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7/27/2019 JCIA Q & A 2010
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JCIA Q & A
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JCIA Survey
Specially Trained Surveyors Will Visit & EvaluateEach Health Care Organization s Compliance
And Identify Strengths And Weaknesses. TheSurveyor s Goal Is Not Merely To FindProblems, But Also To Provide Education AndConsultation So Health Care Organizations Can
Improve.
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Best Motto: Stay PreparedIt s very important that you have to be ready for the
survey
Keep up-to-date & thorough with all thestandard procedures involved in your assigned
job & related medical records procedures.
Seek your direct supervisors help & clarify your doubts
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Tips to get educated
Try to review your departmentalannouncements & policy / guidelinesinformation from outlook public folder
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What do I say if I don t know the answer to a Joint Commission surveyor s question?
Inform him/her where you would go tofind the answer (e.g., I would ask my
supervisor, reference a specific policymanual, etc.).
NEVER RESPOND, "I DONT KNOW."
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ACCESS TO CARE& CONTINUITY OF CARE
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How do you provide for continuityof care throughout the patient s hospital stay?
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How do you assure that onelevel of care is provided for operative and other procedures
throughout the facility?
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Does the clinic provide thepatient and their family with
information about continuingcare, treatment or services andhow to access the resources?
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Does the clinic/ambulatorysetting explain treatments andfollow-up care to dischargedpatients?
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How do you provide for theexchange of appropriate patientcare and clinical information whenpatients are admitted, referred,
transferred, or discharged?
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Do patients with alike healthcareproblems and needs receive the
same quality of care throughoutthe hospital? How are you sureof this?
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Do you have a Discharge planner?
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What is Nursing s role in thepatient admitting process?
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How are you sure that a patient s
discharge is based upon his/her assessed needs and that care willcontinue as necessary in the
home environment?
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How do you arrange for home
care and/or home equipment for patients dischargedunexpectedly during off hours?
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Who conducts dischargeplanning activities during theweekend?
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If a physician refused to respondto an emergent call from staff regarding a patient, what is your process to arrange for care for
the patient during off hours?
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Describe the process (es) for
referral, transfer, or discharge of a patient.
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How do you provide for theexchange of appropriate patient
care and clinical informationwhen patients are admitted,referred, transferred, or discharged?
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What type of patients do you
routinely transfer to outsidefacilities? Why?
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What is done with mental healthpatients? How are they
managed if you do not have apsychiatric component of your facility?
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What type of circumstances slow
the progress of ED patients?Why? What is being done toimprove in these areas?
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How do you handle primary carereferral sources?
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Within what time frame arepatients seen and examined by aphysician? What do your medical staff bylaws or ED rules
and regulations require?
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Has this unit ever transferred
one of your postoperativepatients to an ICU as anunplanned event?
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What would PACU staff do if anunplanned admission to ICU fromthe PACU was necessary and theICU was full to capacity?
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Can patients be dischargedwithout a physician s order? If this center uses dischargecriteria, describe the elements of
the criteria
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What is the process if a patient
scheduled for an outpatientprocedure must be converted toan inpatient?
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Tell me about your dischargeplanning?
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What has been done to
accommodate patients andvisitors with disabilities?
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What has been done toaccommodate culturallydiverse patients andvisitors?
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PATIENT & FAMILY RIGHTS
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How is the patient s right to treatmentor service respected and supported?How does your hospital respond torequests for care that it cannotprovide based on its capacity, stated
mission and philosophy, and relevantlaws and regulations?
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How does your hospital demonstraterespect for the following patientneeds in this setting:
Confidentiality;Privacy;Security;
Resolution of complaints; andCommunication?
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Describe how patients are involved in thefollowing functions:
Giving informed consent;Participating in care decisions (family
members);
Assessment and management of pain;Outcomes of care including unanticipated
adverse outcomes;
Deciding to withhold resuscitative services;and
Deciding to forgo or withdraw life-
sustaining treatment;
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Describe the medical staff s rolein developing the hospital s code of ethical behavior:
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Describe the medical staff s involvement in the EthicsCommittee:
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Describe the medical staff s rolein developing and implementingprocesses related to patientrights
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What was the medical staff sparticipation in the developmentof policies regardingprocurement and donation of organs/tissues?
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What access is available to
knowledge-based information thatmay be required in patient careactivities, research and other
clinical activities?
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When and how do you obtain consent?
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What happens if the patient isunable to sign the consent form?
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What procedures needobtaining an informedconsent?
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What rights and responsibilitiesdo our patients have?
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How is the patient informedabout is/her rights?
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What is your role inobtaining informed consent?
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What structures are in place toaddress end of life decisions
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How do we evaluate the need for restrictions such as telephones,visitors, etc.?
