Environment of Care
What is the first step in preparing your practice for a DNV survey?
Ensure all areas are clean, free of dust and clutter, and remember if you see something out of compliance, correct it immediately.
Remember, "Always alert. Always accountable." If you see something, fix it immediately, and/or involve your leaders if you need assistance.
What acronym is used to remember how to properly use a fire extinguisher and what does it stand for?
PASS - Pull, Aim, Squeeze, Sweep
What process is used to improve patient care and safety based on performance data?
Quality Improvement
Where should team members go to find a policy?
PolicySTAT is located in the citrix receiver. If you created a shortcut, it may also be on your desktop.
Who is DNV?
Det Norske Veritas (DNV) is an organization dedicated to improving the quality of care in healthcare settings. DNV's National Integrated Accreditation of Healthcare Organizations (NIAHO) align with Centers for Medicare & Medicaid (CMS) regulations but contain additional standards. St. Mary's Regional Medical Center, including our practices, are NIAHO accredited.
What are some requirements within our practices that help us ensure patient safety and decrease infection risk?
Some things we require include:
- No storage under sinks
- No shipping boxes for storage and no corrugated cardboard at all.
- Patient supplies must be at least 4 inches off the floor. Wire/metal shelves must have a protective liner on the bottom shelf to prevent splashing when the floor is washed.
- Clear separation of clean and dirty areas. Clean supplies cannot be stored in dirty utility rooms.
- No storage less than 18 inches from the ceiling.
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What does the acronym RACE stand for and when would you use it?
RACE - Rescue, Alarm, Contain, Extinguisher
You would use it when you find a fire in the clinic to assist you with taking steps in the proper order.
What type of data does the practice track to monitor quality and performance?
Where can you find your current QI projects and data in your practice?
Quality metrics and performance measures.
These should be available on all huddle and/or quality boards within every practice. All team members should be able to speak to this work, and during a survey, if asked, should be able to show this to surveyors when asked.
Why is it important to follow policies related to your job duties?
To ensure safe, consistent, and compliant patient care.
How often will we have DNV surveys?
Surveys occur every year, so we need to always be ready to highlight the high-quality, patient-centered care we provide to every patient, every time.
Sharps and medication must be stored how?
All sharps and medications must be stored securely, in a locked room or cabinet, with access limited to only those who need it.
Why: Unattended medications and sharps can cause harm if taken by an unauthorized person.
What is the name of the document that explains how the team responds to fires, disasters, and other emergencies?
Emergency Operations Plan (EOP)
In what ways do we gather patient feedback for our practices and how do we use it?
- Patient and Family Advisory Council, run by our Patient Experience Manager, Mariah Rinck
- Press Ganey Surveys - sent to patients after qualifying visits. Comments are sent directly to providers and leaders review and respond to patient feedback when applicable. This feedback is also used to help improve care.
- Midas entries for compliments and complaints are reported into this database when patients speak directly to staff members.
***If you cannot speak to at least one project, workflow, or process that is being worked on based on patient experience feedback, please speak with your manager or director for more information. ****
How does DNV verify staff knowledge of policies during a survey?
By interviewing staff and using "tracer" method to follow it through to ensure it was properly applied. Reminder, team members CAN and SHOULD pull up the policy if asked vs. trying to speak to it from memory if not sure. Using appropriate resources is allowed and encouraged.
When will DNV arrive?
Surveyors can and will talk with team members, including our front line healthcare workers, providers, leadership, and patients.
Why do we check for expiration dates upon every use and at minimum weekly?
To keep patients safe.
Will also accept: "To prevent Ashley from losing her mind." and/or "To keep Ashley happy." =)
Minimally, how often should EOPs be reviewed and where can you find them?
EOPs should be reviewed annually, and all team members must sign the roster to confirm they have reviewed them. The Emergency Binder, which has the EOPs for each code, can be located in the practice and are updated on the Emergency Plans sharepoint site.
What does PDSA stand for and what is it?
Plan-Do-Study-Act is a continuous improvement model used by the practices and monitored when applicable by our quality department.
Per policy, oxygen tanks must be stored how?
- Oxygen tanks must be stored securely and clearly labeled full, partially full, or empty.
- Empty canisters need to be stored separated and must be removed from the practice as soon as practically able.
- Signage must be posted on doors of rooms that store oxygen tanks.
............................................................................................. Yes! But all team members are also required to wear badges every shift, at all times.
Team members wear badges to:
Clearly identify themselves and their role to patients and visitors
Prevent unauthorized access to clinical and restricted areas
Support safety and security within the practice
Help patients feel comfortable and informed about who is caring for them
A) What do you do if you find broken equipment?
B) What do you do if you find damage to a wall, or some other permanent fixture?
A) Remove from use, fill out and then tag with details, submit ticket to appropriate department, notify direct supervisor
B) Enter maintenance ticket, print and provide to direct supervisor for tracking to completion.
Name at least three requirements that help ensure proper egress within the outpatient practice.
An egress is the path we would take to leave a practice at all times, but especially during an emergency, and must be obvious, unobstructed, and useable. Some requirements include:
Illuminated exit signs that are visible at all times
Hallways and exit routes kept free from clutter or storage
Exit doors that are unlocked (going out) and in the direction of egress
Clearly marked exits
Fire and smoke doors that are not propped open
Access to exits not blocked by furniture or equipment
Minimally, how frequently does updated QI data come out for review and where is it found? Who can I ask if I have questions?
QI data is updated and emailed monthly from Missy Douglass, our Quality Manager. It can be found on huddle and/or quality boards and any questions can be directed to your lead, manager, director, and/or Missy. In addition to this, the Practice Quality Specialist Team attends team meetings to discuss quality and performance data and are a great resource and help track the impact of the changes we make to improve quality and patient experience.
All employees are provided training upon hire and annually regarding Hand Hygiene. Per the policy, what indications require hand hygiene to be performed?
Hand hygiene indications include:
What do I do when a surveyor arrives in my department?
- Stay calm, be confident in what you know!
- If interviewed, be respectful, kind, and always start by introducing yourself and your role.
- Listen carefully, and when responding, answer questions directly (do not give additional/extra information) and to the point. Be polite and it is okay to stop talking once you answer an wait to see if they have a follow up.
- Ask for clarification if you don't understand the surveyors question.
- Be honest. If you don't know the answer, simply say, "I don't know currently but I would ask my lead, manager or look at the policy (or name resource) to find the answer"
Never argue, become defensive, or come across as negative. Be positive and shine!