1

2/16/2010
2

*
*
O B J E C T I I V E S O F T H I I S B O O K L E T
*
I I N T R O D U C T I I O N T O T H E J O I I N T C O M M I I S S I I O N
Who are they and why do we care?
Survey Overview
Tracer Methodology
Survey Etiquette
*
S U R V E Y R E A D I I N E S S
Environment of Care
Emergency Management
Human Resources
Infection Prevention and Control
Information Management
Leadership
Life Safety
Medical Staff
Medication Management
National Patient Safety Goals
Provision of Care
Performance Improvement
Record of Care
Rights and Responsibilities of the Individual
Transplant Safety
Waived Testing
* RESOURCES…………………………..
3

4

Who is The Joint Commission?
The Joint Commission (TJC) evaluates and accredits more than 15,000 health care organizations and programs in the United States. An independent, not-forprofit organization, TJC is the nation’s predominant standards-setting and accrediting body in health care.
Why do we seek accreditation?
Accreditation is voluntary, not a requirement. In order for a health care organization to participate in and receive payment from the Medicare or Medicaid programs, it must meet the eligibility requirements for program participation, including a certification of compliance with the Conditions of Participation, or standards, set forth in federal regulations. Because The Joint Commission has and enforces standards that meet or exceed the federal Conditions of Participation, CMS had “deemed” authority to TJC. We have elected to achieve accreditation via TJC for several reasons:

TJC is a widely recognized standards setting organization known for driving patient safety and risk reduction efforts

TJC is known for their collaborative approach and work with predominant professional healthrelated organizations in the development of those standards
 We are not subject to full annual validation surveys by CMS through our “deemed” accredited elections

The majority of our payers (insurance carriers) will not contract with healthcare entities that are not accredited by TJC
What is the Survey process?
Since 2006 all TJC surveys have been unannounced. We are subject to an unannounced survey between
18 and 39 months after a previous full unannounced survey. Our last survey was (insert facility dates) therefore we can anticipate survey anytime between (insert 18-month timeframe) through (insert 39month timeframe)
The Joint Commission accreditation survey process provides an assessment of an organization’s compliance with st andards and their elements of performance. Our organization’s compliance will be based on:

Patient and staff interviews via tracing actual patient care including the documentation of that care

Performance improvement data/trends

Verbal information provided to the Joint Commission

Surveyor observations of care, activities and the environment
What is tracer methodology?
The “tracer” is the method by which the surveyors determine how well we are delivering patient care.
They will select a patient, typically one whose care is more complex and is receiving a variety of services, and will literally trace that patient’s course of care from the moment they entered the hospital, through each department that provided services. Surveyors want to know what you do and how you do it.
During the tracer, surveyors will review the medical record with the staff caring for the patient. Items in the medical record typically reviewed include:
 Initial Admission data (including H&P’s)

Assessments and reassessments, including pain

Fall Risk Assessment and related interventions

Patient education

Interdisciplinary Plan of Care

Medication Lists and Medication Reconciliation

Orders for Care

Surgical/Procedural notes
5


Anesthesia notes

Moderate Sedation records

Discharge planning and Discharge Summaries
In addition to asking staff for assistance in review of the medical record, Surveyors will interview staff about:

Hand-off communications

Use of data/ performance improvement initiatives

Any issues of patient flow- delays in care, admissions, procedures, discharges

National Patient Safety Goals

Patient Education

Orientation, Education and Competencies

Patient and Environmental Safety
They will observe the patient care areas for safety, environment of care and infection control issues.

Proper storage of chemicals and supplies

Medication Security and storage

Departmental security if high risk area (pediatrics, ED, Women’s Services)

Clean vs. Dirty storage areas; including how equipment is brought into and out of these areas when brought back to patient rooms

Clear exit paths (hallways are free from equipment, carts or furniture)

Privacy violations

Dignity violations (i.e.- patient curtains not drawn)
They may also observe direct care. Typical Observations include:

Patient Identification procedures

Medication passes

Hand hygiene

Isolation procedures

Lab collection or point of care testing

Verbal and telephone order processes

Preprocedure verification and other preparation of patients for surgery/procedures

Surgical and other invasive procedures, including time-out

Hand-off Communications
Other items you should be prepared to respond to include:

Location of fire pulls and fire extinguishers

Evacuation routes

Oxygen shut-offs

Eyewash stations

Hazardous chemical inventories (Material Safety Data Sheets)

Use and location of Personal Protective Equipment (PPE)

Emergency Codes and how to respond

Policies and Procedures

How you the department is staffed and how assignments are made
What if the surveyor wants to talk to my patient or his/her family?
This is okay – it does not violate any confidentiality or privacy regulations. However, you are the caregiver and you know the patient’s condition. You can say if it is a bad time to visit the patient. Surveyors do expect that we will ask the patient for permission for the surveyor to question him/her. Because the tracer methodology drives the things surveyors are looking for, the questions asked of patients can take a variety of courses.
6

Survey Etiquette
Surveyors want to know what you do and how you do it. They are here to not only evaluate but also educate and provide consultation. They also want to identify what we do well as an organization. Below are some tips to help you feel successful with surveyor interactions:
1. Be positive!

Talk about things that you, your unit and Memorial Hospital does well.

Talk about improvements that your department has made and how you participated in the improvement.

Be professional and not place blame or criticism on others or other departments
2. The surveyors are our guests . Let’s all be the best hosts possible.

Observe common courtesies. All behaviors are observed by the surveyors.
3. When surveyor is in your area:

Surveyors may ask anyone a question – any role, any person, any time.

Do not avoid surveyors. We want them to feel welcomed by our organization and for staff to convey confidence.

Know your resources: Clinical and Safety Policies and Procedures and where to find them: Hard copies, DocuShare, other online resources like MSDS sheets, Physician directories, National
Patient Safety Goal posters.

Perform a quick environmental assessment- make sure medications are secure, halls are clear, protected patient information is private, and that the department is clean and safe

Refresh your memory on the location of fire extinguishers, oxygen shut-off valves and general fire procedures
4. If a surveyor asks you a question:

Do n’t panic. You know your job the best.

Think about the question before you answer.
 If you get scared and go “blank:”
­ Ask the surveyor to restate the question.
­ Someone else in the group can answer, but the same person shouldn’t be answering all of the questions.
­ Managers: ask the surveyor for clarification if your staff is not assertive
­ Managers: Offer supportive comments like, Amber, tell her about ____________ that we just did.
 If you don’t know the answer, know where to find it: manuals, management, badges, etc.
 If you do not know the answer, it’s OK to say, I don’t know, but I would ask my supervisor, or, I don’t know but I would tell the nurse.

Please do not say, " I am too busy to do this", and walk away. If you are involved in a true emergency, explain this and make a respectful exit.

Remember, a surveyor is not asking questions outside of your scope or practice or work to trick you or trip you up.

If you disagree with a surveyor, it is okay to discuss the issue and request clarification, but do not argue with a surveyor.

Always, always tell the truth. If you lie, we are at risk of being cited for falsification which may result in less than full accreditation. Give the correct, honest answer in your own words.

They would rather know that you have identified an issue and are working on it, even if it isn’t
“fixed,” than to see that you didn’t realize there was a problem.
7

March 21, 2011
The goal of this chapter is to promote a safe, functional, and supportive environment within the hospital so that quality and safety are preserved.
Who is your Safety Officer?
Grady Padgett
Where would you find a copy of the Safety policies?
In the Policy and Procedures Manual on “My Net Apps”.
Do we have a Safety Committee?
The Safety Committee is composed of representatives from all areas of the hospital. Committee members meet regularly to analyze safety issues, recommend solutions to problems, support and promote safe work practices, and create system policies for health and safety.
How often does staff receive safety training?
At least on an annual basis and more regularly as needed.
What is the hospital’s smoking policy?
There is a no smoking policy anywhere on our campus.
How does the hospital identify individuals entering its facility?
All vendors must check-in using Vendor Clear (computer near Administration) – they will be issued a one day name tag. Those working with the Facilities Department will be issued a one-day badge through
Facilities. All other employees, doctors, contractors should wear a badge issued through Human
Resources. Employees have a thin black line around their picture. Doctors (including their AHPs) have a blue line around their picture, Auxillians have a red line, HCA contractor has a green line, and an outside contractor has a yellow line. Women’s Services employees have a purple line (plus an extra hang tag for security purposes).
What is a Code Adam and how would you respond?
A Code Adam is called when an infant or child is discovered missing. Staff will be asked to monitor all exits and hallways and report any suspicious activity to security ext. 6999.
How do you find out about product notices and recalls, including medication recalls?