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How does the organizationensure patient s care is not
negatively affected if a staff member asks not to participate inan aspect of care due to
personal, Ethical, cultural or religious values?
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If you have an ethical questionon any aspect of patient caredelivery, what resources areavailable to discuss the
situation?
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How are you as a staff member made aware of theethical issues surroundingpatient care and the hospital s
policies governing theseissues?
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What is your department s role in the development andimplementation of themechanisms designed to
address patient rights?
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How is the patient complaintmanaged?
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How are patients (spiritual) needs met?
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How do inform other departments that a patientbeing transportation to their area has valid DNR orders?
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What rights do patients haveregarding pain management?
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How do you involve the patientin participating in care
decisions? How do youinvolve the patient s family?
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What is the nurse s role inaddressing ethical issues inthe patient care process?
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What is Nursing Service s involvement with the EthicsCommittee? Are nursingpersonnel assigned as Ethics
Committee members?
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Do we have a ComplaintManagement Policy?
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What type of ethical issues doyou deal with in your department?
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What is the mechanism your department follows if there is aconflict between familymembers as to whether someone should be made aNo Code?
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What are the patient s responsibilities and rightsrelated to patient safety?
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How is confidentiality of patientinformation maintained at your registration desk?
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Does housekeeping staff have
access to your department after hours? If so, how do you maintainconfidentiality of patient information
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What does your staff do if thereis no informed consent for aprocedure on the patient s record prior to the procedure?
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What mechanism does thepatient care unit staff have in
place to access the EthicsCommittee? How are patientsand their families informed about
their right to access the EthicsCommittee?
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How does your hospital demonstraterespect for the following patientneeds:
Response to patient and familyrequests for pastoral services?Communication of information in a
way and language understood bythose making care decision?
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Describe the informed consentprocess on your unit. Who must
inform the patient about operativeand other procedures, and whatmust the patient understand prior to signing an informed consent?
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What process does your hospital
have in place to support thepatient s right for DNRintraoperatively?
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Can you list some of the rightsthat both the JCIA and thefederal government requirehealthcare institutions to extend
to patients?
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What is meant by"informed consent?
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How are patients informedof their rights as apatient?
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Do you have access toother religious sects
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ASSESSMENT OF PATIENTS
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What is your process for nutrition screening?
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What are the criteria you use
for identifying patients atnutritional risk?
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What are the criteria for
developing a plan for nutritionaltherapy?
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Is there a Nutritional Care
Manual? Who has copies? Isthere a copy available on eachpatient care unit?
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Describe the functionalassessment process
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What elements are assessed
when a functional assessmentis performed?
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Describe your interdisciplinaryapproach to nutritional care
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When patients enter the sameday surgery area, does thenurse perform the sameassessment as he/she would
on an inpatient?
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Does the initial patient assessmentinclude an evaluation of physical,psychological, social, andeconomic factors, including, aphysical examination and healthhistory?
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Describe the initial assessmentprocess, including which
disciplines are involved inassessing the patient, the scopeof their assessment, and the time
frame to complete theassessment.
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In the initial assessment, how isthe patient s pain identified?
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Are the initial assessment,medical history, and physicalexamination competed in a timelyfashion, as defined by hospital
policy or the standards?
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Do you periodically reassesspatients at appropriate intervals todetermine their response totreatment and to plan for
continued treatment or discharge?
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How is a patient s painassessed and managed?
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What waived testing proceduresare your nurses allowed to
perform? What type of treatmentis based on the results of thewaived tests? What is your policyon this?
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Who evaluates or deals with thepsycho social needs.
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How do you provide for services
not available at this facilityduring off hours (i.e., mobileMRI)?
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What is your turn-around-time ondiagnostic radiology films orderedSTAT during off hours? Can youprovide documentationsupporting your answer?
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What do you do in the event of a reagent recall?
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What is the turn-around-time for STAT laboratory orders? Can youprovide documentation to supportyour answer?
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What types of tests are batched?
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What percentage of collectedspecimens must be rerun dueto human error? Due totechnical (equipment) error?
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What process is followed for providing STAT and urgent testingin the event of laboratoryequipment failure?
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How are medical and nursing
staff informed of critical or paniclaboratory values?
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What is the Laboratory s processfor taking orders from physiciansover the telephone? Where isthe documentation kept?
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How does the Laboratory protectconfidential patient information?
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What type of staff safety
equipment is available in theLaboratory?
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How are blood/blood productordering patterns established?
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How blood reactions are monitored?
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What is your process whenblood is not available?
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What is the role of the MedicalDirector of the ClinicalLaboratory? Does he/shereview abnormal results prior tofinal printing of result?
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What is the process used toevaluate and select referencelaboratories and contractservices used by your
laboratory?
