During the JC 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?
100
Certain equipment can be staged in an 8 foot corridor as long as this clear width remains and hospital employees have a plan for removing wheeled equipment.
What is 5 feet?
100
Where are the fire extinguishers in the Breast Center?
Bonus: Where's the oxygen shutoff values in case of a fire?
(1) In E hallway by the assignment board, by U and T elevators.
(2) The oxygen shut off valve is in Bluebonnet main hallway only to be shut off by Respiratory Therapist
100
These are designed to provide protection from smoke horizontally.
What are smoke compartments?
100
When properly designed, installed and maintained, these systems contribute to the reduction of Hospital Acquired Infections. Environmental controls create a compliant, highly reliable patient care setting.
What are ventilation systems?
200
What is "tracer methodology"?
Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.
200
At the current time, The Joint Commission and CMS are using this 2000 Edition.
What is the Life Safety Code?
200
What number do you call to report concerning behavior, perceived threats or acts of hostility?
333
200
The room, smoke compartments, 2 hour construction floor assembly, fire rated doors, smoke barriers and exits to the outside..
What are the levels of defense (protection) from smoke and fire?
200
This is used to contain airborne contaminants within a room.
What is negative pressure?
300
What is HIPPA? Name one way protected health information is kept private in your department.
No! Not Hippo
HIPPA: Health Insurance Portability and Accountability ACT.
States the PHI may only be used for purposes of treatment, payment, healthcare operations.
(1) Shedders, (2) don't discuss patient information in the hallway or elevators, (3) keep door to exam room closed, (4) close computer screens.
300
A management process, managing deficiencies and their correction.
What is the Statement of Conditions? (SOC)
300
What do RACE and PASS mnemonics stand for when there is a fire?
R - Rescue, A- Alarm, C- Contain the fire (close doors), E- Extinguish the fire when it is safe to do so or E - Evacuate
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
300
Positive latching, self or automatic closing device, not >1/8" gaps at edges, not >3/4" undercut.....
What are fire doors?
300
Provides protection to patients in operating rooms and protective environment rooms from airborne pathogens that may be present in adjacent areas.
What is positive pressure?
400
What does JCAHO stand for?
Hint: It's not "Julia comes and hangs out"
Joint Commission on Accreditation of Healthcare Organizations
400
This is initiated when the fire alarm or sprinkler system is out of service more than 4 hours in a 24 hour period in an occupied building.
What is a Fire Watch?
400
What should you do in the event of a hazardous material spill?*
* Material more hazardous than cafeteria food, but less hazordous than anthrax
Evacuate at a safe d
400
Use this as protection when a duct penetrates a two hour fire rated barrier.
What are examples of positively pressurized rooms?
500
How often are fire drills conducted?
We conduct them monthly at the hospital and annually in offsite buildings.
500
This should be used during construction if life safety is compromised.
What are Interim Life Safety Measures? (ILSM)
500
What level of operational status are we working at during hurricane season?
Normal Operations - All managers and employees assigned responsibilities for hurricane/severe weather and emergency planning and implementation are required to assess, review and prepare plans to ensure a constant state of readiness
500
These must be sealed with approved fire rated material in order to prevent the transmission of fire.