Communication from manufacturer

Communication from wholesaler, buying group or HCA Supply chain

Consulting website such as FDA and ASHP
What types of security incidents do you report?
Are you aware of any injury or potentially dangerous or threatening situation involving staff, patients, or visitors? If so, these must be reported.
How do you contact security?
Call ext. 6999
What do you do if you notice someone suspicious or if someone in the hospital becomes disruptive?
8

When any employee or physician perceives that a situation may/or has become threatening verbally or physically, call the hospital operator by dialing 1911 and state “I need Campus Safety stat” and give the location. If a weapon is involved, inform the operator so that can be pass on to Campus Safety also.
What should you do if you discover the loss of hospital or personal property?
Contact my Supervisor and Security.
When should I wear my name badge?
All employees are to wear their Memorial Hospital name badge while at work. The name badge must be visible, displayed within 12 inches of the employee’s face, and with picture, name and credentials showing.
Where is your department’s inventory of hazardous materials?
On the shared drive at: S:\MHJ\Chemical Inventory
Where do you get information about hazardous substances used in YOUR work area?
From a MSDS sheet (Material Safety Data Sheet)
What is an MSDS (Material Safety Data Sheet)?

Information provided by the manufacturer concerning hazards employed with their product

MSDS includes identification, hazardous ingredients, physical and chemical characteristics, fire and explosion hazard data, health hazard data, safe handling, use and control measures, spill, leak and exposure procedures
How can you get a MSDS sheet?
Contact the 3E Company @ 1-800-451-8346. Simply give them the Chemical Name, Manufacture Name
(if known), and a fax number to where they can send you the MSDS sheet.
When do you have to label a container into which you pour chemicals?
Always
Who do you call for a chemical spill?
Campus Safety @ 6999 for hazardous material spills. If involved in the spill, I should clean up the spill if properly trained to do so using appropriate personal protective equipment but only if the spill does not put me or others in danger.
What is the process used if you were to discover a fire?
RACE and PASS (note: order of process is important)
What does the acronym RACE stand for?
R = Rescue anyone in immediate danger
A = Alert (activate the fire alarm by activating the nearest pull station and/or calling 1911)
C = Contain the fire (close all doors and windows to help prevent smoke and fire from spreading)
E = Extinguish/Evacuate (Only attempt to put out small fires if you have been trained to do so. Follow evacuation procedures as directed.)
If patients need to be evacuated in an emergency, how would you proceed?


Listen to person in charge
Evacuate horizontally first past the smoke/fire doors
 Know your department’s emergency route
9

Where is the nearest fire extinguisher and how do you activate it?

Know location within your work area. Activate a fire extinguisher using P –A–S–S
P = Pull the pin
A = Aim the extinguisher at the base of the fire
S = Squeeze the handle holding the extinguisher upright
S = Sweep from side to side at the base of the fire
How often do you have fire drills?
A minimum of 1 drill per shift per quarter
How do you know equipment is working properly?

The user checks equipment before it is used.

Biomed does an incoming inspection of equipment and it is tagged when it is functioning according to manufacturer specifications, is calibrated, has functional and audible alarms set as appropriate, and is safe. The tag indicates the date it was checked, and the date it due to be rechecked.

The user verifies that the equipment has a current inspection sticker.

The operator notifies Biomed if there is a problem with equipment functions or if the equipment does not have a current inspection sticker. Any equipment without a valid inspection sticker or found not functioning properly should be tagged and immediately removed from service.
What do you do with broken or expired medical equipment?


Tag it and remove it from service
Notify Biomed
What do you do if equipment has harmed the patient?

Pull the equipment from service, tag it and send to biomed along with related items

Complete an occurrence report
How do you learn to use new equipment?

In-services

Company representatives

Posters, pamphlets and videos
What do you do if there is a utility system failure, i.e., water, power, etc.?
Refer to Utilities Systems Contingency Responses Policy (II.13) in the Interdisciplinary Policies Manual
How is your facility prepared for a power outage?

The facility has emergency generators that provide power during power outages.

Essential equipment is always to be plugged into red outlets. All non-essential equipment is to be removed from red outlets during power outages.

Fire safety equipment is powered by emergency generators, such as exit lights, smoke detectors, and emergency lighting.
What should you do if the water supply to your department is cut off?
Use waterless hand disinfectant. Assess your immediate water needs and await instructions.
Where is the oxygen shut-off valve in your work area?
Know the oxygen shut-off valve locations in your area and what areas or rooms are shut off by those valves.
10

Who is permitted to shut off the oxygen zone valve in your unit?
Nurse Director, Charge Nurse, charge person on duty, or their designee
Are you storing or moving oxygen safely?
Oxygen cylinders that become damaged can become a deadly projectile object. Here are some safety tips:

When moving oxygen cylinders, even for short distances, use a cart or carrier designed for their transport

If transporting via hospital bed or stretcher, ensure the cylinder is safely secured. It should not be removed from holder’s and placed laying on patient beds

Containers should be stored in the vertical position and properly secured

Oxygen tanks should never be left in any area unsecured

Close the container valve after each use and when empty, even if still connected to equipment

Open valve slowly to avoid pressure shock
Are you transporting patients with oxygen safely?
In addition to oxygen tank safety, it is also important to ensure patient safety when transporting patients with oxygen tanks

Prior to moving a patient with oxygen to a procedure or another area the following should be addressed via hand-off communication: O
2 flow rate for patient, amount of pressure in tank, amount of time left in tank based on O
2 tank duration chart, and tank time calculation

Any tank time calculation that is less than 1 hour must have new tank applied or spare tank going with patient

Any patient requiring a flow rate of 6L or above will be considered a high risk patient for transport.
This high risk patient must be accompanied by a clinical staff member (respiratory therapist or whoever is appropriate) for the travel time and for the duration of the test/exam

{insert other facility specific requirements}Richard Robinson
How does the hospital minimize risk during a demolition, construction or renovation project?
The hospital should perform a pre construction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services. Based on the results of the risk assessment, extra fire drills may be performed; barriers may be put in place, etc.
If you are injured on the job what would you do?
Barbara Thomas
If you were exposed to blood or body fluids what would you do?
Barbara Thomas
11

March 28, 2011
The Emergency Management chapter helps to facilitate hospitals in their planning and response to the effects of potential or actual emergencies that fall on a continuum of disruptive to disastrous. There are four phases of emergency management: mitigation, preparedness, response and recovery.
Emergency Codes/Plans identified for the hospitals and reviewed annually. What types of codes have been defined by our EOC/Safety/Emergency Preparedness committee(s)?

Code Grey – Disaster response – internal or external disasters

Code Silver – Controlled Access / Lockdown

Code Red – Fire

Code Pink – Infant/child abduction

Code Black – Bomb threat


Code Orange – Hazardous Materials Spill Internal
Code Blue – Medical Emergency

Code White – OB Emergency

Code Green – Violent Behavior/Security Assist

{insert facility specific, if applicable}
What are the various phases of a Code Grey?
{Insert facility specific P&P. Example: Code Grey “Standby”- means that an event is imminent and likely to impact our hospital. After hearing Code Grey Activate, you will either hear Code Grey “Activate” or
Code Grey “Stand-down”. Code Grey “Activate”- means that we are in the implementation phase of a specified event. “Activate” typically occurs at different levels based on the anticipated disruption of services and care about to occur}
What am I supposed to do when a Code Grey “Activate” is called?
{Insert facility specific P&P Example: Clinical departments should prepare bed count, review staffing and be prepared to accept patients. It is also important to note that core disaster team members of {insert facility} will assemble at the Hospital Incident Command Center (HICC). If instructed by HICC, I may also be asked to: activate department call tree, discharge patients, or inventory supplies and equipment.
Listen for additional instruction from the HICC}
Where is the command center located in the event a Code Grey is called?
{Insert facility specific}
What do I do when Code Silver is called?
When a “Code Silver” is paged, all entrances into the facility will be secured. During this time, no employee will be allowed to leave the building unless authorized to do so by the Incident Commander. All employees will be required to enter and exit through the approved entrances and have name tags with them at all times. At no time will any doors be propped open. Employees will also assist security in checking exits to ensure that they are locked and remain locked during the event.
What do I do if I am in receipt of a Bomb Threat?
Threats Received in writing or by phone must be immediately reported:
{Insert facility specific}
12

April 4, 2011
This chapter addresses the hospital’s responsibility for hiring, orienting and ensuring ongoing education, training and competencies of staff.
How long have you been at Memorial Hospital?
Answer as appropriate
Did you go through hospital orientation?
For each new employee, Memorial Hospital provides:

A full day of hospital orientation

4 days of RN orientation

2 days of PCT orientation
 New GN’s participate in 12-week program

Department/position-specific orientations
Were you oriented to your department? What did it include?
A supervisor, preceptor and/or educator facilitates a department/position-specific orientation and signs off on the orientation checklist.
What makes you competent to do your job?

