TRACERS/MOCK SURVEY
INFECTION CONTROL
ENVIRONMENT OF CARE
MISCELLANEOUS
SAFETY
100
Joint Commission Tracer access
What is:
Toluna
Intranet
100
A)water, soap (all surfaces), 40-60 seconds
B)apply to all surfaces, dry 20-30 seconds
C) sanitize between use, potential exposure to infectious materials
Handwashing
vs
Hand sanitizer
vs
Gloves
100
What is Daily 360 Check
100
Process done upon receipt of items, new shipment, new lot number.
Some items process is done monthly
Control Testing
Process needs to be documented on intranet
200
MC Intranet: Provider Preparedness, Joint Commission Readiness, Clinical Education, Operations Support Lab Manual, Infection Control Manual, Policies and Procedures
Where to Find Joint Commission Tracer answers/explanations
200
Used POCT patient samples
What is disposed of in Sharps container
200
Name 3 HUB or Toluna Tasks
MMR/Menactra Counts
Monthly POCT Controls Monthly Expiration count Monthly Fire Drill Environmental Hazard review Quarterly Emergency alarm Tubersol date Exam Table cleanliness
200
Monthly fire safety task that requires a manual signature
MONTHLY: Initialing the label of the fire extinguisher (closest to the clinic) post inspection
200
EPIC/Patient Safety Event Reporting
What is: Method of documenting patient and non patient safety events.
INTERNAL use for risk assessment/root cause analysis to educate providers in order to prevent future safety events.
300
True or False,
Providers need to memorize answers on the mock survey/tracers
False: The tracers and survey are meant to remind providers/stimulate awareness of how and where to access answers.
If during an actual survey a provider forgets an answer they need to at least verbalize what resources are available to them to answer any given question.
300
Non permeable gown
Gloves, Mask
proper on/off procedure
What is PPE for high risk communicable disease
(See: Intranet Infection Control Manual)
300
What do these have in common:
Tubersol vial, A1c controls,
Strep test vial, Hydrogen peroxide bottle (not wipes)
What is “needs labeling on bottle/vial”
300
Item and frequency for cleaning the glucometer
What is
Super Sani -Cloth and clean glucometer after every use.
300
Tool that is tested quarterly via HUB task, used when: Threatening patient, in clinic emergency.
Emergency Alarm System
Wall and FAB systems
See: Emergency Acton Plan for CVS & Corp Locations
400
Current JC Certificate Date
Next JC survey
What is
June 26, 2018 and (clinics should have received 11/2018)
What is 2021
400
A-3min dwell time for C-diff
B-3min dwell for bacteria/5min yeast (kiosk,surface)
C-15 seconds dwell time (stethoscope, BP cuff, pOx)
What is:
A) Chlorox Whipes
B )Hydrogen peroxide
C) Alcohol wipes
400
True or false: 1) You only need two SALAD stickers in the refrigerator? 2) Epi training pens are kept separately from the actual injectors 3) You can keep your leftover lunch/drinks in the fridge as long as it is properly sealed
What is
1) False: must separate pedi from adult and any other potential SALAD
2) True
3) False
400
Flu Veritor D cartridge disposal
1) patient specimen
2) Control
What Is:
1) Sharps container
2) Strongpak
(MC Inventory Managment a resource for where to dispose of itmes)
400
High risk for respiratory depression if overdosed.
What is:
label that is attached to Diphenhydramine Bottle
500
Clinic signage addressed in MOCK Survey
What are updated:
Patient Rights and Responsibilities (in/out)
JC Certificate
Clia Certificate
500
Oh No! I think its the measles what do I do now?
What is: provider/patient/clinic procedures.
Intranet>>Clinical Quality and Patient Safety>>Infection Control>>Measles precaution
500
Spent light bulbs Used Vials
Used Batteries vs Flu Veritor
Expired Hand sanitizer machine
What is StrongPak Non-Clinical Hazardous Waste (store manager)
vs
Strongpak Clinical Hazardous Waste (in clinic/periodic transfer to pharmacy)
500
Persons with safety and/or quality concerns regarding the health care services provided at MinuteClinic locations may report them directly to the Joint Commission in the following ways
What is: E-mail: complaint@jointcommission.org
Fax: Office of Quality Monitoring (630) 792-5636
Mail: Office of Quality Monitoring The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 6018
500
Immediate reference items that direct providers on how to prepare and respond to emergencies
Egress map
Emergency Evacuation Procedures flip chart (Incident Command Procedures)
Emergency Procedure Plan Summary (need to include MinuteClinic circuit numbers on electrical panel)
600
What is assessed specifically in the CVS storeroom
The electrical panel that contains the Minute Clinic circuits must be labeled and there are no items within 36" of the electrical panel.
600
Specific Minute Clinic Protocol for these MDV vials
What are:
Tubersol and IPV
600
Protects patient privacy
Privacy Screen
HIPPA garbage stored away from patient view or no papers pointing upward.
No patient identifiers visible
600
Where to find Who's in charge of what?
What Is:
Intranet>>Joint Commission Readiness>>JC official documents>>MC governance structure
600
1-888-464-2960
What is CVS Safety Hotline- MSDS/Poison/Spills
700
Name 3 performance improvements made since last JC survey
1) Age Friendy Health systems 2)Managing high risk vitals 3)Antimicrobial stewardship 4)Paraprofessional oversight 5) Vaccine quality and safety 6) Clinical Quality documentatin
MC Intranet>Quality and Safety>Quality Initiatives
700
Quality Improvement initiatives related to infection control
Name at least 3
What are:
Antimicrobial Stewardship (Statement and Council)
Communicable Disease outbreak response plan (Infection Control Manual)
Disaster Relief Resources (Clinical Education)
Addition of Pediatric HEDIS URI measure
700
Six Aims of Quality Care
Safe, Effective, Patient Centered, Timely, Efficient,
Equitable
700
CVS Minute Clinic
1) Purpose
2) Core Values
Innovation, Caring, Collaboration, Integrity, Accountability
700
National Pateint Safety Goals
What are:
Accuracty of Patient Information (2 identifiers)
Saftey of Medication Usage
Reduce Risk of Infection