Quality Management Office- Ongoing Survey Readiness Tips
In an effort to promote continued survey readiness, the Quality Management
Department will provide regulatory tips on a weekly basis to ensure that we are providing
optimal care for our patients and their families.
Tip#1 Medication Management
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Two patient identifiers must be checked prior to administering medications.
Medication carts should be clean and dust free.
Pill cutters/ crushers should be cleaned before and after use.
Medication carts must be locked when not attended (for those areas that have
medications carts -- ancillary areas such as PACU, OR, etc...)
Fluid warmers should NOT be set higher than 104 degrees F.
Always check medications for expirations prior to use.
Multi-dose vials must be dated and discarded after 28 days. Label with expiration
date
Automated Drug Cabinets (ADC) {Omnicell} are secure. Staff should remember to
log off of the machine when they are done.
Medication refrigerators connected to ADC {Omnicell} are automatically monitored.
Appropriate personnel are notified of excursions. In ancillary areas, staff from those
areas monitor temperatures of medication refrigerators. Pharmacy must be
contacted to access medication integrity.
Blanket orders such as “continue previous medication orders” are NEVER acceptable.
PRN medication must include indications
SCAN medications and patients
Know which medications require double checks
Reconcile medications on admission, at transfer (ICU), and at discharge
Follow guidelines for RANGE orders
Always ensure that medications are secure
Tip#2 FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE) & ONGOING PROFESSIONAL
PRACTICE EVALUATION (OPPE)
Practitioners granted initial or new clinical privileges must undergo focused professional
practice evaluation (FPPE) at that hospital to assure competency. Additionally, any
triggered evaluation (issue-based) event should also cause an FPPE to be performed.
In addition, the Medical Staff is required to conduct an ongoing evaluation of each
practitioner’s professional performance (OPPE). The OPPE process is a summary of
ongoing data collected for the purpose of assessing a practitioner’s clinical competency
and professional behavior. OPPE provides each practitioner with useful feedback that will
help improve the quality of performance and identify professional practice trends that may
impact quality of care and patient safety.
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To ensure focused & ongoing professional performance evaluations are
conducted in a complete and concise manner, please contact Delinda Pendleton
for more information at ext. 2660 or delinda.pendleton@fccc.edu
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Quality Management Office- Ongoing Survey Readiness Tips
Tip#3 Documentation
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When documenting on a pre-printed form, ALWAYS complete every box or line.
If the element is “Not Applicable” to your patient, indicate that.
Always sign, date and TIME every entry whether it is a pre-printed form or
progress note or H&P.
Document completely and clearly so that the next person taking care of the
patient can continue the care without concern or question. Read what you wrote
– do you understand it? Could you provide care based on what you wrote?
Make sure all your chart entries are legible!
Entries:
 All entries signed, dated, timed, legible
 NO unapproved abbreviations
Verbal/telephone orders:
 Write it down and then READ it back
 Physician to sign, time, date within 24 hours
Verbal test results:
 Write it down and then READ it back
Tip#4 APPROVED ABBREVIATIONS- Administrative Policy #2
Please refer to the list of approved abbreviations for your review.
https://myportal.fccc.edu/portal/c/document_library/get_file?groupId=11406&uuid=681159
57-c6a3-4fd0-9889-7d956520d4fb
Tip#5- Radiation Protective Equipment (RPE)
Lead aprons and thyroid collars are provided for your protection against scattered
radiation. Care must be taken to prolong the life of this RPE. All aprons must be hung
properly on apron racks after use to avoid creases and cracks. RPE should be cleaned
regularly using a gently cleaner and a soft brush. Do not use bleach, machine wash or dry
clean. All aprons are checked for integrity each year by the Radiation Safety Staff and
labeled with a color coded sticker. Please assure yours was checked by looking at the
sticker. New RPE must be checked by Radiation Safety Staff and added to the inventory
database. Report any aprons that are removed for repair or replacement. Make sure that
your radiation badge is on the apron before you wear it.
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Quality Management Office- Ongoing Survey Readiness Tips
Tip#6 Pain Management
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Screen every patient for pain, regardless of whether they are being admitted as an
inpatient, visiting a clinic or diagnostic service or having ambulatory surgery.
Convey report of pain to treating clinician.
When pain is present, treatment (pharmacologic and non-pharmacologic) or referral
should occur as appropriate
Involve the family in the patient’s plan of care for pain.
Be sure the family is adequately educated about pain and medications - particularly
upon admission and at discharge.