Annual education via HealthStream – Rapid Regs I, II, and III

Annual Code of Conduct training

Maintaining current licensure and required certifications

Department specific competencies

Ongoing education

Skills fairs
What are some ways you receive ongoing education?

Newsletters, flyers, mox mail updates

Online Meditech training

BLS/PALS/ACLS/NRP

Equipment, new services, high risk/low volume, documentation changes, etc. – training in department meetings, demos in education, etc.

Digital Med offerings via HealthStream
How is staff made aware of cultural diversity needs and concerns?
New Employee Orientation, Rapid Regs, new Population Specific competencies
What are the ages/populations of the patients you care for and have you had specific competencies related to these populations?
Yes- if you care for different age/populations (i.e. neonates, infants, pediatrics, and geriatrics) you should have age/population specific competencies; Other populations can also include types of patients (i.e., bariatric) and different cultures, national origins, or race.
Are you allowed to work if your license or required certifications expire?
No. It is our policy that employees are responsible for maintaining current licensure and required certifications. As such, appropriately maintain required licenses and/or employees that do not certifications will not be allowed to work until the certification or license is
Do you oversee students as part of your job? renewed.
What is your role?
13

Student rotations are coordinated via our education department. All students are supervised by faculty or an appropriate Memorial Hospital preceptor. Discuss how you act as preceptor to student if applicable.
What education/training have you received that incorporates team communication?
We have had training on team communication through our annual Code of Conduct program and our annual “Rapid Regs” mandatory education. We follow a structured hand-off communication process on which all applicable clinical staff is trained. Employees who participate in classes such as ACLS or ETLA incorporate team communication in their coursework. We also promote teamwork and team communication during our United Way and Hope Fund campaigns as well as our annual Employee
Survey.
How do you report an unanticipated adverse event?
Through the variance report system in Meditech and departmental chain of command
Have you been notified that you can notify The Joint Commission if you have concerns about quality of care or safety without fear of retaliation?

All new hires are informed of this during New Employee Orientation

Included in annual Rapid Regs mandatory education
14

March 14, 2011
The goal of infection control and prevention is to identify and reduce the risk of acquiring and transmitting infections among and between patients, staff, physicians, and anyone entering the organization.
Who are our Infection Control practitioners?
Vicki Gordon, RN CIC and Ashley Lloyd, RN
What precautions do you take to prevent infections in patients?

Proper hand hygiene is the single most effective way to stop spread of infection

No artificial nails or extenders

Standard precautions are used for ALL patients, regardless of diagnosis. These precautions are designed to protect oneself and others by treating all body fluids as potentially infectious .

Transmission based precautions o Contact (yellow sign) - used for patients with bacteria/infections that spreads by touch, and those with open, draining wounds, diarrhea, or certain skin outbreaks. Examples include: MRSA , VRE ,
C. difficile , Resistant Organisms including ESBLs, KPC, CRAB, etc., shingles, and scabies.
Health care workers should use a gown and gloves at each point of entry to the patient’s room.
 Patients with C. difficile should also have a “Stop, Hand washing with Soap and Water
Required” sign on the door alongside the Contact Precaution sign.
 Patients with a history of MRSA or VRE should automatically be placed in Contact
Precautions upon re-admission. o Droplet (pink sign) - used for patients that have an infection that spreads by respiratory secretions. Examples include: known or suspected meningitis, Seasonal Influenza, and Pertussis.
Health care workers must use a mask with an eye shield. o Airborne (green sign) - used for patients that have an infection that spreads via air transmission.
Examples include: known or rule-out Tuberculosis (TB), chickenpox, measles, and disseminated shingles. Health care workers must use an approved N95 mask (3M or duckbill) for any illness requiring airborne precautions. A negative pressure room is required and the door to the room must remain closed except for entering and exiting the room.

All items removed from a patient’s room must be appropriately cleaned with a hospital-grade disinfectant. You can use Sani-wipes for cleaning accucheck machines, walkers, stethoscopes, telemetry packs, etc. The item must stay wet for 2 minutes to ensure adequate disinfection.
When are you required to sanitize your hands?
Waterless hand disinfectant or soap and water must be used:

When entering the patient rooms

When leaving the patient rooms

Before and after patient contact

After handling any equipment, dirty linens, or specimens

Before applying sterile gloves

Before performing any invasive procedure (inserting a foley, starting an I.V.)

After removing gloves
When are you required to use soap and water?

Any time hands are visibly soiled

After glove removal for a patient on contact precautions for C. difficile

When you feel a significant buildup of the waterless hand product on your hands
15

What precautions are in place to prevent infections to employees?

Appropriate Personal Protective Equipment (PPE) - gloves, gowns, goggles or face shields, surgical mask (with or without visor attached), N95 Respirator mask

Employee Vaccine Program including influenza vaccine - Employee Health section?

Employee Health Screening (at hire and annual TB testing)

Sharps Protective Devices

Standard Precautions for all patients and Isolation Precautions for designated patient
How do you dispose of hazardous waste?

Place in Biohazard red bag and take to Biohazard container in Soiled Utility: o Items that are soaked or saturated with blood o Items that are soaked or saturated with certain body fluids-- lymph/synovial fluid, semen/vaginal secretions, cerebrospinal fluid (CSF), pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid o Plastic tubing that is visibly bloody o Visibly contaminated gloves and PPE o Blood or blood products o Tissue/Body parts

Use regular trash bags for feces, nasal discharge, saliva, sputum, sweat, tears, urine, and vomitus

Needles and syringes are to be placed in Sharps container (No re-capping of needles)
Where can you find policies on Infection Control practices?
In the Policy Manager under the MHJ Hospital-Wide Infection Control manual
16

March 21, 2011
Every episode of care generates health information that must be systematically managed by the hospital.
All data and information used is categorized, filed and maintained. The privacy, security and integrity of health information is vital.
What is health information?
Any information, whether oral or recorded in any form or medium, that:
 is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse; and
 relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or payment for the provision of health care to an individual.
What is HIPAA and why is it important?
HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. HIPAA outlines the regulation which provides guidelines that ensure protected health information is kept private throughout our organization. Violations can result in fines. Confidential information must be kept secure and confidential in accordance with Memorial Hospital’s policies and applicable laws, including the Health
Insurance Portability and Accountability Act (HIPAA).
Do patients receive a notice of privacy practices when they enter our organization? What is a
Notice of Privacy Practices?
All patients entering our hospital should receive a Notice of Privacy Practices (NPP). Patient Access is responsible for providing that information upon registration. For patients that bypass registration (i.e. - direct admissions), patient access will distribute this information when they visit the patient on the unit.
The NPP:

Provides individual notice of the ways the organization uses and discloses
Protected Health Information (PHI)
 Explains an individual’s rights to confidentiality and access to his/her PHI
If I discover a concern regarding privacy or security who do I contact?
Memorial Hospital’s efforts for privacy and security extend beyond compliance with HIPAA and cover a wide range of regulations and standards. Privacy and Security often overlap in their functions because while keeping information private is of utmost importance, it is also important to maintain the appropriate levels of security so that data is not compromised in any way. If you have any questions, please contact:
 Privacy : Privacy line 904-399-6103 or the Privacy Official Cindy Vorhees 904-399-6062

Data Security: Facility Information Security Official Roberta Ashton 904-399-6876.
What if law enforcement requests Protected Health Information (PHI)?
The Memorial Hospital’s “Release of PHI to Law Enforcement” policy governs our facility’s response when law enforcement officers request medical records or other confidential patient information. That policy is located in Policy Manager Policy number VI.37.
Like anyone else requesting medical records, law enforcement officers must have the required legal authorization for their requests. This means that unless the officer has a court order or a search warrant signed by a judge, the general rule is that patient authorization is required before releasing confidential medical information. There are, however, a few, limited exceptions to this general rule. You can refer to the corporate policy referenced above or contact the Facility Privacy Officer or the Facility Ethics and Compliance Officer.
If information systems were to fail, have you established downtime procedures?
17

Downtime procedures have been established for Meditech applications for all types of delays outages and downtimes. Each Department has established its departmental downtime procedures to handle various outages.
Formerly a National Patient Safety Goal, what abbreviations are unacceptable in the patient record?
U or u x3d
Zero after decimal point (1.0)
No zero before decimal dose (.5mg)
Apothecary symbols
IU
Q.D.
Q.O.D
MS or MSO4
MgSO4
µg unit for three days or doses
1 mg
0.5 mg dram, minim
International unit once daily every other day morphine sulfate magnesium sulfate microgram write out the word unit write out the word days or doses do not use decimal zeros for dose expressed in whole numbers always use zero before a decimal when dose is less than a whole number use the metric system write out international unit write out daily write out every other day write out morphine sulfate write out magnesium sulfate use
“mcg” or write out Microgram
18

March 21, 2011
The goal of the Leadership chapter is to provide a framework for planning, directing, coordinating, providing and improving quality and safe care, treatment and services and improve patient outcomes.
What is the vision of Centura Health and (facility name)?
Centura Health will fulfill a covenant of caring for our communities with excellence and integrity to become their partner for life.
What is the mission of Centura Health and (facility name)?
We extend the healing ministry of Christ by caring for those who are ill and by nurturing the health of the people in our communities.
What are our core values? We embrace these values as set forth by Jesus Christ:

Compassion

Respect

Integrity

Spirituality

Stewardship

Imagination

Excellence
What are (facility name’s) strategic objectives (the goals we need to reach and meet our vision)?
{Insert facility specific priorities}
Who are the members of Memorial’s leadership team?

