What you do for active shooter? OR what not to do when a surveyor shows up in the building?
100
This governing body develops Conditions of Participation and Conditions for Coverage that must be met in order to participate in the Medicare and Medicaid programs.
What is CMS?
What is Centers for Medicare and Medicaid Services?
100
This popular and frequently used technique/process helps people identify and answer questions of why a particular problem occurred.
What is a Root Cause Analysis?
100
Because this is the most effective means or process of preventing hospital acquired infections, we perform secret shopper audits to confirm compliance with this activity.
What is handwashing?
100
Change is not made without inconvenience, even from worse to better.
Who is Richard Hooker?
200
To comply with this policy, we must immediately take equipment out of service, tag it, place it in the dirty equipment room and call maintenance.
What is the policy, "Medical Equipment Failure"?
200
These are the most cited standard categories for Joint Commission Surveys.
Hint: There are three.
What are Life Safety (Environment of Care), Patient Safety (NPSG) and Infection Control?
200
Identify patients correctly, Improve staff communication, Use medicines safely, Use alarms safely, Prevent infections,
Identify patient safety risks, and Prevent mistakes in surgery
What are the National Patient Safety Goals?
200
These are the two greatest risks to our patient population.
What are falls and infections?
200
Different than a routine complaint, this is a complaint that can not be solved easily or quickly and requires more workup by director level staff to address. There are federal and state guidelines for timeliness and documentation that we must meet.
What is a grievance?
300
This process requires maintenance to ensure that the correct air exchanges are occurring before a patient is admitted to this room.
What is implementing negative pressure?
300
These are resources for teaching staff about the National Patient Safety Goals and other compliance information.
What is the Joint Commission Survival Guide?
300
This non-punitive culture encourages staff to report observed risks and near misses.
What is a Just Culture?
300
This process that leaders use to ensure that change was implemented into practice.
What is "inspect what you expect"?
300
This is the methodology we use to address process improvement.
What is PIIE?
Extra points if your team can say what that acronym stands for.
400
This is the company that is called when Life Safety equipment fails and the company the performs all preventive maintenance inspections on Life Safety equipment.
What is UHS?
400
This is the process in which facilities report their compliance with standards half way through the survey cycle.
What is the ICM or Intracycle Monitoring?
What is the PPR or Periodic Performance Review?
400
According to policy this process is an integral part of all clinician's daily assessments and should be performed during rounding schedules for all patients. The process is proven to reduce patient falls and to have a positive impact on patient perception of care statistics.
What is Offering the Four Ps?
Extra points for your team if you can say what each P stands for.
400
Caring for a patient with this infectious disease means no using hand sanitizer, a bleach cleaning to the room BID, and enhanced contact precautions.
What is c. difficile?
400
These are the two types of change in relation to change management teachings.
What are technical and adaptive?
500
This should be performed formally by department managers at least monthly in the departments, on the units, and in other patient care areas. Managers, supervisors and directors must be aware of hazards at all times.
What is a Safety Inspection?
500
This is the document submitted to The Joint Commission after a survey that outlines what the facility will do regarding the survey findings.
What is the corrective action plan?
500
At a minimum, SR up, Bed in low position, Bed wheels locked, Call bell within reach, Four Ps offered/addressed.
What are the minimum fall prevention interventions to be addressed q 2 hr?
500
The lack of proper use of this is heavily cited by surveyors. Often the staff isn't even aware that they are being watched. Therefore, it is better for managers, directors and supervisors to audit for compliance routinely and not just during survey prep periods.
What is PPE or Personal Protective Equipment?
500
This is the type of change that requires an alteration in unit specific safety culture before success can be achieved.