Use language and age-appropriate pain-intensity tools consistently.
Evaluate the effectiveness of every step taken to manage a patient’s pain. If one
approach is not effective, try another.
Document your evaluation, management activity and effectiveness of treatment
prominently in the medical record.
Assess patients for pain on an ongoing basis, with vital signs for inpatients (while
awake) and before and after interventions used to relieve pain.
Restraints—Non-Violent:
 Documentation of care plan
 Order on chart for the appropriate restraint
 Physician MUST authenticate the order
 Reordered every 24 hours if needed
 Document patient monitoring every 30 min.
Restraints—Violent:
 Paper order & Documentation
 Requires close monitoring – every 15 minutes
 Reorder every 4 hours
For additional information, refer to link…
http://www.fccc.edu/patients/support/painManagement.html
Tip#7 Material Safety Data Sheets (MSDS)
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Material Safety Data Sheets (MSDS) provide detailed health and safety information
and precautions for handling hazardous substances, including emergency and first
aid procedures – they are specific to each chemical.
MSDS binders can be located on the units and in your departments.
In case of a computer and network shutdown, MSDS Binders can be found in the
Safety Office, please contact Joe Rawson at ext. 2573 or joseph.rawson@fccc.edu
(R-281) during normal business hours. After hours contact security by calling the
operator.
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Quality Management Office- Ongoing Survey Readiness Tips
Tip#8 Occupational Exposures
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OSHA – The Occupational Safety and Health Administration of the Federal
Government prohibits eating, drinking, applying cosmetics or lip balm, and
handling contact lenses in work areas where there is a likelihood of
occupational exposure.
They have clarified this to include nurses’ stations as work areas where there is a
likelihood of occupational exposure.
So be safe – keep food and drinks (covered or not) in the lounges and outside of
patient areas and work areas. This is for YOUR protection.
If you are working, save your food and drink for your breaks. Breaks are not held in
work areas or patient care areas.
Tip#9 Eye Wash Station Maintenance & Testing
Weekly checks of the eyewash station must be conducted to ensure proper function, flush
out stagnant water and remove sediment from the emergency equipment.
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Remove the eyepiece caps
Push the handle to the “on” position
Allow the eyewash station to run for three (3) minutes
Replace the caps
If the eyewash station does not function, immediately report the
problem to Maintenance at ext.2217 or go online and put a work ticket in.
• Document this procedure on the Emergency Equipment Log weekly
Tip#10 Drying Time Sani- Wipes(Alcohol) and Sani wipes (Bleach) Wipes
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Red Sani-wipes and (Gold) Bleach wipes are disposable wipes that kills germs
The effectiveness of the Sani wipes depends on their dwell time
Sani Wipes = remain on the surface, visibly wet before drying, do not dry with
towels as this will make the product ineffective.
Bleach Sani-Wipes are used for C. Diff patients only, call CSR for this product.
Questions: Contact Infection Control at 3125, or Environmental Services at 2736
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Quality Management Office- Ongoing Survey Readiness Tips
Tip#11 Expiration Dates
UPDATE
Product
Expiration
Multi-Dose Medication Vials:
Meds
Peroxide, Alcohol, Betadine:
Saline Solution for Irrigation
Glucose Strips:
Glucose Controls:
Hemoccult / Gastroccult Slides:
Hemoccult / Gastroccult Developer:
Meds
Urine Dip Sticks:
PDI Wipes:
(example: label reads MFG 2009/11)
POCT
POCT
POCT
POCT
POCT
Insulin: 28 days *
Other’s: Manufacturer’s Date
Manufacturer’s Date
24 hours **
120 days from opening
90 days from opening
Manufacturer’s Date
Manufacturer’s Date
Manufacturer’s Date
Expires two (2) years after
manufacturer’s date (ex: expires 2011/11)
All vials & containers must be labeled with date opened, date expires, and initials.
*Date expires & initials on label only
**Date opened, date and time expires, and initials on label
Tip#12- SMOKING POLICY
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Fox Chase Cancer Center is a smoke-free campus
Under no circumstances will patients, families, visitors or staff be permitted to
smoke on campus- This includes contractors
Absolutely no smoking is permitted near entrances of hospital buildings,
which includes the Receiving/Loading Platform
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Tip#13- ID Badges
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Identification badges are a required part of your work attire.