Chief Executive Officer – Jim Wood

Chief Nursing Officer – Sandi Grimes

Chief Medical Officer – Dr. Gary Winfield

Chief Financial Officer – Ashley Johnson

Chief Operating Officer – Eric Goldman

Senior Vice-President – Scott Montgomery

Vice President Quality – Carol Landry

Vice President Human Resources – Laura DeMotte

Senior Vice-President Marketing – Bradley Garcia
Does {insert facility} have an Integrity Program?
Yes. Each employee is required to read and sign that they have read and acknowledged the Centura
Integrity booklet. All employees are encouraged to report integrity concerns, to the Centura Health
Hotline at 1-888-424-2458.
How do management and staff gather information and share it with each other? How do you learn about new things in your department and in the hospital? {Review and verify following for facility specific}

Town Hall meetings

Various nursing governance councils

Medical Executive Committee

Board of Trustees

Quality Assurance Council
19


Department newsletters

Communication books

In-services, CME offerings

Unit and department meetings

E-mail, flyers, pamphlets, education carts, unit rounding

LEARN

Talking Points

In The Know

Infection Prevention flyers

Publications: E-Connect, Connections newsletter, Vim and Vigor magazin
20

March 28, 2011
The Life Safety chapter has been developed based on code which protects lives from the harmful effects of smoke and fire. It also includes aspects of building safety- from the type of construction used to the requirements for fire detection and suppression. Life Safety is just patient Safety in the environment.
Are you allowed to leave items unattended in exit corridors?
If items are on wheels and readily movable, they may be kept in the corridor, however any item unattended in the same location that is not actively being used should not be left for more than 30 minutes. Additionally Items should never be parked in front of electrical panels. The rule for exit corridors is that the maximum wall protrusion is 3.5 inches, with the exception for alcohol-gel hand rub dispensers and retractable wall-mounted computer desks, which may protrude up to 6 inches. We keep our corridors free from clutter because it is in the best interest for the safety of our patients. For this reason , the best practice is to keep corridors free of any items .
Are we allowed to use extension cords?
Extension cords are to be used on a temporary basis only; therefore it is best that they not be used.
Contact Facilities Management if you do not have adequate access to outlets. Contact {insert Safety
Officer Name} if you have questions.
If I notice that doors do not close or latch properly, what should I do?
Notify Facilities Management as appropriate
What are the requirements related to storage?
You must maintain at least 18 inches of clearance from the sprinkler head to items stored on the top shelf or any other tall object. Items should not be stored on the floor directly due to infection control purposes. Contact {insert Safety Officer Name} if you have questions.
Why is it important to keep trash chutes and laundry chutes closed?
These chutes create vertical openings. If there was a fire involving unlatched chutes the fire could rapidly spread to other floors and be spread throughout the facility. If you notice chutes are not closing and latching properly, contact Facilities Management Are we allowed to use portable space heaters?
Portable space heaters are not permitted in smoke compartments that contain patient sleeping or treatment areas. Portable space heaters with elements that exceed 212 degrees F are not permitted.
Contact {insert Safety Officer Name} if you have questions.
Are we allowed to prop doors open?
Absolutely not. Contact your manager or Facilities Management for alternative door-hold-open devices.
What is the maximum capacity that should be used for trash and soiled linen containers?
Any soiled linen and trash containers larger than 32 gallons must be kept in a room designated as a hazardous room. Containers used to collect papers for shredding are included in the purpose of this requirement. Contact (your Safety Officer) if you have questions
Are we allowed to put decorations on exit doors?
Exit doors are not allowed to be covered with any device (decorations, mirrors, draperies) that could obstruct or confuse occupants as to its use. As a general rule of thumb, combustible decorations should not be permitted in hospitals. Contact {insert Safety Officer Name} if you have questions.
21

March 28, 2011
The Medication Management Chapter is representative of core Medication Management processes including: Selection and Procurement of medications, Medication Storage and Security, Prescribing and
Ordering of Medications, Preparation of Medications, Dispensing of Medication, Administration of
Medications and Monitoring of Medication management processes and adverse events
What is considered a medication?
A medication is any product designated by the
(FDA) as a drug, as well as any sample
Food and Drug Administration medications, herbal remedies, vitamins, nutriceuticals, over-the-counter drugs, agents, respiratory therapy treatments, parenteral intravenous solutions (plain, with electrolytes medication does not include enteral nutrition vaccines, diagnostic and contrast nutrition, blood derivatives, and and/or drugs). This definition of solutions (which are considered food products), oxygen, or other medical gases.
How do we know what medications are available at (Insert Facility}?
There is listing of drugs available in the hospital called a formulary. This list can be found in the
Meditech Mox library simply go to Mailbox – Library – Pharmacy Hospital Formulary. If medications are ordered but are not on the formulary, pharmacy will change to a Pharmacy and Therapeutics Committee approved alternative (therapeutic interchange), clarify the order with the physician, or ask the patient to bring their own medications for administration in the hospital.
How do ensure medication security in your department?
ALL MEDICATIONS should be secured at all times (see medication definitions above). Secure is defined as being in a locked room, locked container or under constant surveillance. Therefore we store medications as follows:

In PYXIS machine

In medication refrigerators either locked or in locked medication rooms

In locked nurse servers

In clean medication rooms

In locked emergency kits or blue carts
.
What medications require that we label them with an expiration date?
Multidose medications will be labeled with an expiration date of 28 days from time of dispense if dispensed from the pharmacy. Other multidose containers will be labeled with an expiration date of 28 days from time of opening.
Multidose medications exceeding this date will not be used for drug administration. Unused medications will be returned to the pharmacy. Opened medications will be discarded. Examples include insulin vials which are labeled with expiration date at time of dispense.
Other examples may include Hydrogen Peroxide and Alcohol which are labeled with expiration date 28 days after it is opened. (Medication Administration Interdisciplinary Policy III.26)
What role does pharmacy play prior to the administration of medications?
After me dication orders are scanned to pharmacy, it is pharmacy’s role to verify that the medication is appropriate for the patient’s weight, age and diagnosis, and that drug interaction, allergies or other contraindications are not apparent.
Can medications be removed from PYXIS without pharmacy verification?

There are times when medication is needed immediately and can be removed from PYXIS

If the medication is urgently needed, the nurse should contact a charge nurse and complete the following steps together. Charge nurse and primary nurse will:
1. Scan order to pharmacy using a STAT sticker
2. Evaluate physician order to ensure appropriate dose and route for drug ordered
22

3. Verify selection of the correct patient
4. Verify correct medication in the correct quantity is obtained from the ADC.
5. Check for presence of allergy to selected medication
6. Verify selected drug has not expired.
7. Sign in to ADC as a witness for all high risk drug overrides
8. Document a reason for the override
Who can dispense medications? Pharmacy is responsible for dispensing medications throughout the hospital. In clinics and physician practices that are departments of the hospital, a physician must dispense the sample medications to patients.
How do you know you are giving the medication to the correct patient?
We use two identifiers, ensuring that those identifiers are matched against the medication administration record each time a medication is given. We also involve the patient in the process
What do you do if you suspect an Adverse Drug Reaction (ADR)?

Stop the medication

Monitor the patient

Call the doctor

Call the pharmacy

Complete the ADR form
How is the patient educated about food and drug interactions?
Pharmacy educates all patients on food and drug interactions related to coumadin and other anticoagulation therapies. Other education on food and drug interactions may be conducted by a dietician.
Formerly a National Patient Safety Goal, what actions to prevent errors involving look-alike, sound-alike medications are taken at Memorial Hospital?


