Regulatory 101
This organization accredits and certifies health care organizations. ____accreditation/certification is recognized as a national symbol of healthcare quality.
What is The Joint Commission (TJC)
R.A.C.E stands for this
What is:
Rescue those in immediate danger
Alarm
Confine (shut doors)
Evacuate
This is why cardboard shipping boxes cannot be in clean supply or patient care areas
What is:
boxes are dirty from being in warehouses, trucks or on the ground during transport
corrugated cardboard can carry insect eggs into your practice and cause an infestation
Name a policy you are required to follow:
What is: Examples include, Medication Management, Falls, Interpreter Services, EMTALA, HIPAA, Approved Abbreviations, Occurrence Reporting (PMSN), Clinical Emergencies, Universal Protocol (Time Out), Suicide Precautions, Patient Identification, Workplace Violence
This is a process where all care is stopped and a patient's name, date of birth, type of procedure and why procedure is being done, and side of the body (if relevant) are reviewed with the patient and care team.
What is a "Time Out"
Ensures that the right patient has the right procedure on the correct part of their body
This document explains how to operate and correctly clean a piece of equipment
What are the Instructions for Use (IFU)
P.A.S.S. is an acronym to guide someone using a fire extinguisher. It stands for this:
What is
Pull the pin
Aim (at the base of the fire)
Squeeze
Sweep (side to side)
This type of cleaning wipe is used to clean a Novastat Glucometer
What is a bleach wipe?
This is how to find a policy on the UPHS Intranet site
What is: Type "policies" in the search box or click on Policies
CPUP practices: If a patient's score on the ___ is 3 or higher, the person performing intake should immediately notify the provider to perform the PHQ9
What is the PHQ2?
When a patient expresses a concern that occurs outside of the patient visit (such as in a telephone call, message or survey). This type of concern must be shared with a practice manager/supervisor. The manager will work with Patient & Guest Relations to resolve.
What is a grievance
When using the eyewash, flush your eyes for ___ minutes
What is 15 minutes?
bonus: or per the amount of time stated in the Material Safety Data Sheet (MSDS), located on the Intranet
This is how we know which wipe to use on a piece of equipment (exam table, blood pressure cuff, etc)
What is by reading the IFU (Instructions for Use)
If a patient reports this, you should stay with the patient (even in the bathroom), call for help and be within one arm's length of patient at all times
What is potential for self-harm (suicide)
Cyracom and DHCC are examples of...
What are Interpreter Services?
HIPAA, EMTALA and Scope of Practice laws
Hospital/Entity policies
OSHA, EPA, AMMI standards
CMS Conditions of Participation, TJC standards (for practices on a hospital license)
Local fire codes
What are examples of laws, standards and policies that Penn Medicine is required to comply with
This is where you find the location to meet with your team after a building evacuation
What is the Department Specific Fire and Emergency Management Plan
This refers to how long equipment (such as an exam table) must stay wet during cleaning to ensure it is disinfected
Hint: you can usually find this on the wipes/cleaning product container or in the product IFU
What is dwell/wet/contact time?
What is: When you are drawing a medication into a syringe that you will administer immediately after drawing.
If the syringe is set down or given to another person to administer, it must be labelled per policy.
Door Handle, phone cord, cord from the blinds, call bell cord, picture frames, mirrors
What are examples of things that can be used to as a ligature (any object that can be used for strangulation or self harm) ?
These projects use data to improve the quality and safety of healthcare. Healthcare organizations are required by CMS/TJC to complete these projects as part of ongoing process improvement.
What are Quality Assurance and Performance Improvement projects (QAPI)?
This is how much space must be between the ceiling and any object (for example, in storage rooms).
What is 18 inches?
In your practice, this is how you know that a patient room has been cleaned before rooming the next patient. Name what you do in your practice setting
What is_______________________
(each practice should have a process, so everyone is certain the room is clean)
This is why medications must be stored in locked rooms, drawers or cabinets.
To prevent tampering, misuse and theft.
This is how long you should wash your hands with soap and water
refer to your entity's policy
PPMC and PAH 20 seconds
HUP 15-20 seconds