Show:
1. Test Your Standards IQ!
2. Know your Facilities Department
3. Clarifying Changes in the Life Safety Survey Process
4. Performance Improvement and the
Environment of Care
5. Mixed Bag
100
Which of the following is considered a hazardous gas or vapor? a. Steam b. Ethylene oxide c. Oxygen
What is b, Ethylene Oxide?
100
Kristin's husbands last name.
What is Campos?
100
NFPA 25-2011 4.3.1 states: Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having __________ upon request.
What is jurisdiction?
100
Standard EC.02.03.03, EP 1, states the organization conducts fire drills _____ per shift per quarter in each building defined as a health care occupancy.
What is Once?
100
In a Joint Commission Survey, This is an RFI? (Define RFI).
What is Requirement for Improvement?
200
How often is a health care organization required to conduct a fire drill in a building defined as a health care occupancy according to the Life Safety Code®? a. Once per shift, per quarter b. Once per shift, monthly c. Once per shift, annually
What is a, once per shift, per quarter?
200
Who is the youngest Facility Department Employee?
What is Joey?
200
NFPA 25-2011 4.3.3 states: Records shall be maintained by the _______ owner
What is property?
200
EC.04.01.01, EPs 12–13, state the organization conducts environmental rounds every ___ months in patient care areas and ________ in non-patient care areas..
What is every 6 months and annually?
200
Instruction 9305.1 defines the process to connect new or ______ existing electrical circuits.
What is remove or disconnnect?
300
How often is a diagnostic medical physicist required to conduct a performance evaluation of all positron emission tomography imaging equipment? a. Monthly b. Quarterly c. Annually
What is c, annually?
300
What Facility employee had 3 sons with their first wife, one of those sons which has had 4 daughters with his wife?
What is Mitch.
300
Years ago, The Joint Commission adopted the familiar catch phrase, “not documented, not done,” to describe document-related observations...... However, the clarifications process allowed documents not found or unavailable during survey to be submitted following survey for Joint Commission central office review. Effective January 2017, any unmet document-related request during survey results in an ___.
What is an RFI?
300
Performance improvement is not a new concept for those working in health care. Some of the earliest first performance improvement activities can be traced back to the work of Florence Nightingale while she worked as a nurse at the Barrack Hospital in Istanbul in ____ (year).
What is 1854?
300
Interim Life Safety Measures (ILSM) create alternative measures to protect occupants when a deficiency is identified and is pending __________actions.
What is corrective?
400
Which of the following is a required indicator that staff and licensed independent practitioners are familiar with their roles and responsibilities in the environment of care? a. Staff and licensed independent practitioners can describe or demonstrate methods for eliminating and minimizing physical risks in the environment of care. b. Staff and licensed independent practitioners are able to cite Joint Commission Environment of Care standards that apply to their daily activities. c. Staff and licensed independent practitioners demonstrate familiarity with the Life Safety Code.
What is a?
400
In the Facilities Department, who's current state of residence is Texas?
What is LTJG Piester?
400
Changes to the Statement of Conditions™ Effective August 1, 2016, The Joint Commission changed its survey process for the Life Safety (LS) standards. The Plan for Improvement (PFI) and Basic Building Information (BBI) are no longer reviewed as part of the ______ event.
What is survey?
400
“An emphasis on performance improvement should not to be considered a burden but rather an opportunity to improve our _________ in the hospital.”
What are processes?
400
if a surveyor encounters a project with ILSM implementation, the surveyor should not be citing the project deficiencies as RFIs, as the ILSM is already providing _______ measures to reduce the impact of the deficiencies. However, if the ILSM policy is not being followed, an RFI will be generated for not following policy at the specific EP related to noncompliance.
What is interim?
500
Upcoming Revisions to the Standard LS.01.01.01 The following element of performance is pending final approval, intended for January 1, 2017, implementation: • EP 1 The organization assigns an __________ to assess compliance with the Life Safety Code®*, and manage the Statement of Conditions (SOC) when addressing survey-related deficiencies.
What is Individual?
500
Who is driving this car?
What is Gary?
500
All LS deficiencies are now documented as RFIs. As an RFI, they must achieve compliance and submit Evidence of Standards Compliance (ESC) within __ days. For those deficiencies that can be completed within this time frame, the organization may manage the corrective actions by work order or any other internal process to show compliance.
What is 60?
500
Through monitoring and evaluation, those involved in the EOC can collect and analyze data and put practices into place that will _______ the hospital environment and provide a safer place for their patients and staff.
What is Improve?
500
Of the first 13 surgeon General's how many were female?
What is none?