Scan Bar-Code
Separate Storage in Pharmacy and Pyxis Machines

Electronic warnings at time of order entry
Look-alike/Sound-alike List

Oxycontin and Oxycodone

Insulin

Lorazepam and Alprazolam

Celebrex , Celexa and Cerebyx

Cardene and Cardiazem

Dopamine and Dobutamine

Retrovir and Ritonavir

Lamivudine and Lamotrigine

Metronidazole RTU IV Bag and Levofloxacin RTU IV Bag

Vinblastine and Vincristine
 Lipid based Amphotericin B (Ambisome® and Abelcet® and Conventional Amphotericin B
(Fungizone®)
 Lipid based Daunorubicin (Doxil) and Conventional Daumorubicin (Cerubidine®)
 Concentrated liquid morphine (Roxanol® 20 mg/ml) and Conventional liquid morphine (Morphine
10 mg/5ml)
23

April 4, 2011
The medical staff chapter is outlined to ensure that there is an organized medical staff that is responsible to oversee care, treatment and services provided by members of the medical staff. All practitioners must be competent, privileged and credentialed. The medical staff bylaws, rules and regulations create a framework within which medical staff members can act with a reasonable degree of freedom and confidence.
How do I know that physicians are qualified to care for my patients?
All physicians that care for patients at Memorial Hospital are required to apply and meet rigorous standards before they are credentialed to practice here.
What is credentialing?
Credentialing is a multifaceted process in which evidence of a practitioner’s professional training, experience, and clinical competence is collected, verified and assessed.
Who makes the final decision of credentialing?
The Board of Trustees of the hospital makes that
Credentialing Committee (made up of physicians).
If a physician you didn’t recognize came to your or perform a procedure, how would you find out if that care or perform that treatment?
determination with input from the area to provide care to a patient, they had privileges to provide
I can locate this information on MyNetApps under I-Cacti which lists all medical staff members, their demographics and the approved clinical privileges for each practitioner.
Does Memorial Hospital have medical staff bylaws and rules and regulations?
Yes. The medical staff developed and adopted bylaws, rules and regulations that guide the processes for credentialing, appointment to the professional staff, and granting of clinical privileges.
How are you notified if a physician has been suspended?
There are times that the hospital suspends a physician. Reasons for suspension vary but can include delinquent medical records, lapse of license or liability insurance. If suspended this means that the physician will not be permitted to admit, care for, or perform procedures/surgery while the suspension is in place. As suspensions occur the following employees are notified

Administrative Nursing Supervisor

Surgery scheduling

Central Scheduling

Practitioner is suspended in Meditech and I-Cacti
24

March 7, 2011
National Patient Safety Goals:
The National Patient Safety Goals are reviewed annually or more frequently by Joint Commission. New goals may be added and others may be retired, becoming part of another chapter of standards. Goals may be clarified and revised mid-year.
Refer to your department National Patient Safety Goal poster for detailed information about the National
Patient Safety Goals and how they are implemented at Memorial Hospital. Know the goals, their purpose and how we carry them out. The National Patient Safety Goals are an area of emphasis during survey but more importantly, they are the right thing to do for our patients, every day.
Be aware that our implementation may differ from other facilities where you have worked, including other
HCA facilities. Although some of the goals are universal, most give facilities latitude to determine facilityspecific processes that work the best. What works well in one facility may not work well in another.
National Patient Safety Goal posters and badge buddies are available in the Quality Department. If you have questions about National Patient Safety Goals, or would like to learn more, contact Kelly Mullee,
Patient Safety Officer at ext 6709.
April 11, 2011
The nursing chapter ensures that the quality of nursing services is built upon the leadership of a nurse executive. The nurse executive is responsible to promote quality by incorporating current evidence based practice, nationally recognized professional standards and other expertise into policies and procedures governing provision of nursing care, treatment and services.
Who is our Chief Nursing Officer?
Sandi Grimes
What is the process for development and sign off of hospital wide-clinical policies and procedures?
All hospital-wide policies go through the Interdisciplinary Policy and Procedure Committee for review and approval.
What is the process for development and sign off of unit-based policies and procedures?
Unit-based policies and procedures are developed and reviewed within that specific unit according to applicable laws, regulations, and standards.
25

April 11, 2011
The Provision of Care, Treatment and Services Chapter outline requirements relative to core processes of planning, implementing and discharge or transfer. It also provides guidance relative to special conditions
(i.e. - Restraint and Seclusion).
Interdisciplinary Plan of Care
What is the purpose of an Interdisciplinary Plan of Care?

To set individualized goals for the patient with the healthcare team
 To identify problems impacting the patient’s progress through the continuum

To facilitate communication and coordination of care between patient/staff/physicians
 To document the patient’s progress or lack thereof

To identify needs for patient education

To identify needs for patient discharge
Assessment and Reassessment
What is the time frame for the initial assessment of patients on your unit?
 The patient’s H& P, nursing assessment and other screening assessments are done as soon as possible and within 24 hours of

Other disciplines: know your unit/department admission. standards
When are further reassessments done?
Minimally:

At regularly specified times based on standards of
 When a significant change occurs in the patient’s condition
 When a significant change occurs in the patient’s diagnosis
 According to the patient’s treatment to assess their response care
{insert facility specific requirements- consider including nursing, physical medicine, case management, nutrition, respiratory and other disciplines}
How is the assessment data used?
It drives the care of the patient. The data is used to individualize each patient’s plan of care. Be prepared to speak to individualized aspects of patient care.
Discharge or Transfer
How do you provide for coordination of care, including discharge or transfer?
During the admission process, patients are assessed for ongoing care needs and need for possible services. Case managers and/or nurses collaborate on continuous care and the discharge plan.
Communication regarding patient care occurs via:

The use of high-risk screening assessments

Documentation of various disciplines

Formal and informal case management rounds/staffing

Family/significant other case conferences when needed
How do patients and families learn what their care needs will be after leaving the hospital?

Patients and families are included in the discharge planning process.
 If being referred or discharged to other agencies, the patient’s right to choice is protected

After assessment and planning, nurses and/or case managers discuss anticipated needs with the patient and their family.

Patient and family education included on discharge: o Reason for discharge o Specific discharge instructions
26

o Referrals to other community services o Current Home Medication Lists and medication instructions o Arrangements for home health, hospice, support groups, rehabilitation services, etc.
When is the discharge planning process initiated and how is it handled?
On admission to the hospital by all disciplines! All patients are continually reassessed (initial assessment, interdisciplinary rounds, up until discharge) to determine their needs. The plan of care is developed as the patient progresses through the course of treatment and plans are revised, as needed, to transition the patient to the next level of care. Discharge plans are discussed during rounding to evaluate, prioritize and implement the patient’s plans.
Is there a resource for discharged patients who need help at home, yet aren’t eligible for home care or other services?

Anyone can refer patients to Case Management for further information.

Case managers work with the physician and other healthcare providers to coordinate care
Abuse and Neglect
If you suspect that a patient is a victim of abuse or neglect, what are your responsibilities?
Whenever any member of the medical team suspects abuse or neglect, he/she must contact the physician and case management staffs, who notify the appropriate agencies. Abuse and neglect victims may be children, adults or elders. Specific procedures are outlined in the {insert facility specific P&P).
What criteria do you use to identify whether a patient is a victim of abuse?
There are several categories of abuse: Physical, Emotional, Domestic, and Sexual.

Physical abuse: unexplained injuries, burns or bruises

Sexual abuse: bloody underclothing, unexplained genital infections/disease

Psychological abuse: excessive fears, insomnia, weight changes, loss of interest

Domestic abuse: any of the above
What criteria do you use to identify victims of neglect?
Neglect can be more challenging to assess than abuse. Some patient clues might include: feels hungry often; does not regularly attend school (for school age); does not have adequate clothing; parents/ care giver do not provide medications as scheduled; has had many accidents; is homeless; does not feel supported or cared for by parent/caregiver
End of Life Care
What is the priority of care for patients during the dying process?
Priorities for end-of-life care include providing comfort to the patient and family. This involves:

Patient and family comfort (pain management, cots, recliners/sleepers, extra chairs, large rooms)

Dignity (privacy)

Psychosocial, emotional and spiritual support(pastoral care, social services)
What training do you receive for “end of life” issues? What resources are available to the patient and for staff?
{Insert facility specific orientation training and education- Example provided Completion of the “End of
Life” care course in LEARN. Palliative Care Symposiums, including aspects of the dying process, bereavement support, pain management, unit-based education. We have a palliative care nurse who may be consulted for any end-of-liferelated issues. A doctor’s order is needed for a palliative care consult, but if staff has a need or concern, the palliative care nurse is always available. If staff has encountered difficult feelings when dealing with these cases, the palliative care nurse and the chaplains are available as a resource for short-term grief counseling. The employee Assistance Program is available through Human Resources.}
27

Moderate Sedation
What is moderate sedation?
A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accomplished by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.
Who can administer moderate sedation?

A qualified staff member, usually an RN, who is dedicated to just that task. This cannot be an RN assisting with the procedure.

ACLS certification is required.

A special competency is required for those who administer moderate sedation.
What are the monitoring requirements?
{Validate facility specific requirement with list provided below}

Level of consciousness/mental status

Blood pressure

Heart rate

Respiratory rate

Oxygen saturation

EKG monitoring, if clinically indicated

End tidal CO
2
What age-appropriate equipment needs to be immediately accessible?

