DNV Basics
During the DNV survey, the surveyors will talk primarily to: A. The Hospital Administrators B. The doctors, nurses and staff C. The patients D. The Houston Chronicle
B. YOU! That's why you are playing this game, right?
Name one of HMC 2022 QAPI Goals
1. Prevent Hospital Acquired Infections
2. Reduce Falls
3. Maintain Leapfrog A
4. Reduce Reportable Patient Safety Indicator (PSI) events
5. Improve NPS
6. Early recognition of Sepsis
The corridors and hallways need to be clear of cludder. Nothing should be left in the hallways for more than____
30 Minutes
How often are pain assessments performed?
On Admit, before and after pain interventions, and as needed based on patient condition
What is the process for patients using own medications?
1. receive an order
2. Send to pharmacy for verification and labeling
3. administer medication as you would any med
4. return unused portion to patient at DC
Name one way you reduce the risk of health-care associated infections in your department.
Handwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 20 seconds. Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected. Use of artificial or long fingernails is prohibited. LATHER UP!
If you wanted to know what your role is in a bomb threat, where would you look?
Multi-Colored Code Flip chart
How soon after admission should the Nursing Assessment be Completed?
As soon as possible, but within 24 hours
An LIP approaches you with assistance with a procedure. How do you know if that provider has privileges to perform that procedure?
Look up provider privileges in MIDAS using icon on desktop MidasPrivlng
What is HIPPA? Name one way protected health information is kept private in your department? Who is HMC's Privacy Officer:
Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. Examples of how to protect a Veterans PHI: 1. Don't discuss patient information in the hallway or elevators, 2. Keep doors to exam rooms closed, 3. close computer screens when away from PC and lock screen. Kristin Eeg Ext 52108
How do you improve the accuracy of patient identification in your area?
Use TWO (2) of the 3 identifiers used at HMC when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's FULL name, patient's FULL Social Security Number and/or patient's FULL birthdate.
What do RACE and PASS mnemonics stand for when there is a fire?
RACE - R - Remove patients and others, A- Alarm, C- Contain the fire (close doors), E- Extinguish the fire when it is safe to do so or E - Evacuate PASS - P- Pull the pin, A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle form side to side
When apply restraints in an emergent situation, how long after application should you obtain an order?
Within 15 minutes
How do you know the medical equipment you are using is safe to use?
Biomed inspects all equipment prior to being put into service and does preventative maintenance at regular intervals. We check the tag on each piece of equipment and report any out of date PMs
What do the acronyms "DNV" and "CSR" stand for?
DNV = Det Norske Veritas
CSR = Continuous Survey Readiness
What is a sentinel event?
An unexpected occurrence involving death or serious physical or psychological injury
1) What should you do in the event of a Minor hazardous material spill?
2) For Major Spills?
1) Check the MDS on-line and follow instructions
2) Evacuate patients and staff away at a safe distance and Call Safety Manager and/or the Engineering Manager (Administrator on call after hours), and Security to help secure the area
When do you label medications?
Whenever you are not going to immediately administer the medication...meaning when you are going to prepare and administer without a break in the process.
This should occur even if only 1 medication is to be given
If a surveyor asks if all of your Infection Prevention policies follow the CDC guidelines, what do you say?
DO not be afraid to say, "I am not sure"
I am not certain of every IP policy's reference, but we do follow our hospital's policies, which are located within Policytech.
The DNV survey is conducted: a) Annually b) Every 2 Years c) Every 3 Years d) Every 4 Years
c) Annually
Name 3 of the unapproved abbreviations.
(1) .U or u (unit) (2) IU (international unit) (3) Q.D., QD, q.d. (daily) or Q.O.D., QOD, q.o.d. (every other day) (4) 1.0 (no terminal zeros) .5 (always use a leading zero - "always lead never follow" (5) MS, MSO4,MgSO4 (morphine sulfate or magnesium sulfate)
Per Life Safety Standards there needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.
18"
How do you screen and care for a patient at risk of suicide?
1. Immediate 1:1 continuous observation, staying within arms reach of patient
2. Search of Patient and belongings and removal of items that could cause harm
3. removal of unnecessary equipment from rooms
4. Documentation on Obs record and in EMR
What is one thing you should never give a surveyor?
More information than what they ask for! Do not volunteer information. Answer the question being asked...no more, no less.