Joint Commission Basics
What is a "Hand-off"?
A Hand-off is a transfer of information during transitions in patient care and acceptance of patient care.
What PI model does BAMC use?
BAMC primarily utilizes the Plan-Do-Study-Act (PDSA) Performance Improvement Model.
How are the needs of the patient known or identified?
Information about the patient’s physical, psychological, social, cultural, and spiritual needs are obtained during the initial assessment, primarily by the physician and nurse caring for the patient.
How are staff members educated about safety?
Safety education is provided during New Employee Orientation (NEO), annually through SWANK Health, Environment of Care rounds, and Fire and Safety inspections through the BAMC Safety Specialists.
What does POCT stand for
Point of Care Testing
What does SBAR Stand for?
Situation
Background
Assessment
Recommendation
What are the goals of our PI Program
To improve safety and quality of care by collecting and analyzing data to identify trends, patterns, and performance levels that indicate opportunities for improvement, supporting improvements, and monitoring the improvements to ensure the desired changes are achieved and sustained.
What are the names of our Rapid Response Teams?
Adult RRT
ER Assist Team
ISR RRT
Pediatric RRT
OB-Neo Response Team
What does RACE stand for?
R- Rescue persons directly threatened by the fire.
A- Activate Alarms
C- Contain the fire by closing doors and windows
E- Evacuate the zone or area
What is a "Waived Test"?
As defined by The Joint Commission, a Waived Test is a test that meets the Clinical Laboratory Improvement Amendments of 1988 (CLIA ‘88) requirement for waived tests and is cleared by the Food and Drug Administration (FDA) for home use. These tests employ methodologies that are so simple and accurate that the likelihood of erroneous results is negligible, or they pose no risk of harm to the patient, resident, or individual served if the test is performed incorrectly.
What is Leadership Rounding?
Rounding by senior leaders, managers, and supervisors is an opportunity for meaningful and open communication between staff members and organization leaders, and provides leaders with important information about what is going well, and what improvements can be made.
How can staff members participate in PI?
Participation in hospital-wide, department, clinic, or unit-based committees or teams established to measure and/or improve performance of patient care and/or business processes.
Collect and analyze data, and implement actions to:
How are crash carts exchanged?
Sterile Processing Division (SPD) (basement) is the central location for exchanging crash carts.
The Environment of Care consists of these three basic elements:
1. The building or space, including how it is arranged and special features that protect patients, visitors, and staff
2. Equipment used to support patient care or to safely operate the building or space
3. People, including those who work within the organization, patients, and anyone else who enters the environment, all of whom have a role in minimizing risks
What goes in a red bag for disposal?
- Anything saturated with blood or wound drainage
- Any container with bulk blood or body fluids with visible blood
- Blood Transfusion tubing/bags
- Dressings, cotton balls, and gauze saturated with blood or wound drainage
- Filled thoracentesis bottles
- Pleurovac
- Emptied suction canisters (bloody)
- Emptied wound drains (i.e. Hemovac, Jackson-Pratt, etc.)
What should you do if you do not understand a question from a surveyor?
Ask the surveyor to restate/reword the question.
If you do not know an answer, say so, and tell the surveyor where or to whom you would go for the answer. Remember you may use any resources available to you, such as intranet policies, department resources, or your manager.
Remember. YOU will not be alone.
What is the BAMC Memo that addresses PI?
BAMC Memo 40-213 Performance Improvement and Patient Safety Program
What are the contents of the bag in the AED housing Boxes located throughout our hospital?
2.1. An adult pocket mask with one way valve,
2.2. A pediatric pocket mask with one way valve,
2.3. Adult and pediatric AED pads,
2.4. Clean gloves,
2.5. A safety razor, and
2.6. A copy of MEDCOM Form 679 Emergency Resuscitation Record, BAMC Form 1248 Code Blue After-Action Report, and BAMC Form 1254 Automated External Defibrillator Inspection Log.
What are the four phases of Emergency Management?
Mitigation
Preparedness
Response
Recovery
What are ASHMS Primary Elements:
- Management, Leadership, Employee Involvement
- Worksite Analysis
- Hazard Prevention and Control
- Safety and Health Training
How do you locate BAMC's Emergency Operations Plan from the BAMC Intranet Home page?
1. Scoll down to the quick link at the bottom of the home page and click red button (EM OPER PLAN which is hyperlinked to the Emergency Management Homepage. EOP is here.
2. Go To: Departments and Divisions -+ BAMC Operations (G-2/G-3) -+ Emergency Management
How does the organization identify and reduce adverse events and safety risks?
One method utilized is the Failure Mode and Effects Analysis (FMEA), which is a type of Proactive Risk Assessment. An FMEA is a team-based, systematic, and proactive approach for analyzing a high-risk process and identifying ways the process can fail, why it might fail, and how it can be made safer.
What are the criteria to discontinue restraint use?
This will be determined by the physician order but example criteria may include the following as examples:
The patient no longer presents an immediate physical threat to themselves or others.
Change in the patient’s physical condition, indicating a need for discontinuation.
Name three of the eight Life Safety components.
Statement of Conditions
Interim Life Safety measures
Building Requirements
Building Services
Special Provisions
Means of Egress Requirements
Protection
Operating Features
What phone number do you call for a follow-up appointment after a blood or body fluid exposure?
Occupational Health 916-3703