed in the course of business within the hospital. Information should be exchanged on a “need to know” basis only. Information should only be shared in work areas in which others cannot over hear conversations (i.e.: no hallways, elevators or cafeteria conversations).
Q. What is HIPAA?
A. HIPAA is the federal Health Insurance Portability and Accountability Act. These regulations create restrictions on the access to and release of protected health information.
Q. What is privacy, confidentiality and information security and how do we protect them?
A. Privacy is the right “to be left alone” – to be protected from an invasion of your physical and psychological being, property and/or information. Confidentiality is a “tool” to protect patient privacy. When information is given a “confidential” status, we are able to mandate specific controls over that information, monitor it, and limit access and disclosure. Security involves safeguards of information systems. This includes hardware, software, policies regarding authorized computer access (like passwords), and disaster recovery plans.
Q. What information is confidential?
A. Any patient-identifiable and clinical information is considered confidential. This includes information such as patient name, address, phone number, and diagnosis.
Q. What training have you received in Information Management?
A. Upon employment, all staff is given orientation and training on confidentiality, systems security and passwords, legalities of documentation, and chart order on the units. Staff also signs confidentiality and security agreements.
Q. How is the Health Information Management department involved in continuity of care?
A. The Health Information Management department is responsible for insuring medical records are available to authorized personnel for continuity of care.
Q. How should staff make entries to the medical record?
A. When documenting in the medical record, always: Write or print legibly in black ink if you are documenting on paper. Record the date and time of the entry. Document promptly and accurately. Record factual information; quote the patient when necessary. Do not use unapproved abbreviations. Sign your name legibly with your title. Correct an inaccurate written entry by lining through the inaccurate information once, label it as “error” and place your initials and the date next to the corrected information. All entries in the medical record have to be dated, timed and signed.
Q. What types of “benchmarking” information do we use?
A. Our customer satisfaction scores are “benchmarked” or compared to our own and to similar hospitals throughout the nation, using Press Ganey. We also use clinical performance improvement data that are benchmarked nationally. Clinical Performance is benchmarked utilizing the Premier data, Centers for Medicare and Medicaid (CMS) and The Joint Commission.
Q. What abbreviations can be used in the medical record?
A. ARHS has a list of abbreviations that cannot be used.
VII. PATIENT SAFETY
Q. If a patient has valuables with them upon admission, where would you document this and where are they secured?
A. Valuables are placed in a valuables envelope, labeled, and secured with patient access.
Q. What is an incident report?
A. A confidential and internal form to report any deviation from the routine operation of the Hospital, especially if an injury resulted or could have resulted. They include the facts, and only the facts. Do not give judgments or evaluations, i.e., “I think he was incompetent” or “she didn’t seem to care”, etc. Instead document, who, what, when and where.
Q. How soon should an incident report be submitted to the Risk Management department?
A. We encourage all events to be reported as soon as possible, but within 24 hours. By using the on-line RiskWeb tool, the appropriate managers / supervisors are also informed as soon as the event is reported. We also have a “hot-line” that can be used to report incidents: 386-2034
Q. How does ARHS minimized blame and fear of retribution for staff involvement in medical/healthcare errors?
A. A non-punitive approach to the management of errors and occurrences was implemented. Our goal is to have a culture of learning where all staff feel comfortable to share all errors or concerns.
Q. Are patients and/or families informed about outcomes of care, including unanticipated outcomes?
A. Yes, The physician or his or her designee clearly explains the outcome of any treatments or procedures to the patient and, when appropriate, the family, whenever those outcomes differ significantly from the anticipated outcome.
Q. What does ARHS do to improve patient safety?
A. 1. Standardization of order sets where appropriate 2. Infection Control Committees 3 3. Disaster Preparedness 4 4. LEAN activities 5 5. Just Culture journey 6. Interdisciplinary Rounds 7. Universal Protocol 8. Rapid Response Teams 9. RCA (Root Cause Analysis) 10. Read Back Policy 11. SBAR for handoff communication 12. Smart pumps 13. Non-punitive reporting 14. Suicide screening at time of admission 15. Sound a-like, look a-like drug precautions
Q. How is the staff educated on patient safety?
A. Staff will receive education and training during their initial orientation process and on an ongoing basis regarding job-related aspects of patient safety, including the need and method to report medical/health errors.
VIII. IMPROVING ORGANIZATION PERFORMANCE
Q. What is performance improvement (PI)?
A. PI is a process to improve patient care outcomes through communication, collaboration and commitment. All staff members look and identify the things that we can do better individually and/or as a team.
