Policy
NPSG
Process Practice
Performance Improvement
Infection Control
100

Maximum length of time allowed for restricting movement of adult patient

4 hours

100

The most important action to prevent infection

Wash Your Hands

100

This process allows a patient to voice their concerns regarding care or treatment 

Grievance 

100

Document that stores monthly data on measures

QAPI Workbook

200

5 Rights of Medication Administration

Right Person, Medication, Dose, Time, Method

200

A way to match the patient with the right treatment 

2 Patient Identifiers

200

This list of requirements ensures that patients are treated with dignity and respect

Bill of Rights/Patient Rights

200

The rate typically set for a PI Project

Target Rate

300

This must be reported within *** minutes of receiving to the practitioner

Critical Lab Results

300

These documents comprise treatment for the first 7 days

VRRP, Nursing Assessment, Nursing Plan of Care, Psychiatric Assessment, H&P

300

A 6 to 12 month initiative to improve an area of concern

PI Project

300
These items are worn by staff to protect against hazards in the environment

Personal Protective Equipment

400

With this, practitioners assess high risk patient who may self-harm

Comprehensive Suicide Risk Assessment

400
This process compares patient meds and meds ordered by the hospital administrator

Medication Reconciliation

400

This form is submitted when a patient's rights or safety has caused harm, or potential to cause harm

Vulnerable Adult Report

400

Short term project to fix an immediate need

Quick Hit

400

The 2-3 minute interval to kill bacteria on a surface

Sanitizing Wet Time

500

This document is completed an internal review after a sentinel

CER/CIR

500

This treatment may help manage A-fib, deep vein thrombosis or heart valve implant

Anti-Coagulation Therapy

500

This permission form allows for administration of controlled substances

Informed Consent

500

This review process determines the cause of a sentinel event

Root Cause Analysis

500

When dirty items are stored with clean items and have the potential to transfer germs

Cross Contamination

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