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 visitors
B. YOU! That's why you are playing this game, right?
Name one of the 2018 National Patient Safety Goals
NPSG 1- Identify patients correctly NPSG 2- Improve staff communication NPSG 3- Use medications safely NPSG 6- Use alarms safely NPSG 7- Prevent Infection NPSG 15- Identify patient safety risks NPSG 14- Prevent mistakes in surgery
The corridors and hallways need to be clear of clutter. Nothing is to be left in the hallways for more than____
What is 30 Minutes rule
What are 3 things a Corrective Action Plan needs to contain?
Identify the cause of the nonconformity, actions taken to correct the nonconformity, other areas affected by the nonconformity.
What is CMS and CoP
Centers of Medicare and Medicaid Services (CMS) created rules of safety for hospitals > Conditions of particpation (CoP) that must be followed.
"internal audits"?
What is Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient?
Name one way you reduce the risk of health-care associated infections in your department.
What is Handwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 15 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, which binder/ policy would you find the information in?
What is the Life Safety/ Disaster Plans - Emergency Preparedness, code black bomb threat policy.
For every DNV survey there is an __________________ and ____________ meeting.
opening and closing
ISO Policy that specifies how long documentation must be retained and method for disposing
What is Record Control?
What is HIPPA? Name one way protected health information is kept private in your department?
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 patient's 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 or log off if leaving area.
How do you improve the accuracy of patient identification in your area?
Use TWO (2) identifiers when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's FULL name, and patient's FULL birth date.
What do RACE and PASS mnemonics stand for when there is a fire?
What is 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
An ______________________ is a finding without a clear reference to a standard requirement, or a finding without clear evidence.
What is an observation
Expired, recalled, spoiled, or damage foods, medication equipment and supplies are _________products
What is Nonconforming?
What do the acronyms "DNV" and "CSR" stand for?
DNV= Det Norske Veritas
CSR = Continuous Survey Readiness
Adverse events/ near misses
What is the policy and procedure of informing patients and/or their families about unexpected adverse events?
1) What should you do in the event of a Minor hazardous material spill? 2) For Major Spills?
1)Follow the 4, Emergency Action Plan for Cleanup of Medical Waste Spills and Emergency Action Plan for Cleanup of Medical Waste Spills for details.
2) Evacuate patients and staff away at a safe distance and Call Plant Operations
Why is it important that our hospitals and clinics meet CMS standards?
2. Bottom line - we receive reimbursement for care of medicaid and medicare patients ONLY if we adhere to the CMS regulations (CoPs)
Within the sample, the surveyors will select at least ___ ____ from each nursing unit. In addition to the inpatient sample, the surveyors will select a sample of _______ in order to determine compliance in ________ departments, services, and locations.
One Patient
Outpatients,
Outpatient
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"
The Organization will submit Corrective Action Plans to DNV to address the nonconformities identified within _____ calendar days of the date of the __________ ____________
What is (10) days, final report
A ____________ _______________will be reported as a positive finding. It can be an improvement compared to the previous audit, or processes that perform better than expected, e.g. best practice.
noteworthy effort