Environment/Safety
In the halls, you can't park carts, or computers in front of these.
What are Electrical panels, fire extinguishers or medical gas?
Surveyors will assess SJB's compliance with CMS regulations & DNV NIAHO standards.
What is a DNV survey?
Database used to store Hospital Policies.
What is PolicyStat?
Department specific continuous study to improve a process, with a goal to improve outcomes & decrease/prevent unexpected events.
What is Department Quality Performance Improvement? What is your department collecting data on and how are you doing????
The time it takes a cleaner to kill germs on a surface.
What is cleaner dwell time?
Drinks on computers, at a nursing station or in an empty room that can be used for a procedure.
What is an Infection Prevention citation? OSHA regulation.
Patient information on an unlocked computer screen.
What is a potential HIPAA violation & survey citation? If a family member walking by can see patient information, it would be a citation.
1. Using proper patient ID.
2. 5 rights for medication
3. Fall prevention
4. Time outs for procedures
5. Proper cleaning of patient rooms & equipment.
What is patient safety?
Focus for 2020 accreditation survey.
What is Infection Prevention?
Explain how I provide care, follow SJB/Covenant policies, answer the question asked and only the question asked, know resources if you can't answer the question.
What is my job during the survey?
Your role in the Emergency Management Plan.
What is know what the Color Codes, RACE & PASS?
Hospitals can lose this if NOT compliant with CMS Conditions of Participation regulations.
What is hospital license (& CMS reimbursement)?
Customer focus
Leadership involvement
Process approach & consistency
Engagement of people
Continuous improvement
What is the goal of ISO 9001?
Best way to prevent the spread of infection.
What is hand hygiene?
Your resources to use when surveyor asks you a question you don't know the answer.
What is rephrase question, Policy Stat & Chain of Command?
Refrigerator or blanket warmer is out of range.
What is document it was out of range and what you did to resolve it? Follow through on getting it resolved.
Additional Quality Management System Standards adopted by DNV.
What is ISO 9001?
Surveyor identifies staff/providers are not following policies.
What is survey citation?
Reason that DNV conducts annual surveys in the years between accreditation years.
What is continuous readiness?
Process to properly ID a patient.
What is patient name and DOB?
Frequency code carts must be checked.
What is daily when the unit is open? If not open on a day - write closed on the log.
Say what you do, do what you say, prove it, improve it.
What is the ISO Creed?
Right thing to do
Patients (Customers) come back
Negative Customer feedback results affects reimbursement $$
What is Customer/Patient Satisfaction?
State requirement - Something I must wear everyday (besides clothes & shoes!)
What is a SJB/Covenant name badge?
Only having access to the most recent version of a document.
What ISO 9001 document control? Policies = PolicyStat