Oxygen

Intubation equipment

Ambu bag

Suction device

Airways

Emergency drugs for reversal

EKG monitor & defibrillator
What are the requirements for a patient to receive sedation?

Complete nursing assessment

History and physical must include an airway evaluation
 Assessment of the patient’s ASA classification

Consent for both the procedure and the sedation

REMEMBER: If the procedure is invasive, Universal Protocol applies. This includes a preprocedure verification (must use a checklist), sitemarking, if applicable and a “Time Out” is done immediately before the procedure. All elements of the Universal Protocol are documented.
Immediately prior to administering sedation or anesthesia, what must be done?
A re-evaluation of the patient inclusive of vital signs, O
2
saturation, etc.
Nutrition
How do we screen and assess a patient’s nutritional status?
There is a list of nutrition risk triggers that are part of the Nursing Admission Database in the clinical information system, which is completed within 24 hours of admission. These triggers automatically generate a notification to the clinical nutrition department for follow-up. The clinical nutrition staff also rescreens all patients, based on criteria including: certain diets (nutrition support, prolonged NPO or clear liquid diet status), weight, ALB/pre-ALB, diagnosis, and other risks factors and assigns a risk. {Insert facility specific Clinical Dietician Assessment Turn-Around-Time requirements}
Where can you find the diet manual?
{Insert facility specific response: example provided-The American Dietetic Association Nutrition Care
Manual is online and updated annually. A copy of how to access the manual is in all the patient education binders in all patient care units. Additionally, there is a copy in the Clinical Nutrition
Manager’s office.}
28

Pain Management
How is a patient’s level of pain assessed?
We use a pain scale appropriate to the patient’s age and cognitive development.

Numerical scale, 0 to 10

Verbal scale, no pain to worst possible pain

Happy to sad faces

FLACC – for pediatric patients

FRACC – non-verbal or sedated patient

NIPS – neonatal

PIPP – premature infants
What do I need to know about pain management?
Patients have a right to pain management.

Pain must be assessed: upon admission, at least every shift, after intervention (pain medication or nonpharmacologic intervention), as needed and prior to discharge

Pain must be addressed with some intervention: medication, nonpharmacologic interventions, referral for chronic pain, etc.

Pain must be reassessed within {insert facility specific timeframe i.e. 1 hour} of an intervention
Patient/Family Teaching
Who is responsible for teaching patients?
All clinical staff and practitioners are responsible for patient education. Whenever possible, family members/significant others, who are involved in the care of the patient are included in this teaching.
Teaching must be documented. Referrals for health education classes or counseling are made as needed.
What are the critical components of patient education that must be documented?

Assessment of individual learning needs (What do they need to know?)

Assessment of individual learning style ( How do they learn best?) and then delivering education based on the learning style
 Assessment of the patient’s readiness to learn and/or barriers to learning

Response or effectiveness of teaching
Be prepared to demonstrate above aspects in your documentation.
What resources are available to teach patients and families?
Support materials include printed patient information sheets, booklets, videos and patient education channels. Patient education materials are approved and reviewed regularly to ensure they are current and reflective of evidence based practice.
Restraint and/or Seclusion
What is considered a restraint?
Restraints include all manual, physical, mechanical and material devices used to involuntarily limit freedom of movement. (Examples include: Wrist, Ankle, and Elbow restraints, Leather restraints, Physical holds, Geri-chairs, Specialty Beds, and Side Rails for bed with 4 side rails and all 4 raised). Chemical restraints are comprised of a drug(s) or medication(s) used as a restriction to manage a patient’s behavior or restrict freedom of movement and when its use is not a standard treatment or dosage for the patient’s condition
29

What is our policy about restraint use?

We recognize the right of patients to be free from restraints of any form therefore out goal is to limit restraint use

Restraint may only be used when alternatives to restraint use have been determined to be ineffective and may never be written as a standing or PRN order.

Type of restraint used must be least restrictive

Restraint must be discontinued at earliest time possible, regardless of the length of time identified in the order.

Once a patient in restraint or seclusion meets Criteria for Release, they will be removed from restraint or seclusion.
Do we use seclusion here?
{Insert facility specific locations}
What is the difference between a behavioral restraint and non-behavioral restraint?
While both forms of restraint involuntarily limit freedom of movement, the purpose of the restraint differentiates between the two. Non-behavioral restraints are to be used in order to assess, stabilize or treat a patient receiving medical or surgical services and situations where unlimited movement would prevent or seriously hinder efforts to provide those services, resulting in serious harm to the patient or others. Behavioral restraints are to be used when the patient demonstrates violent or self-destructive behavior (danger to self or others). Location of the patient is not a factor for determining whether a restraint is to be ordered for behavioral or non-behavioral purposes.
Can posey vests be used as restraints?
No, Centura CNO’s made a group decision that posey vests will no longer be used. Most healthcare organizations have eliminated vest and posey restraints from their inventory of restraint devices due to the number of employed injuries and deaths.
What has to be included in an order for restraint or seclusion?

Type of restraint to be used

Time-limit for order (which should be age appropriate if behavioral)

Date and Time of the order
If a patient is in restraints and it looks like he can do without them, and I take them off, can I then put them back on, if after 30-40 minutes it looks like he is going to need them after all?
No, you may not. That is called a trial release. And trial release constitutes an as-needed (PRN) situation, which is prohibited in the regulation. Once a staff members ends a restraint intervention, staff should only reinstate after obtaining and order, unless emergent.
If a patient has been assessed for continued need of a chemical restraint and you cannot order any form of restraint PRN, does the nurse have to call for orders for new medications when the time-limit expires?
Yes, the nurse would have to call. When chemical restraint is used for behavioral purposes (patient is a danger to self or others) a physician or practitioner in charge of the patient must order the medication.
If a patient needs to be restrained for behavioral (violent, or self destructive) reasons:

Restraint or Seclusion must be ordered by a physician or other LIP who is responsible for the care of the patient.

If the attending physician did not order Restraint or Seclusion, the attending physician must be consulted ASAP.

Patients in behavioral restraint or seclusion must be monitored through continuous in-person observation by an assigned staff member o After the first hour, a patient in seclusion without restraints may be continuously monitored using simultaneous video and audio equipment which are in close proximity of the patient, if consistent with the patient’s condition or wishes
30



Assessment and monitoring will be documented every 15 minutes
The physician or other LIP responsible for care of the patient must perform a face-to-face evaluation within one hour of a behavioral restraint or seclusion to evaluate underlying conditions and need for further behavioral restraint or seclusion

(for facilities allowing qualified and competent RN or PA to perform the one hour face to face assessment- inser t this language…At (insert facility) a qualified and competent RN or PA may perform this face to face assessment, however they must consult with the attending physician after the evaluation is completed)
Resuscitation Services
Where is the nearest Code Blue cart for your department located?
Know location of carts
How often are Code Blue carts checked?
The following are checked daily for 24/7

Integrity of the lock

Critical Equipment is functioning plugged into red outlet, portable oxygen

Staff should also observe carts for when expire

{insert other facility specific information} departments:
(defibrillator, EKG monitor) and supply is sufficient. next medication or supply is to
What number is called when a patient has a medical emergency requiring CPR?

{insert other facility specific number}
When is a Rapid Response Team to be called?
The Rapid Response Team can be called to provide specific early assessment and stabilization recommendations when

Any staff member is worried about the patient

When criteria have been met o {insert facility specific criteria}

It is a patient responsibility to notify staff to request assistance with changes in condition or symptoms o {insert facility specific information if families are to be educated and empowered on how to call a
RRT- Example provided: “Condition HELP” will empower patients and families to call an RTT}
What is our standardized process for hand-off communication?
(Insert facility specific process). Minimal information exchanged should include the patien t’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these. Hand-ff communications occur during shift t changes, staff relief and transfers. The receiver of information always has an opportunity to ask questions.
Fall Prevention Program
How does (insert facility) assess and manage the patient’s risk for falls?

Initial and on-going fall risk assessment is conducted in all settings and for all patient populations.