Q. What does PI do?
A. It creates a framework for organization-wide and collaborative efforts to fulfill our mission and vision. The impact of PI is that patient care becomes of a higher quality and is safer. It helps healthcare providers save time, avoid complications/problems, reduce stress and save money.
Q. Does the hospital have a planned, systematic, hospital wide approach to performance improvement? What is the method for Performance Improvement at ARHS?
A. Yes. We use the PDCA model. P Plan D Do C Check A Act
Q. How are PI measures used?
A. Performance Improvement measures are used to: To improve patient care processes, patient outcomes and patient safety. To identify staff educational needs. To use in annual evaluations/credentialing process.
To reduce cost.
Q. What is your involvement in PI?
A. As a staff member: You are introduced to PI during your orientation and ongoing. You may be a PI team member at the department level. You may participate at PI meetings (unit based/departmental). You may collect data for performance measures. You may participate in patient satisfaction survey results. You may implement a change. You may check to see if the change worked
Q. What are some of the tools employed throughout the PI process?
Brainstorming-group gives ideas on problems/solutions. Flowchart - the steps/path of a process are defined to identify areas for improvement. Cause and Effect - possible causes of a specific problem/condition are discussed. Pareto Chart or Diagram - vertical bar graph to determine which problems to solve in what order. A3 with rapid improvement events Value stream analysis
Q. What is the CMS/ Joint Commission Quality projects?
A. CMS and TJC have quality indicators that hospitals report on. Many of these indicators are part of the public reporting data. Our Healthcare System reports on Indicators specific to the following diagnoses / processes: Acute Myocardial Infarction, Congestive Heart Failure, Pneumonia, Stroke, ED flow of patients, timeliness of pain management, early elective deliveries, and immunizations.
THE FOLLOWING SECTIONS ARE FOR CLINICAL STAFF ONLY
IX. Provision of Care
Q. How do you assess a patient?
A. Patients are assessed on admission by members of the interdisciplinary team. Admission assessment must be completed within 24 hours. Interdisciplinary team approach is used in formulating the patient needs and plan of care.
Q. How do you determine the patient’s nutritional needs?
A. Nutritional needs are identified using several components of assessment that are obtained upon admission and during hospital stay. Nutritional screening is completed by the nursing staff upon admission utilizing a section of the admission assessment. Nursing places a dietary consult if patient is at nutritional risk. During hospitalization, patients are reassessed periodically as deemed appropriate by clinical nutrition’s written policy.
Q. How do you screen for the functional status?
A. Screening is a part of admission assessment for Physical Therapy, Occupational Therapy and Speech Language Pathology. It focuses on identifying the patient’s functional ability in dressing, mobility, elimination, hygiene and the ability to transfer. If the patients fail the screen, a physician order is obtained for physical therapy.
Q. How do you determine the patient’s discharge planning needs?
A. Discharge planning starts from the time the patient is admitted. Discharge planning needs are based on identified or assessed needs that will affect post hospital care. Components of discharge planning needs assessments are as follows: 1. Illness or condition that alters lifestyle and/or family living situation. 2. Medication. 3. Diet/nutrition. 4. Treatments. 5. Referrals. 6 Functional ability. 7. Follow-up.
Q. What is the policy on restraints?
A. We endeavor to create a culture that eliminates the use of restraints. Appropriate alternatives to restraints should be attempted prior to the initiation of restraints unless, to do so, would carry a greater risk to the patient or others. The least restrictive device will always be used. Patients’ rights, dignity, and psychological well-being will be protected throughout the restraint use. Restraint use is indicated for the following reasons and when all other alternatives have failed; Acute Medical Surgical Care (Non-violent, Non-self destructive) Restraints are used in order to maintain safety within the course of treatment and only on the individual verbal or written order of a licensed independent practitioner. The order will include the type of restraint to be used, the reason for the restraint and the time limit (not to exceed 24 hours). The physician will assess the patient and sign the verbal order within 24 hours of initiation. The patient’s well-being and needs will be monitored and documented by the RN every two hours. Behavioral (Violent, Self Destructive) Restraints are initiated for violent, uncontrollable or aggressive behavior and are used only on the verbal or written order of the physician. The order for behavioral restraint is valid for only 4 hours for adults, 2 hours for ages 9 to 17 years and 1 hour for children up to 9 years of age. A face-to-face evaluation by the physician, ARNP, PA and RN deemed competent after the initiation of restraints by the RN must be done within in 1 hour of application. A qualified RN will monitor the patient’s well being and needs closely. Safety needs of patients in four point restraints are observed every 15 minutes, and other needs are observed at least every two hours. If the patient requires continued restraints after 24 hours, the physician must conduct a face-to-face assessment.
