Accreditation
Life Safety
Accreditation Cont.
Our Environment
Infection Prevention
100
Stay calm. Say, "I can get the answer: or "I know where to find it".
What should you do if a surveyor asks you a question that you are unable to answer?
100
The acronym for: Rescue, Activate alarm, Confine the fire, Evacuate/Extinguish
What is the acronym RACE stand for?
100
Identification from their agency, an ID badge, or letter regarding the visit.
What is agency identification?
100
Not on stored wheelchairs.
What is the proper storage requirements of oxygen tank storage?
100
Cart that is always covered and free from items on top.
What is linen carts?
200
1. Accreditation Manager – Lauren Beirne = 847-535-7090 or cell 630-935-9222 2. Quality Manager – Melissa Frank = 847-535-6529 or cell 847-477-7451 3. Quality Director- Candice Krill = 847-535-6546 or cell 312-339-0456 4. Administration – Kristi Sparks = 847-535-6483
Who do you call when The Joint Commission arrives?
200
Areas that must be accessible and have a 3 foot clearance.
What is electrical panels and oxygen shutoffs.
200
Focus for their visit and contact person.
What is important information to help to leadership?
200
Surrounding hallways have a secure means of egress; halls are passable and all equipment is stored away.
How do we ensure patients and staff can exit hallways safely in the event of an emergency?
200
Staff have been properly trained by Infection Prevention to enter ___________ isolation patient rooms.
What is only droplet isolation patients
300
State: “our process is” or “our policy requires that” “our procedure states that” “in the interest of patient safety, we”. Avoid saying: “I think we mostly do it this way” “we’re supposed to” “I usually do…”
What should you keep in mind as you answer a surveyor's question?
300
Unobstructed hallways, doors and fire alarms allow for a quick response and safe egress in case of an emergency.
Why can't carts or other equipment be located in front of fire alarms or exit doors?
300
Discuss the scope of the survey, the length of the survey, the survey agenda, who they need to meet with, what documents are initially requested, and other logistical needs they have related to the survey event such as technology support. Most of this should be provided in writing from the lead surveyor.
What is important information to gather for leadership?
300
Movement would be done horizontally and beyond the nearest fire doors to a safe area of refuge Please review your evacuation route
Where would your patients/visitors/staff be moved to in the event of a fire?
300
Areas that must be free from food and drink.
What is nurses station, patient care and laboratory areas?
400
Helps organize and strengthen patient safety efforts – Patient safety and quality of care issues are at the forefront of Joint Commission standards and initiatives. Strengthens community confidence in the quality and safety of care, treatment and services – Achieving accreditation makes a strong statement to the community about an organization’s efforts to provide the highest quality services.
Why is it important to be accredited by The Joint Commission.
400
Storage units must have a liner (plastic) on them to prevent floor dirt or cleaning materials from contaminating items on the bottom shelf.
What is the required for the bottom shelf storage units?
400
Leave a detailed message including the following information: 1. Agency surveyors are from, 2. Number of surveyors, 3. Focus of the visit, 4. Who/department they initially want to meet with.
What is when administration doesn't pick of their phone.
400
No visible PHI, open charts are not left unattended, staff log off when leaving a work station, staff are aware of people walking by or standing near computers when logged in.
What are examples of following guidelines for HIPAA?
400
A goal greater than 95%, completed by trained observers at least 40 times a month and documented on an electronic audit tool on NMI.
What is hand hygiene audits?
500
To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
What is the Joint Commission Mission Statement.
500
This equipment, located at entrances and exits on units and throughout the building is required by law to be checked monthly. (Could you speak to where they are on your unit/department?)
What are fire extinguishers.
500
Call Telecommunications to announce: “Northwestern Lake Forest Hospital welcomes the survey team from _______ today”
What is this is to be done each day of a multi-day survey?
500
Pull pin, Aim at base of fire, Squeeze the handle, Sweep the extinguisher across the fire until the product is completely used up
What does the acronym "PASS" stand for?
500
Sani-Clothes (from Purple tub) with contact time of 2 minutes.
What product is used to clean personal equipment (wheelchairs) which are used between patients?
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