Interventions are implemented based on the p atient’s assessed risk.
31

April 18, 2011
The goal of performance improvement is to continuously improve patient health outcomes. It involves measuring the functioning of important process and services, and, when indicated, identifying changes that enhance performance. These changes are incorporated into new or existing work processes, products or services, and performance is monitored to ensure that the improvements are sustained.
What performance improvement methodology(s) at {insert facility name?
{Insert facility specific}
Who has ultimate responsibility for the quality of care and performance improvement at (insert facility name)?
The Community Board is responsible for quality of care and for prioritizing the performance improvement activities
How are the staff and physicians involved in performance improvement?
All staff and physicians are responsible for and involved in performance improvement activities either through ongoing data collection, analysis of results, development of action plans, and implementation of those plans and/or measurements of success or PI team participation. {Insert facility specific}
How are Performance Improvement projects chosen?
Recommendations for PI activities may come from staff, leaders, or physicians, Leaders set priorities for both departmental and organizational PI activities, giving priority to high-volume, high-risk, or problemprone processes. PI Team activities are prioritized and re prioritized in response to significant changes in the internal or external environment.
What current hospital wide performance improvement projects are you aware of at {insert facility specific}?
{Insert facility specific}
What PI activities have YOU been involved in?
Prepare and know your answers. Have an example and for the hospital.
What is your role in PI activities? from your department/unit
Examples can include:

How you have been involved in improving patient satisfaction

Your role and understanding about Core Measures

Your participation in a departmental PI team
What is your responsibility for improving care and services at {insert facility specific}?
It is everyone’s responsibility to look for opportunities to improve care and services. When you see opportunities, discuss them with your department director and participate in making improvements. Also, incorporate performance improvement principles and values into your everyday work processes.
What is a sentinel event?
Any event resulting in unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying conditions or the event is one of the following:

Suicide of any patient receiving care, treatment or services in a staffed around-the-clock care setting or within 72 hours of discharge

Unanticipated death of full-term infant

Abduction of any patient

Discharge of an infant to wrong family
32


Rape while being treated on hospital premises or while being treated

Hemolytic transfusion reaction involving the administration of blood or blood products having major group incompatibilities

Surgery on the wrong patient or wrong body part

Unintended retention of a foreign object in a patient after surgery or other procedure

Severe neonatal bilirubinemia (bilirubin >30 milligrams/deciliter

Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose

A patient fall that results in major permanent loss of function as a direct result of injuries sustained

Patient death, paralysis, coma or other major permanent loss of function employed with a medication error

Restraint related death

Health-care employed infection resulting in unanticipated death or major permanent loss of function
{Facilities should check their SE P&P’s to ensure their lists are reflected of the requirements posted in
‘08}
What is the process for handling a potential sentinel event?
Your role is recognition of a sentinel event or potential sentinel event, preserving the equipment/supplies involved and environmental conditions, and alerting your immediate supervisor/department director.
What is a Root Cause Analysis?
Root Cause Analysis (RCA) or Critical Event Analysis sentinel events and other potentially catastrophic contributing causes of the event. RCA’s/CEA’s have

An interdisciplinary team, involving those closest to
(CEA) is a systematic review of events to identify basic and the following characteristics: the process under review, performs the review

The review focuses primarily on systems and processes rather than on individual performance
 The analysis digs deeper by asking “what” and “why” until all aspects of the process are reviewed and contributing factors are considered

The analysis identifies and suggests changes that could improve the systems and processes evaluated

These changes could include redesign of processes/systems or development of new ones that could improve performance and reduce the risk of future adverse events or close calls
What is an FMEA?
It is a Failure Mode Effects Analysis - a proactive way to evaluate a process, identify possible failures and to correct them before an occurrence happens.
What FMEAs have been done at {insert facility specific}?
{Insert facility specific}
33

April 25, 2011
The Rights and Responsibilities of the Individual chapter recognized that care treatment and services should be provided in a way that respects and fosters patient dignity, autonomy, positive self-regard, civil rights, and involvement in his or her care. Care should be planned and provided with regard to the patient’s personal values, beliefs and preferences. It also recognized that patients have obligation to take on certain responsibilities.
Where can patients get information about their rights and responsibilities?

A copy is provided with the hospital admission paperwork

On Patient Rights and Responsibilities posters located in all major hospital entrances
 It’s in the Patient Handbook & Visitor’s Guide
How many patient rights can you name?

Right to be notified of their rights in advance of receiving care

Right to impartial access to care

Right to give informed consent

Right to participate in care, discharge plans and care decisions

Right to pain management

Right to information on health status and prognosis

Right to be treated with respect and dignity

Right to privacy, comfort and security

Right to be free from Restraint or Seclusion

Right to have access to visitors, telephone calls and mail

Right to access interpretive services and communication aids at no cost

Right to have access to pastoral or spiritual care

Right to have access to protective services

Right to receive care in a safe setting

Right to freedom of abuse or harassment

Right to request medically necessary care

Right to refuse care

Right to research information

Right to information on Advance Directives

Right to participate in decisions regarding ethical issues

Right to have family and physician notified of hospital admission

Right to know names, professional status and experience of caregivers

Right to access of clinical records

Right to be examined, treated and transferred (if necessary if having an emergency medical condition

Right to information regarding hospital charges, co-payments, deductibles, and general billing procedures

Right to information on hospital complaint and grievance procedures, including how to contact other agencies
How many patient Responsibilities can you name?

Responsibility to ask questions and voice concerns

Responsibility to give full and accurate information

Responsibility to report changes in condition or symptoms and request assistance

Responsibility to participate in planning care

Responsibility to follow recommended treatment plan
34


Responsibility to be considerate of other patients and staff

Responsibility to secure valuables

Responsibility to follow facility rules and regulations

Responsibility to respect property

Responsibility to understand and honor financial obligations related to care
In your job, how do YOU protect the patient’s privacy?
All patient information is to be kept private and used only in the course of business and patient care. We follow HIPAA guidelines and regulations. HIPAA is an acronym for H ealth I nsurance P ortability and
A ccountability A ct. It sets strict rules about how we handle a patient’s confidential health information in our medical records, computer systems and even the conversations we have. Be prepared with an answer. For example:

I do not discuss patients in public areas (elevators or cafeteria).

I read and signed the Memorial Hospital Confidentiality Agreement during my annual performance appraisal.
 I do not look at a patient’s record of medical care, manually or electronically, unless I need the information to provide their care.

I close or minimize computer screens displaying protected health information when completed and ensure that printed patient-specific information is secure.

Any patient-sensitive written material is shredded after use vs. being put in a regular trash can.
Who is Memorial’s Facility Privacy Officer?
Cindy Vorhees and her number is 399-6103
Who is Memorial’s Information Security Officer?
Roberta Ashton and her number is 399-6876
Who is Memorial’s Patient Safety Officer?
Kelly Mullee and her number is 399-6106
Who is Memorial’s Ethics and Compliance Officer?
Eric Goldman and his number is 391-1314
Who is Memorial’s Safety Officer?
Grady Padgett and his number is 399-6907
What would you do if you saw another staff member breaking the confidentiality of a patient’s medical information?
Approach the staff member directly and remind him/her of our obligation to patient confidentiality. If you are uncomfortable doing this, you may report your concerns to the manager. You may also call the
Privacy Officer, Cindy Vorhees and 3996103. It is each employee’s responsibility to report these concerns.
What is an “Advance Directive?”
An Advance Directive is a written instruction expressing a patient’s wishes about medical treatment decisions. There are many types of Advance Directives, for example:

Living Will

Healthcare Surrogate

Florida Portable DNR (do not resuscitate) Form
What things are done to ascertain whether a patient has an Advance Directive or whether they need information on Advance Directives?

Ask the patient/family if he/she has an Advance Directive.
35

 If, “yes,” ask the patient/family for a copy and place it on the patient’s chart. If copy has not been provided, ask patient or family to bring so that information may be placed in the record ASAP.
 If, “no,” offer information and provide an opportunity to establish Advance Directives. Contact Case
Management for assistance.
 Physicians may document the status of the patient’s Advance Directive in the Progress Notes.
How do we identify patients wi th “Do Not Resuscitate” (DNR) orders?

If a patient arrives with a Portable DNR Form , notify the physician and obtain “DNR” order.

We place a purple alert wristband on patient with any level of DNR order. This indicates that the patient wants less than a full code performed should his/her heart stop. If your patient has a purple alert wristband, check the patient’s chart to determine specifics of the DNR status.
Who is responsible for performing Informed Consent?
It is the patient’s right to be informed about their medical treatment. It is the Physician or LIP’s responsibility to obtain informed consent from a patient. The Physician or LIP has the medical knowledge necessary to provide pertinent information to the patient concerning the patient’s condition, the probable results of a proposed treatment, and the risks of alternatives of the treatment. The Practitioner (MD or
LIP) who is privileged to do the procedure may obtain consent for the procedure.
What is your response when issues related to personal beliefs, values or ethics come up?

Discuss with your supervisor
If you suspect that a patient is a victim of abuse, what are your responsibilities?
Whenever any member of the medical team suspects abuse or neglect of a vulnerable adult or a minor child, he/she must contact the supervisor and call 1-800-96-ABUSE. Specific procedures are outlined in the Abuse-Identification and Reporting Policy - #V.01.
How does Memorial Hospital deal with pain management?
Pain management is part of the patient’s Plan of Care. Patient care staff assess and re-assess each patient’s pain and intervenes as needed.
How do you manage complaints from patients, family members or visitors?

First, try to resolve the concern at the time the complaint is voiced.