Q. What is the policy on reporting of abuse, neglect and sexual cases - disabled adult/child/elderly and other injuries?
A. It is the legal responsibility of hospital staff to alert the Department of Children and Family Services in the event a child; elderly adult, or disabled adult patient is identified as a victim of suspected neglect or abuse including sexual abuse. Discuss your concerns with your supervisor or Social Worker.
Q. How do you assess patient satisfaction?
A. Press Ganey conducts our patient satisfaction surveys through random phone calls.
Q. How do you assess the patient for psychological and social needs?
A. Upon admission, psychosocial and social needs are routinely assessed. These assessment elements are part of the admission form, i.e., behavior, sleeping patterns, dwelling, social support of family and friends, and history of alcohol/drug use. On-going assessments and evaluation of the psychosocial aspect of care is conducted daily using an interdisciplinary approach.
Q. How do you assess and document patient’s reaction to medication?
A. Before administering any medication to a patient, the nurse provides drug information as to the indication of any adverse reaction to report, and what food may affect the efficacy of the drug. Any report from the patient, plus on-going assessment, determines patient’s responses to medication and subsequent treatment. Adverse drug reactions are immediately reported to the physician for evaluation and treatment. Documentation includes completion of the occurrence report online. Progress notes documentation includes signs and symptoms observed, treatment rendered, etc.
Q. What is the process for a patient using their own medication from home?
A. There must be a physician order to use the medication from home. The pharmacy must inspect the medication. The medication will be dispensed by the nursing staff as any other medication. We discourage the use of medications from home except for special circumstances.
Q. How do you assess and document the patient’s level of pain/discomfort?
A. Pain will be managed through a collaboration effort by an interdisciplinary team that may include; patients and their significant others, physicians, nursing, pharmacists, physical therapy, pastoral care and social services throughout the continuum of care. The patient and families personal, cultural, spiritual/ethnic beliefs are taken into account in the assessment of the patient’s pain. Documentation of pain/discomforts is assessed upon admission using the Pain Scale (0 to 10). We have different pain scale methods for different populations.
Q. How often is pain reassessed?
A. Patients who complain of pain will have their pain reassessed at least every 4 hrs or more frequently based on interventions that are being used. When medication is given for pain, the effectiveness of that medication will be assessed within one hour of administration.
Q. How do you plan the care, treatment, and rehabilitation that will meet the individual needs of the patient?
A. Upon the patient’s admission, care planning is initiated by activating the interdisciplinary team. The existing standards of care are used as guidelines to develop an individualized care plan or individualized pathway.
Q. How does our Food and Nutritional Services meet the patient’s needs for special diets and accommodate altered diet schedule?
A. Food and Nutrition Services provides special diets based on assessed patient needs i.e., therapeutic needs, cultural and religious needs, and individual preferences. Special diet schedules are coordinated between nursing
and nutrition service, i.e., late/early trays, and snacks, etc. If a patient is admitted during the hours that nutrition service is closed, the nursing supervisor or clinical manager has access to retrieve nourishment from the unit kitchen.
Q. Do patients receive adequate information to participate in care decisions and give informed consent?
A. It is the policy of ARHS to obtain and receive consent before any surgical or invasive procedure. The responsible physician meets with the patient and/or the family and explains the indications, the procedure to be done, benefits, risks, possible complications and alternatives to the procedure. Other procedures that may supplement the surgical interventions are also explained and consent obtained. The consent signed by the patient or family and must be witnessed by another health care provider or staff, i.e., nurse.
Q. Who participates in the planning and development of education you provide to patients and families?
A. All members of the healthcare team are responsible for patient and family education. .
Q. How do you determine the learning needs of patients and families?
A. Learning needs are assessed on admission and evaluated on an ongoing basis by determining the patient’s need to know and his ability to learn.
Q. Do we consider variables such as culture, religion, emotional barriers, motivation, physical and cognitive limitations, language and cost when assessing a patient’s needs, abilities, and readiness for education?
A. Yes, all these variables are assessed on admission. There is a specific area that allows the nurse to identify what, if any, variables exist. The multi-disciplinary team also references this sheet to tailor their teaching strategy to meet the identified barriers.
Q. Related to patient and family education, how would you say we address medication use issues?
A. This begins on admission with the assessment of what medications the patient is currently taking, any allergies the patient may have, and other input from patient, family or significant other. There are on line resources available to provide information to patients about their medications. We also have clinical pharmacists available if needed to assist with the education.