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Who performs the tests onproficiency samples? Do thesepersonnel also test patientsamples?
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Are there tests that are notincluded in a proficiency
testing program? If so, whatmeans do you have of verifying their accuracy and
precision?
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What is your process for reviewing quality control and
patient results and where is thisreview process documented?Who performs the review?
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What are your policies regardingunacceptable quality controlresults, and how do youdocument remedial action whenthis occurs?
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Describe how your hospitalprovides pathology and clinical
laboratory services andconsultation, whether on thepremises or in a contact laboratory.
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Do you have set time frames for
communicating laboratoryresults to patient care staff?Please provide an example?
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How do staff members
determine what is a normal range for a test?
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Describe how your laboratorysafety program is coordinated withthe organization s safetymanagement program.
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How are reagents that are usedto provide laboratory servicesperiodically evaluated for accuracy and results?
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Who is responsible for reviewing
the quality control results for alloutside sources of laboratoryservices?
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Does the organization haveaccess to experts in specializeddiagnostic areas, such asparasitology or virology, whennecessary?
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Who draws blood besidesphlebotomists?
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How do you assure right
person is getting right blood atright time?
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Describe the reassessmentprocess. What are thecomponents of a reassessment?When are reassessmentsperformed? Do you have criteria
for this?
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Have assessment activities beendefined in writing?
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What are the time framesestablished by the organizationfor initial assessmentsperformed by each discipline?
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What process is in place t identify
those patients that need dischargeplanning?
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What is your triage process?
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Explain the difference betweentriage and medical screening
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Who can perform triage activities?
Who conducts medical screeningexaminations?
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How do you know you areassessing pain accurately?
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Is blood stored in the surgical
services environment? What isyour policy on this?
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Describe the preoperative and
intra-operative nursingassessment process
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Do you perform blood draws in thecenter? If so, how do you knowstaff is competent? Do you monitor laboratory requests for redraws? Do you monitor hematomas after
blood draw?
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What is the policy for pain
assessment in Adults(inpatient settings)?
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Are ambulatory clinics required
to conduct pain assessment onall patients?
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CARE OF PATIENTS
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How do you know whether or
not your patients like the foodthey receive as inpatients?
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What is your policy on restraintand seclusion?
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How the staff members are
educated and trained onrestraint use?
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What are some of the alternative
measures you ve employed toreduce restraint use?
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How are patients assessedwhile in restraint/seclusion?
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What measures are in place to
assure all patients have accessto resuscitative measures?
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How do you monitor resuscitation outcomes?
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What processes are in place tooptimally manage patient pain?
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Have you addressed the specialneeds of patients who arepossible victims of alleged or suspected abuse or neglect?
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How do you plan care to ensure
that it is appropriate to thepatient s needs?
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How the same level of care isconsistently assured?
Explain the medical staff s role in theuse of restraint or seclusion related to:
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use of restraint or seclusion related to:
Plans, policies, priorities: Assessment processes that identify
and prevent, when appropriate,potential behavioral risk factors:
Design and delivery of care:
Development and promotion of preventive strategies and use of safeand effective alternatives to restraint:
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What type of performanceimprovement activities areconducted related to restraints?
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How do you provide for special
nutritional requests of the patientwhen the kitchen is closed?
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Who monitors food preparation,
safety and storage and how arethese processes monitored?
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What has the Nutritional CareServices Department done to
improve the provision of food andnutrition to the patient population?
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What has the Nutritional CareServices Department done toimprove the meal serviceprovided?
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How do you ensure that members of the Nutritional Care ServicesDepartment, Pharmacy, Nursing andthe medical staff find out promptlywhen a patient is on a drug in which
there is a potential interaction withfood?
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Are dietitians available on weekends?
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Describe how patients areinvolved in the assessment andmanagement of pain?
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Do you periodically evaluatepatient s progress against care
goals and the plan of care? Are theplans or goals revised whenindicated?
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How do you provide for coordination among the healthprofessional(s) and service(s) or setting(s) involved in patient care?
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Describe the informed consentprocess on your unit. Who must
inform the patient about operativeand other procedures, and what mustthe patient understand prior to
signing an informed consent?
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Is there a discharge planner available on the weekends andholidays? If not, what education
has your staff received regardingordering of home health supplies?How does the discharge processwork in this instance?
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Who on this patient care unit isapproved to take verbal or telephone orders? When must theorder be signed by the orderingphysician?
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What procedures are used to guidethe care of patients in restraint and
seclusion? How do you know thatstaff members follow the guidelines,when restraint and seclusion are
used in the care if a patient?
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Can restraints be initiated by an R.N?
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What must the physician order
include for the use of restraints?
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How long is an order for
Medical/Surgical restraint on apatient valid?