Listen attentively in a caring manner and try to correct the problem right away, when possible.

If unable to resolve the complaint, involve your supervisor and follow the chain of command.

If necessary, call our Memorial Hospital Patient Representative at ext 1215.
How do you ensure that patients who speak other languages can understand what you are saying?

Do not use family members of non-English-speaking patients to interpret medical information for their patient-relatives. If the patient insists on using family, document this request. Family Members may not know how to interpret complex medical terminology or may misinterpret information that they feel is too difficult for the family members to accept.

Use the AT&T Language Line interpreter phones, which are available on patient care units.
How do you communicate with patients who are hard-of-hearing?

Upon identifying or being advised of a deaf or hearing-impaired patient, the patient or family member will be provided with the Hearing Impaired Information sheet that lists the availability of equipment and services.

The Nursing Office or House Supervisor will be contacted if any equipment is needed.
 A “Hearing Impaired Patient” label should be placed over the def patient’s call indicator light at the
Nursing Station.
36


Nursing and other personnel will attempt to communicate by referring to the visual training aid located on every unit.

Face the patient and direct your voice to the better ear, speaking clearly and loudly.

Attempt communication by writing the conversation on paper.

Assess whether and when it may be most appropriate to use a sign-language interpreter.
 Refer to the policy, “Hearing Impaired, Services for (Section 504)” #III.43.5.
How do you care for patients from other cultures?
We are sensitive to the diverse cultural needs of our patient population.

Kathy C – I need to add some information here!!!!!!!
What is the process for informing patients and/or families about unanticipated outcomes?
We follow our Variance/Sentinel Event/ & Code 15 Reporting Policy (#V.11)
How are patients/family members asked about organ or tissue donation?
Employees do not discuss this with patients/families at all. The Organ Procurement Office is contacted and they follow through with contacting patients/family members. Talk to your Supervisor if questions.
37

May 2, 2011
The goal of this new chapter is to define the components of a complete medical record, which comprises all data and information gathered about a patient during their stay. Whether the hospital keeps paper records, electronic records, or both, the contents remain the same.
Can you show me in the patient’s record his plan of care?
Know where to locate plan of care in Meditech and be able to show historical data back to date of admission.
How frequently do you update the plan of
Each shift
Can you show me the initial pain assessment care? and historical data?
Know where to locate in Meditech and be able to admission. show trends back to the date of
How frequently do you document assessments for a patient in non-behavioral restraints?
Behavioral restraints? What types of things are you assessing?

Show Initial Assessment; Ongoing monitoring and assessment, and Teach interventions

For all restraints be able to show Second Tier Review

Also be able to demonstrate how restraints is evident in the plan of care

Prior to initiation of all forms of restraint; there must be a documented assessment demonstrating need for restraint and that alternatives were first attempted, unless emergent. This is completed in
Meditech.

Documentation of Observation and monitoring must occur: o Upon initiation and three times every hour for Non-behavioral restraint o Upon initiation and every 15 minutes thereafter for Behavioral Restraint
ADD ASSESSMENT? SUZANNE?
If a patient is in restraints, how long are the orders good for?
All orders for restraints are to be time-limited

Behavioral restraints time limits: 4 hours for ages 18 and older; 2 hours for ages 9-17 and 1 hour for under 9 years

Nonbehavioral time limit: initial order not to exceed 24 hours and then every calendar day
Do you frequently receive verbal orders?
We discourage the use of verbal and telephone orders. The only verbal orders we accept are those that are emergent. When taking a telephone order, we write down what was stated. Verbal orders and telephone orders are repeated back.
What are your requirements for authentication of telephone and verbal orders?
We require that orders are authenticated within 48 hours. Authentication may occur either by e-signature or written signature. If authentication occurs in a written form they must be dated and timed to prove done within the 48 hour requirement.
REMEMBER: All entries in the medical record must be SIGNED, DATED and TIMED and LEGIBLE
38

May 9, 2011
This chapter focuses on the development and implementation of policies and procedures for safe organ and tissue donation, procurement and transplantation. Organ transplants are often life-saving procedures. Tissue transplants are most often to enhance the lives of recipients, they too can save lives.
Tissues often transplanted include bones, tendons, corneas, heart valves, veins and skin.
When a patient dies or death is imminent, when are we required to notify an Organ Procurement
Organization?
Whose responsibility is it to determine medical suitability of organs for organ donation, and tissues and eyes for donation?
The Organ Procurement Organization or tissue and eye banks are responsible to determine suitability.
The transplantation of tissue has been increasing over the last 10 years due to the successes and advances in this field. As technology improves and transplantation of tissues continues to increase so will the risks associated with it. The risks associated with tissue transplant are well documented. Possible risks include HIV, hepatitis B and C, and bacterial and/or fungal infections.
Why is it important for staff in all areas involved in the use of transplant tissues to carefully comply with all procurement, storage, handling, and tracking procedures?
Careful compliance with procedures is crucial to ensure the safety of out patients and minimize the risk of infection. Complete and accurate patient tracking information is required for the appropriate follow-up of the patient (i.e., testing and/or treatment) in the event there is a recall of a tissue product.
39

May 9, 2011
The Waived Testing chapter addresses some of the tests performed at the patient’s bedside, or point-ofcare. Although simple to perform, waived tests are not “error-proof”, and to ensure patient safety it is important that documented testing procedures are followed, that staff is competent, and that quality control is maintained.
What is Waived Testing?
“Waived” testing is defined as testing that has been cleared by the Federal government to be excluded from Federal laboratory regulation (i.e., these regulations have been “waived”.) This type of testing is often performed at the patient’s bedside or on the nursing unit by non-laboratory staff.
If it ’s “waived” testing, then why the focus on procedures, quality control, and staff competency?
Because even though this testing is not regulated by the Federal government, it is not “error-proof”. The
Joint Commission, in order to protect hospital patients, has implemented performance standards that closely mimic federal laboratory regulation.
What waived testing is performed at Memorial?
The only waived tests that are performed throughout Memorial are Accuchek bedside glucoses. A few other tests (i.e., “dipstick” urinalysis, urine pregnancy, fluid pH, etc.) are performed at specific selected sites. You should know which tests are performed on your unit, and be aware that procedures for all waived tests are available in the Interdisciplinary Procedures on Policy Manager.
How does this facility assess a staff member’s competency to perform waived testing?
Prior to performing patient testing, employees must be trained, and their competency verified by demonstration of the test procedure and completion of a written exam. Each testing employee’s competency is also assessed annually using the same methods. In additional, on-going quality control monitoring ensures that potential performance issues do not go unidentified.
What are our quality control standards for Waived Testing?
Quality control requirements are specific to each test. Again, know your unit’s specific waived testing quality control requirements. For example, Accucheks are quality checked once per 24 hours using a high and low glucose control. Results of Accuchek quality control can be checked on the meter, and are also documented in the RALS data manager where they are monitored by the Point-of-Care Coordinator in
Lab.
Do I have to label point of care tests with patient ID information?
You must use our two patient identifiers to identify the patient prior to testing, but testing performed at the patient’s bedside does not have to be labeled. If specimens are removed from the patient’s bedside to be tested at a workstation, they must be labeled with the patient’s name and account number.
40

If you have questions or would like to learn more:
1. Call or visit the (insert facility quality department’s name and location): You can contact (insert facility quality department contact names and numbers). We will be happy to answer any questions or concerns you have.
2. Visit the Centura Quality and Patient Safety website in My Virtual Workplace at https://www21.myvirtualworkplace.org/SiteManager/UI/Pages/PageViewer.aspx?sID=9 . There is numerous quality, regulatory and patient safety information that you may find interesting or useful
3. Visit The Joint Commission website at http://www.jointcommission.org/ The standards are not on the website, although the National Patient Safety Goals are, along with FAQs for many of the standards. There are interesting articles and updates. We follow hospital standards only.
4. Look at the Joint Commission standards. Go to My Virtual Workplace/Reference/Joint Commission
Manual or http://amp.jcrinc.com/Frame.aspx
You may access The Joint Commission E-dition, where you may search by word or topic or search standards chapter by chapter.
5. CMS standards may be found at: http://cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf
along with survey guidelines and other information for hospitals. Joint Commission standards are more frequently mirroring CMS standards and we must be compliant with both sets of standards.
6. It is your responsibility to know and understand (insert facility name) Policies and Procedures by which we will be surveyed. Know how to access Clinical, Infection Control and Environment of
Care/Safety policies.
7. Get involved with departmental performance improvement activities. It takes many sets of eyes and commitment to be compliant.
Any employee who has concerns about the safety or quality of care provided at (insert facility name) may report these concerns to your department manager, (inse rt facility’s quality department) or to The Joint
Commission. (Insert facility name) will take no retaliatory disciplinary action because an employee reports a safety or quality of care concern.
41