Leadership
What does the Institute's cultural competency and diversity plan describe?
The plan describes how Kennedy Krieger considers the diversity of persons served, personnel, and other stakeholders. Includes culture, age, gender, sexual orientation, spiritual beliefs, cognitive or physical ability, language, race, ethnicity, and socio-economic status.
What is CQIC?
CQIC stands for Clinical Quality and Innovation Committee
1) The Quality Assurance arm of the CQIC reviews data to ensure that regulatory requirements for accrediting bodies are met.
2) The Innovation arm reviews quality improvement projects, support efforts to maintain programs' quality and safety and measures their effectiveness and efficiency.
What is CLEARLY?
Steps to deescalate behaviors that undermine a culture of safety
Calm yourself
Listen
Empathize
Act supportively
Respond collaboratively
Let someone know
Your next steps
How should staff handle a complaint from persons served and other stakeholders?
1. Listen
2. Take steps to address and resolve
3. Escalate via chain of command:
supervisor, manager, or director
4. If applicable, contact Patient Relations Specialist for assistance
What is CARF's Mission?
To promote the quality, value, and optimal outcomes of services through a consultative accreditation process and continuous improvement services that center on enhancing the lives of the persons served.
What are some ways the Institute provides persons served and family centered care?
Addressing culture, age, gender, sexual orientation, spiritual beliefs, cognitive or physical ability, language, race, ethnicity, and socio-economic status
Examples include:
*Scheduling interpreter services or using a CyraCom
* Providing a kosher or halal diet
*Asking about learning preferences/styles and accommodating that preference
*Providing Materials in patients preferred language and at patient/families reading level
*Addressing person served and families with preferred pronouns
*Scheduling visits with preferred clergy for spiritual support.
(Know examples that your program has provided over the last 3 years. Remember to always document in the patient medical record.)
What information is in the Institute's Media Contact Policy?
Written procedure regarding communications that address media relations to reduce risk to Institute reputation, liability, patient confidentiality, etc.:
What are some Human Resource Competencies that focuses on staffs' ability to demonstrate adequate skills, knowledge, and capacity to perform a specific set of job functions?
Age Specific
Fire Safety
Abuse and Neglect
Human Trafficking
Medical Emergency
What are ways to comply with the Health Insurance Portability and Accountability Act (HIPAA)?
*Discuss health information privately and only with those who need to know
*Abide by confidentiality standards
*Access and or/disclose the minimum necessary information to get the job done
*Don’t leave information in public view
*Keep passwords confidential
*Lock or log off computers when leaving work areas
Where can I go to practice interview questions?
The Accreditation and Regulatory Affairs website on the BEACON has CARF resources with interview questions.
Why is it important to report safety events/occurrences in the HealthCare Safety Zone portal?
*Reporting helps identify problems and creates solutions.
*It provides learning opportunities.
*Uses data to understand a variation in performance and to support Q&S.
*Connects isolated incidents, identifies good catches, and supports performance improvement activities.
*Employs a comprehensive, Institute-wide performance improvement program that continually monitors and evaluates quality of care. (CQIC, medical staff Committees)
*Collects and analyzes data to identify opportunities for improvement, applies evidence-based practice.
*The reporting of actual and potential occurrences is encouraged, non-punitive, and essential to Kennedy Krieger's Culture of Safety.
*Employees are encouraged to report any perceived risks to patient safety or quality of care following the department chain of command, beginning with the supervisor or department director. If the concern is not addressed to his/her satisfaction, the employee can contact the patient safety officer at x33280.
How does your department or program seek input from the persons served and other stakeholders?
* Satisfaction surveys
* Family meetings throughout admission
* Community Outreach
*Patient/family representative on committees/meetings
What are some emergency response procedures/codes?
Emergency or Disaster
Fire
Cardiac Respiratory
Active Assailant
Hazardous Material spill
Infant or child abduction
Combative person
Elopement
Why is having consent important?
This needs to be obtained from the patient or their healthcare proxy prior to treatment/evaluation, participation in research, prior to releasing protected health information, and for audio/visual materials.
The consent allows staff to provide treatment, share health information, and take pictures.
How will surveyors determine conformance?
*Review, assess and analyze outcomes-PMMI
*Tour of the facility
*Conduct interviews with staff members, persons served, leadership, board members, and other stakeholders
*Review policies and procedures and other documents; these must be provided in writing and reviewed annually
*Review files of persons served (medical records) and personnel (employee records)
*Observe programs and services
What are some key components of the Institute’s Code of Ethics?
Kennedy Krieger Institute is dedicated to the principle of organization ethics and a commitment to act with integrity. Clinical care and business practices are conducted in an honest, decent and ethical manner. Patients, students and their families, trainees, volunteers, researchers and staff are treated in a culturally-responsive manner with civility, dignity, and respect.
What is the purpose of Performance Measurement, Management and Improvement (PMMI)?
*Continually monitors, measures, and improves the quality of clinical services.
*Assesses and improves processes, systems, structures, and outcomes.
*Ensures that healthcare is high quality, efficient, and cost effective.
*Supports the mission, vision, and values of the Institute, as well as, culture of excellence in quality and patient safety.
*Facilitates a culture of accountability and data-driven action.
*Allows Leadership to identify trends, patterns, and/or variations in data to establish priorities for improvement activities.
What is your departments fire safety plan?
Each building has a fire plan
What does it mean to address persons served and stakeholders learning styles?
Staff should assess persons served and other stakeholders' preferences and abilities to process written, verbal, visual, hands-on demonstration, and multi-modal content and information.
How does your program or the Institute inform the public about services?
*Kennedy website
*Program fact sheets
*Resource Finder
What is the purpose of the Compliance program?
*Maintain and enhance quality of patient care
*Demonstrate sincere, ongoing efforts to comply with all applicable laws and regulatory standards
*Revise and clarify current policies and procedures and develop new policies and procedures to enhance compliance.
Name a department or institute PMMI project.
*Language access
*Patient experience questionnaire
*Suicide risk screening
How are staff, persons served, and other stakeholders educated about safety?
*Persons served and other stakeholders-Plan 9 and Portable Health Profile
*Staff-Physical environment- orientation, competencies, color codes, badges, CLEARLY, admin P&Ps,
*Physical health – IC P&Ps
What is accessibility?
This is the practice of making information, activities, communication, and/or environments perceivable, operable, usable, and robust for as many people as possible.
Name at least 2 Institute programs that are accredited by CARF
*All inpatient programs: Rehab (BI, SCI, CIR), Feeding, NBU
*Outpatient Spine (801, Maple Lawn, White Marsh)
*Fairmount-STP and Community rehab