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All FCCC staff and physicians must wear their photo identification badge
whenever they are at any of the hospital or satellite
Badges must display a full-face photo of the employee, which assures patients,
visitors, and colleagues that you are a part of the organization.
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Lost, displaced or damaged badges must be reported immediately to Security,
Human Resources and your Department Manager.
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Quality Management Office- Ongoing Survey Readiness Tips
Tip#14- Five Minute Clean-up Checklist for Surveys
No food or drink in patient care areas.
Check the clean utility room. Make
sure it is clean. Nothing should be
stored on the floor or 18 inches from
the ceiling.
Make sure everything is on the same
Automated Drug Cabinets (ADC)
side of the hallway. All egress routes
{Omnicell} are secure. Staff should
must be clear.
remember to log off of the machine
when they are done.
Make sure fire exits / doors/ fire
extinguishers are not blocked.
Remove material / papers / charts
with patients’ names from the top of
counters.
Make sure any stretchers in the
Check crash carts: locked, clean, no
hallway have sheets on them and no
out of date supplies in it or on top of
tears in the mattress.
it, defibrillator strips removed.
All oxygen tanks are secured.
Pantry: clean, no out dated food
products, refrigerator log is up to
date.
All linen carts are covered. No linen
Make sure staff are wearing their ID
hamper is overflowing.
badges.
All aspects of documentation are
Medication reconciliation is
complete.
complete.
Verbal orders are signed, dated, and
Unapproved abbreviations are
timed.
written out.
All medical record entries are signed,
IPOC is multidisciplinary and
dated, and timed.
updated.
Restraint orders are current; restraint
Patient Education form is
documentation by nursing is complete.
multidisciplinary, updated, and
complete.
Pain assessments and reassessments
All aspects of nursing assessment
are documented.
are complete.
Fall assessments are complete and
White Board information is current
documented.
and neat.
Advance Directive documentation is
Ensure that Patient Health
complete.
Information Protected.
Patient Care Areas: identify patients in restraints, “fresh” post-ops, and patients
ready for discharge.
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Quality Management Office- Ongoing Survey Readiness Tips
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Tip#15Be Prepared to Respond
• How do you document the multidisciplinary assessment?
• Where are the nutrition assessment and functional assessment
documented?
• How is the need for dietary and rehab consults determined?
• What is the timeframe for completing the initial nursing assessment?
• How do you demonstrate the integration of disciplines?
• Where does each discipline document patient education?
• Can you tell me your policy about restraints?
• How often is a patient in restraints checked?
• How often does the order for restraints need to be written?
• What is a Sentinel Event?
• What is Root Cause Analysis? What is FMEA?
• What is MSDS? Where do you find copies of MSDS?
• What is the expiration date for multi-dose vials?
• What are the approved POCT for RN’s and LPN’s?
• Are POCT used for screening or treating purposes?
• Who has the authority to turn off Medical gases?
• What has been done in your area to improve patient care?
• What do you do during a disaster?
• What do you do during phone outages and computer downtime?
• What is the policy for maintaining the food/medication refrigerators?
• What is the automatic stop time for narcotics?
• What is your institution’s smoking policy?
• Demonstrate to me how you unlock the patient bathroom door when it is
locked and a patient is inside?
• What do you do if you suspect abuse?
• Have you been offered a flu shot? Is this a policy at FC?
Tip#16- Labeling Medications
 Labeling occurs when any medication/solution is transferred from original packaging to
another container.
 Label medications/ solutions that are not immediately administered
 Label each medication/ solution as soon as it is prepared, unless it is immediately
administered.
 Medication or solution labels include the following:
o Medication name, Strength, Quantity, Diluent and volume, Preparation date,
Expiration date when not used within 24 hours, Expiration time when expiration
occurs in less than 24 hours
 Verify all medication/ solution labels both verbally and visually.
 Immediately discard any medication or solution found unlabeled.
 All medications/ solutions both on and off the sterile field and their labels are reviewed
by entering and exiting staff responsible for the management of medications.
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Quality Management Office- Ongoing Survey Readiness Tips
 At the conclusion of the procedure, remove all labeled containers on the
sterile field and discard their contents.
Tip#17- Infection Prevention and Control~ Hand hygiene
 Wash in and Wash out
 Every patient every time.
 Use appropriate transmission based precautions when providing patient care.
 No food or drink in work areas.
