JC Basics
How are patients informed of their rights?
Brochures are available in the waiting room/check in area in all practices. Also, patients can also go to the MG public website/Health InfoNet Consent to treat signed annually
Patients admitted to 3 South receive a copy patient rights at the time of admission
Name two of the 2015 National Safety Patient Goals
What is (1) Improve accuracy of patient identification (2) Improve effectiveness of communication among caregivers (3) Improve safety of using medications (4) Ensure medical equipment alarms are heard and responded to on time. (5) Reduce risk of health-care associated infections (6) Accurately and completely reconcile medications across the continuum of care (7)Identify safety risks inherent to population - suicide (8) Universal Protocol
How can you identify locations of hospital fire extinguishers quickly and oxygen shutoff values?
What is signs located above each extinguisher and oxygen shut off valve .
The large key opens the fire extinguisher
How do you document in your procedure note that you confirmed the correct identity of the patient and the correct site of the procedure?
What is documentation of Universal Precaution/Time out on forms per policy.
What quality performance data is collected in your area? How are you involved?
What is Chart Audits - The data is collected and reviewed on a monthly basis. If there are any deficiencies than a plan is developed on how to improve that outcome. Medication Variance
Reduce the rate of falls
improve patient satisfaction
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.
Name the most important way to 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!
What do you do if you are concerned about a perceived threat or acts of hostility?
What is Versus badge, call 1-6444 to report a code yellow or Code Violet and off campus locations call 911.
When is the Behavioral Health Treatment Plan initiated?
What is at the time of admission?
Dr. X is starting his shift on 3 South. He walks down the hall. Starbucks in hand, and waves "hi" to the nurses and clerk. He rounds the corner, going through the propped open fire door and enters the nurses station . He takes out his breakfast sandwich and dumps his empty coffee cup in the trash. Where's the TJC violation?
What is fire doors may not be propped open and no food in patient care area .
What is HIPAA? Name one way protected health information is kept private in your department.
HIPAA: Health Insurance Portability and Accountability ACT. HIPAA States, PHI may only be used for purposes of treatment, payment, healthcare operations.Other ways to protect PHI (1) Dispose of PHI per policy (2) don't discuss patient information in the hallway or elevators, (3) keep door to exam room closed, (4) close computer screens.
How do you improve the accuracy of patient identification in your department?
What is TWO (2) identifiers when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's name and Patient's DOB NOT patient's room number and chief complaint (e.g the mastectomy patient in E6)
What do RACE and PASS mnemonics stand for when there is a fire?
What is R - Rescue 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 P- Pull the pin, A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle from side to side
What's the fifth vital sign that we document on ALL patients and where do we document it?
What is Pain score! Inpatient-Documented on SCM flowsheet>KBC Adult Assessment Intervention>Pain/Comfort. Outpatient-Touchworks
How do you know a piece of equipment (e.g. defibrillator, ultrasound) is okay to use?
What is Check equipment for Preventive Maintenance Sticker.
What are acceptable methods for demonstrating competencies?
What are quizzes, return demonstration and work with a preceptor.
How are you improving the effectiveness of communication between caregivers?
What is (1) SBAR Format at time of "hand-off" report (2) Telephone orders are read back (3) Critical lab values are read back (4) We use standardized abbreviations and avoid certain unapproved dangerous abbreviations
What should you do in the event of a hazardous material spill?* Material more hazardous than cafeteria food, but less hazardous than anthrax.
What is evacuate at a safe distance and Call 1-6444 to report a Code Green. Look at code Green plan in your Emergency Code Book.
True or false Can a minor sibling translate for a parent if the minor is 13 years old, clearly fluent in both languages and both the minor and the parent consent to using the minor as the interpreter.
What is False! Need qualified Interpreter
What card should you have in your badge?
What is Emergency Codes
How often are fire drills conducted?
What is quarterly fire drills at the hospital and off-campus clinics.
What tool is used to assess the risk for harm to self or others?
The Harm Scale
What level of operational status are we working at during severe weather season?
What is Normal Operations - All managers and employees assigned responsibilities for severe weather implementation plan are required to assess, review and prepare plans to ensure a constant state of readiness
What three questions do you need to review in order to decide if a patient is to be placed on Fall Precautions?
What is Fall in last 12 months, Polypharmacy, Central Nervous system or Psychotropic meds, cardiovascular meds, Age greater than 65, Alteration in elemination, Cognitive or sensory deficient, dizziness, vertigo, depression, mobility deficient, weakness and admitted with substance abuse diagnosis
I have no idea how to answer that question, please don't bother me I am busy and that is a stupid policy/ order anyway.
What is something you would never say to a surveyor!