Q. Who documents patient education?
A. All disciplines involved in the patient’s care i.e., Dietitian, Social Worker, Respiratory, Pharmacy, Physical Therapy, Radiology, and Nursing.
Q. Continuum of Care covers what span of time for the admitted patient?
A. Continuum of Care begins with the patient’s first contact prior to admission, through hospitalization, discharge, follow-up or placement. Example: Triage -> ER -> Floor/Unit Admission -> Discharge to home -> Home Health, Ambulatory Care Center, or Community Health Center for follow-up.
Q. Can anyone be refused care because of inability to pay?
A. NO. It is the mission of ARHS to provide health care to anyone regardless of the race, creed, nationality, handicap, or the ability to pay.
Q. When does discharge planning commence?
A. Upon admission.
Q. How do you communicate patient information to other healthcare professionals?
A. We provide “hand-off” communication during transfers within the hospital. Patients who leave the nursing units for short periods have information communicated using the Ticket to Ride form.
Transfers to other facilities must either have a copy of the transfer form or documentation of the information provided to the other facility. Q. How do we document the plan of care for our patients? A. Patients should have a care plan based on their needs, which is personalized and patient specific. The care plan is created by the nurse upon admission. It will be updated as needed. In addition, at WMC we conduct multidisciplinary rounds on the units (ICU – daily, Monday through Friday; IMCU – three times a week; Med/ Surg – two times a week) during which the plan of care is discussed with input from disciplines present.
Q. When a patient is referred, transferred or discharged to another provider, how is the continuum of care preserved?
A. All necessary patient information must be transferred to the receiving provider, i.e., transfer summary, and other pertinent reports, laboratory and radiological data, copy of patient’s chart. Report is called to the receiving facility. There must be physician approval that the patient is stable to be transferred to another facility. There must be an accepting physician and confirmation of bed availability at the receiving facility. The patient, or the patient’s representative must give consent to be transferred. Non- compliance with any of the above may result in a violation of CMS polity, which may result in an investigation.
Q. Who instructs the patient when further treatment and follow-up is needed upon discharge?
A. All health care providers are responsible to see that the patient is instructed on his follow up care. Physicians, Nurses, Social Workers, and other specialized providers that are involved in the care of the patient, i.e., physical therapy, outpatient therapy, speech, etc are involved in teaching the patient about his follow up care. Discharge instructions are documented in the discharge Instruction form and given to the patient upon discharge and are documented in the medical record.
Q. What is the one thing everyone should do before they do anything that involves a patient?
A. Verify that you have the correct patient. Use your two patient identifiers: Name and date of birth and ask the patient, “what is your name”.
Q. What situations would you need to use two patient identifiers?
A. Giving medications, drawing blood, performing a test or treatment, prior to surgery, administering blood or starting an IV are just a few examples.
Q. How do you document read back of orders?
A. Write the order down and then “read back” to the person giving the order to confirm the information has been written correctly.
Q. What is the patient hand-off process?
A. The hand-off process is a way to provide a “report” about a patient to the next provider of care. We use many types of hand-offs based on the patient status and reason for the hand-off. The tools are standardized to ensure the hand-off of the most important patient information. Some examples are, Ticket to Ride, bedside shift report and SBAR. A important component of the hand-off is the ability to ask questions.
X. 2018 NATIONAL PATIENT SAFETY GOALS
Q. What are the National Patient Safety Goals?
GOAL 1: Improve the accuracy of patient identification. We use 2 identifiers when performing procedures, treatment and taking specimens. The intent of the goal is two-fold: first to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to the individual. We use the patient date of birth and the patient name on the ID bracelet and compare this to another document such as physician order, MAR or consent. We also ask the patient, “What is your name?” We label all specimens at the bedside in presence of the patient/family.
We use two person verification process when administering blood, and only qualified individuals administer blood.
GOAL 2: Improve the effectiveness of communication among caregivers. We evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.
GOAL 3: Improve the safety of using medications. We require all medications in perioperative and other procedural settings both on and off the sterile field to be labeled if not immediately administered. “Table it – label it” We have an anticoagulant therapy program – protocols for Lovenox and Coumadin, including education if the patient is being discharged on these medications. We have a standardized heparin protocol. Nurses ensure on admission, with the involvement of the patient/family, that medications the patient was taking at home are discussed with the physician to determine if they should be continued while in the hospital. Outpatient visits also include obtaining a list of the patient’s medications and if any changes are made, a new complete list is then provided to the patient. The complete list of medications is also provided to the patient on discharge from the facility with documented patient and family education. We remind the patient to take this list with them to their next visit with another provider
Goal 6: Reduce the harm associated with clinical alarm systems. We recognize the importance of establishing alarm system safety as a priority. We have a team that has reviewed the alarms that we currently have in the patient care areas. Default settings have been assessed. Staff and physicians have been educated regarding the purpose and proper operation of alarm systems for which they are responsible.