 Prevent central line infections:
o Hand hygiene
o Use catheter checklist
o Use standardized supply kit
o Sterile barrier precautions for insertion
o Daily review of line necessity
o Disinfect hubs before accessing
o Educate patient and family about prevention
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Prevent ventilator associated pneumonia:
o Daily sedation vacation
o DVT prophylaxis
o Elevate head of bed (30-45 degrees)
o Oral care
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Prevent surgical site infections.
o Antimicrobial agents for prophylaxis according to evidence-based best practices.
o When hair removal is necessary, use clippers or depilatories. Shaving is an inappropriate
hair removal method.
 Prevent foley catheter associated urinary tract infections
o Daily review of catheter necessity.
o Do not use component systems.
o Use securement device to prevent tension and possible dislodgement.
o Do not routinely send cultures post removal
 Isolation:
o Know which patients are screened for MRSA
o Know criteria for which patients to isolate
o Know the types of isolation & associated precautions
o Treat all blood and body fluids as if they are infectious (Standard Precautions)
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Quality Management Office- Ongoing Survey Readiness Tips
Tip#18- Safety and Security
At all times please consider the following:
 Wear your I.D. badge at all times.
 Complete emergency equipment and code cart checklists.
 Do not use hallways for equipment or furniture storage
 Report strangers or unauthorized personnel in your area to security Ext. 41
 Keep hallways and exits clear of obstructions (no blocked exits, fire extinguishers or
utility/gas panels).
 Do not prop doors open.
 Do not store items less than 18 inches from the ceiling.
 Know medical gas emergency shutoff valves’ location, operation and shutoff
procedures.
 Do not store patient care items on the floor or under sinks
Know what FCCC disaster and emergency codes mean and what to do:
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Code Red = Fire
Code Blue= Cardiac or respiratory
Code Gray= Security/Threat
Code Black= Security Alert- Issued by Security personnel relating to a threatening
situation that staff should be aware of.
Code Brown= Campus lock down
Code Pink= Infant/Pedi Abduction
Code White= Internal/External Disaster
Code Orange = Biomedical/Hazardous Materials
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Quality Management Office- Ongoing Survey Readiness Tips
Tip#19- SCRIBES- Do the Joint Commission standards allow organizations to
utilize scribes?
Q. What is a scribe and how are they used?
A. A scribe is an unlicensed person hired to enter information into the electronic medical
record (EMR) or chart at the direction of a physician or practitioner (Licensed Independent
Practitioner, Advanced Practice Registered Nurse or Physician Assistant). It is the Joint
Commission’s stand that the scribe does not and may not act independently but can
document the previously determined physician’s or practitioner’s dictation and/or
activities.
Scribes also assist the practitioners listed above in navigating the EMR and in locating
information such as test results and lab results. They can support work flow and
documentation for medical record coding.
Scribes are used most frequently, but not exclusively, in emergency departments where
they accompany the physician or practitioner and record information into the medical
record, with the goal of allowing the physician or practitioner to spend more time with the
patient and have accurate documentation. Scribes are sometimes used in other areas of
the hospital or ambulatory facility. They can be employed by the healthcare organization,
the physician or practitioner or be a contracted service.
Q. Do the Joint Commission standards allow organizations to utilize scribes?
A. The Joint Commission does not endorse nor prohibit the use of scribes. However, if
your organization chooses to allow the use of scribes the surveyors will expect to see:
Compliance with all of the Human Resources, Information Management, Leadership
(contracted services standard) and Rights and Responsibilities of the Individual standards
including but not limited to:
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A job description that recognizes the unlicensed status and clearly defines the
qualifications and extent of the responsibilities (HR.01.02.01, HR.01.02.05)
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Orientation and training specific to the organization and role (HR.01.04.01,
HR.01.05.03)
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Competency assessment and performance evaluations (HR.01.06.01,
HR.01.07.01)
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If the scribe is employed by the physician all non-employee HR standards also
apply (HR.01.02.05 EP 7, HR.01.07.01 EP 5)
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If the scribe is provided through a contract then the contract standard also applies
(LD.04.03.09)
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Quality Management Office- Ongoing Survey Readiness Tips
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Scribes must meet all information management, HIPAA, HITECH,
confidentiality and patient rights standards as do other hospital personnel
(IM.02.01.01,IM.02.01.03, IM.02.02.01, RI.01.01.01)
Compliance with the Record of Care and Provision of Care standards also apply
and include but are not limited to:
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Signing (including name and title), dating of all entries into the medical record—
electronic or manual (RC.01.01.01and RC.01.02.01). For those organizations that
use Joint Commission accreditation for deemed status purposes, the timing of
entries is also required. The role and signature of the scribe must be clearly
identifiable and distinguishable from that of the physician or licensed independent
practitioner or other staff.
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Example: “Scribed for Dr. X by name of the scribe and title” with the date
and time of the entry
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The physician or practitioner must then authenticate the entry by signing, dating
and timing (for deemed status purposes) it. The scribe cannot enter the date and
time for the physician or practitioner. (RC.01.01.01 and RC.01.02.01)
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Although allowed in other situations, a physician or practitioner signature stamp is
not permitted for use in the authentication of “scribed” entries-- the physician or
practitioner must actually sign or authenticate through the clinical information
system. (RC.01.02.01).
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The authentication must take place before the physician or practitioner and scribe
leave the patient care area since other practitioners may be using the
documentation to inform their decisions regarding care, treatment and services.
(RC.01.02.01 and RC.01.03.01)
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Authentication cannot be delegated to another physician or practitioner.
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The organization implements a performance improvement process to ensure that
the scribe is not acting outside of his/her job description, that authentication is
occurring as required and that no orders are being entered into the medical record
by scribes. (RC.01.04.01)
Q. Can scribes enter orders for physicians and practitioners?
A. The Joint Commission does not support scribes being utilized to enter orders for
physicians or practitioners due to the additional risk added to the process.
Tip#20- Radiation Protective Equipment (RPE)
Lead aprons and thyroid collars are provided for your protection against scattered
radiation. Care must be taken to prolong the life of this RPE. All aprons must be hung
properly on apron racks after use to avoid creases and cracks. RPE should be cleaned
regularly using a gently cleaner and a soft brush. Do not use bleach, machine wash or dry
clean. All aprons are checked for integrity each year by the Radiation Safety Staff and
labeled with a color coded sticker. Please assure yours was checked by looking at the
sticker. New RPE must be checked by Radiation Safety Staff and added to the inventory
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Quality Management Office- Ongoing Survey Readiness Tips
database. Report any aprons that are removed for repair or replacement. Make
sure that your radiation badge is on the apron before you wear it.
UNANNOUNCED SURVEYS:
ARE YOU READY?
10 tips for a successful survey
1. You may ask to see a surveyor’s identification if you are unsure about who he or she is.
2. If you are the first person the surveyors meet as they enter the building, have the
surveyor(s) take a seat and contact Delinda Pendleton’s office (x2660, x2637), or Kathy
Gilman’s office (x2591).
3. Never provide an impromptu hospital tour. A member or the Administrative team (see #2)
will escort them to their meeting location.
4. Patient care comes first. Once the survey begins, if you need to leave a surveyor to check
on a patient, be polite and offer to meet the surveyor again as soon as possible.
5. Be flexible. You may be interviewed once, multiple times, or not at all. Regardless, be
ready.
6. Be polite when answering questions. Offer truthful answers and stick to the three-second
rule.
7. Answer questions with a yes or no, when appropriate. Don’t offer specifics unless asked.
8. Use open body language. Stand facing the surveyor in a comfortable, confident manner.
Make eye contact and do not cross your arms.
9. Surveyors may observe you – sometimes without warning. Focus on providing quality
patient care and following proper procedures and you’ll have nothing to worry about.
10. Relax! Surveyors are your opportunity to shine and show off the exceptional job you do
every day.
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Quality Management Office- Ongoing Survey Readiness Tips
Follow the three-second rule
Try to answer surveyor questions within three seconds. Here are tips to help you answer
surveyor questions effectively (even if you don’t know the answer):
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Ask the surveyor to repeat or clarify a question.
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Use the buddy system: Ask a coworker for help answering a question or offer to help
someone stumped by a question.
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If you don’t know the answer to a question, be able to show the surveyor where you could
find it (e.g., a policy).
Other Tips- Things that should occur at all times
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Doors should not be propped open...this includes clean and soiled utility rooms.
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Staff food and patient food should not be stored in the same refrigerator. All patient food
brought from home must be labeled and discarded after 72 hours.
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Hospital supplies (even in boxes) should not be stored on the floor, even in the utility room.
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Medications and syringes must be stored in secure areas (i.e. locked cabinets and drawers).
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Code carts are to be checked daily when department/unit has patients.
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Patient medication and food refrigerator temperatures must be checked daily when
department/unit has patients. This information must also be logged.
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Follow the National Patient Safety Goals 100% of the time. (Refer to your pocket card.)
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