GOAL 7: Reduce the risk of health care-associated infections. We comply with the CDC recommendations to have 70% Ethyl Alcohol hand cleaner available in all patient care areas, and follow standard precautions for hand hygiene, personal protective equipment, and other aspects of infection control. Caregivers for Patients with C.difficile should always “wash the germs down the drain” and not use the 70% Ethyl Alcohol cleaner due to its inability to kill C.difficile spores. Education is provided for staff on hire and annually related to healthcare associated infection, MDRO and prevention strategies. We have a process to screen high risk patients for MRSA. We have implemented central line and VAP bundles to reduce central line and ventilator infections. We have implemented the evidence based measures to prevent surgical site infections. We have implanted strategies to reduce the risk of catheter associated urinary tract infections. We educate our patients on hospital acquired infection prevention including hand and respiratory hygiene if applicable.
GOAL 15: The organization identifies safety risks inherent in its patient population. All patients in the ED and patients who are admitted are screened for suicide risk. Additional actions are taken based on that assessment.
GOAL UP : Meet the expectations of the Universal Protocol for preventing wrong site surgery. We conduct a preprocedure verification process. This is an ongoing process of information gathering and confirmation. We utilize a standardized list for pre-procedure verification. The purpose of this process is to make sure all relevant documents and information or equipment are: 1) available prior to the start of the procedure; 2) correctly identified, labeled and matched to the patient’s identifiers, and 3) reviewed and are consistent with the patient’s expectations and the team’s understanding of the intended patient, procedure, and site. We perform a time out prior to any procedure involving incision or percutaneous puncture or insertion. We mark any site that involves laterality. The person performing the procedure marks the site except in limited circumstances. We compare the physician order for the procedure with the consent, any relevant radiologic tests, and any applicable schedules.
XI. MEDICATION MANAGEMENT
Q. How do you ensure that medication preparation and dispensing adheres to applicable law, regulations, licensure, and professional standards of practice?
A. There are written policies that ensure the personnel who can order medications, personnel authorized to administer medications, and the personnel authorized to dispense medications.
Q. What is an adverse drug reaction (ADR) and how is one reported?
A. An ADR is any adverse, atypical, allergic, toxic, altered or otherwise undesirable effect of a medication. It is written up on an occurrence report (can be done on-line) by the nurse, physician, pharmacist, etc.
Q. What is the hospital formulary?
A. The hospital formulary is a continually revised compilation of medications that reflect the current clinical judgment of the Pharmacy and Therapeutics Committee. The hospital formulary can be accessed from the intranet.
Q. What do you do when you find an illegible medication order?
A. The nurse (or the pharmacist) contacts the physician to clarify the order before any medication is dispensed or administered.
Q. Do medication orders need to be reviewed when a patient is transferred from one unit to another?
A. Yes. Existing orders must be reviewed when a patient transfers to a different level of care.
Q. Name two medications that are considered “high alert.”
A. Insulin, heparin infusions and injectable potassium chloride are examples of high alert medications.
Q. What is the purpose behind limiting the number of drug concentrations available in the hospital?
A. To reduce the potential for error when ordering, dispensing or administering the medication.
Q. What information do we provide the patient when they start a new medication?
A. We provide information on indication, side effects, adverse reactions, dosage, frequency, monitoring needs, route and administration if indication.
Q. Tell me about the Pyxis System? Do you utilize override system?
A. The Pyxis system is the system we have in place for storage and security of medications and supplies (ED). It automates the distribution, management and control of medications. Pyxis provides a patient’s medication profile. The override system is utilized when the medication is not in the patient’s profile, and is needed urgently, without the prior review of a pharmacist. There must be an order for this medication. There are only certain drugs that are on the override list.
Q What do you do with meds that the patients bring from home and there is no one to send them home with?
A. These medications are placed in the pharmacy designated home medication cabinets.
Q. How long is a vial of multi-dose medication good for?
A. 28 days and the vial must be dated with the expiration date.
Q. Do you know which bin to dispose of what type of medication, vial, etc?
CONGRATULATIONS!!!!!
You have completed reading this preparation manual. Another important way to prepare for a visit is to be sure you know all of your policies; but you should know these already as they guide the care you give to your patients or help you to perform your job role.
You will do a great job if you have to speak to a surveyor! Brag about what you do each day! Brag about your department!
Refer to this manual to assist you in being continually ready for any survey!
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