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if a patient is restrained for suddenaggressive behavior, how soonmust the patients is assessed face-to-face by the physician and howlong is the restraint good for?
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Who is responsible for monitoring resuscitation (CodeBlue) outcomes and how oftenis this performed?
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How can you be certain that acrash cart on a different unit isstocked the same as the cart onyour unit?
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How often do the Nurses checkthe contents of all crash cart?
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What is your visitation policy?
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What is the process if you
suspect a patient is an abusevictim?
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Do you have access to nutritionfor patients after dietary isclosed?
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Describe what steps are taken in
the care of theimmunosuppressed patient
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Describe the process for performing a test or procedure ona patient with a behavior management problem?
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What is your hospital s policy
regarding organ donation? Whattissue bank do you report to?
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If your facility does not treatpatients suffering from mentalillness/behavior problems, whatwould staff do if it becameapparent that a patient with a
medical/surgical illness was inneed of mental health care?
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Can a physician write a PRNorder for restraints?
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How are patient rights, dignity
and well-being protectedduring an episode of restraint?
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Where are patientassessments/interventions relatedto restraints documented?
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How staff are trained in theproper use of restraints?
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What is available for foodpreferences for patients of other cultures/religions?
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ANESTHESIA & SURGICAL CARE
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What do you do if you discover thepatient does not have a signed,
informed consent in the medicalrecord prior to surgical procedure (ascenario where the patient is in the
surgical preoperative holding area):
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Where is IV conscious sedation
given? Are patients receivingconscious sedation recovered thesame as surgical patients?
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Are medical staffs privileged togive conscious sedation? If not,
how are you sure they arecompetent to provide thisservice?
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Do you document informedconsent for anesthesia? How are
you sure the patient has beengiven information about all risks,options and alternatives?
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How do you know which
procedures present a potentialfor blood transfusion?
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What are the criteria for discharge from the PACU?
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How are surgical casesreviewed? Who determinesthe criteria used in the review?
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Are individuals administeringsedation and anesthesiaqualified?
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Is pre anesthetic evaluationpreformed prior toadministering sedation or anesthesia?
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Is anesthesia care of eachpatient planned anddocumented in the patient
record before the patientreceives the anesthesia? Whatinformation is included in theanesthesia plan of care?
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Are anesthesia risks, potentialcomplications, and options
discussed with patients andtheir families prior toadministering anesthesia?
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Is each patient s psychologicalstatus during anesthesia
administration continuouslymonitored and documented inthe patient s record?
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Describe the process for monitoring patients during thepost-anesthesia recoveryarea?
If moderate and deep sedation
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considered a high-risk procedurein your organization? If so, aredata collected and intensively
analyzed from a risk managementprospective, when significantunexpected events andundesirable trends and variationoccur?
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How do you recover patients if
they have received conscioussedation?
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Are all physicians allowed toorder and administer moderateto deep sedation (conscioussedation)?
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What policies and procedureshave been established to guide the
care of those patients undergoingmoderate or deep sedation, if usedin the area?
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What are the qualifications of the individual responsible for
monitoring the patientundergoing moderate or deepsedation?
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Why is it important to assess
reversal agent use?
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How do you know the physicianperforming the endoscopy
procedure is privileged andcompetent?
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What processes are in place toprevent surgery on the wrong
body part or wrong side of thepatient s body?
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What is your policy on allowingrepresentatives from equipmentmanufacturers into the Surgical
Services Department? Are theseindividuals allowed to observeprocedures? Are they allowed toparticipate in procedures?
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What are the minimal preoperative
testing requirements for all surgicalpatients?
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Is a plan of anesthesia careformulated and communicatedamong care providers prior toadministering anesthesia?
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Are anesthesia options and risksdiscussed with patients and their families prior to administeringanesthesia?
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Are patients discharged from thepost anesthetic recovery area byan anesthesiologist or other
qualified individual or by aqualified individual who appliescriteria and discharges thepatient?
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Describe how you monitor
patients during the post-procedure period.
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How is pain managed for thePACU patient? How can staff
determine if the patient justemerging from anesthesia is trulyhaving pain?
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Are patient family membersallowed in the PACU? Arethere ever any specialcircumstances regarding this?
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MEDICATION MANAGEMENT & USE
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What has the medical staff
done with ADR reports toimprove the care of patients?
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What ADR trends have youidentified? What type of follow-up do you do? What is your
ADR rate?
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How are medication errors reported?
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What is your medication error rate? How does this comparewith other organizations?
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How are food-drug interactions
reported?
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How do you educate patientsabout food-drug interactions?When do you provide theeducation?
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Are patient profiles from the
Pharmacy available to allcaregivers?
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How does nursing staff obtain
needed medications when thePharmacy is closed?
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What is your policy on self-administered drugs by patients?
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Describe how you monitor selection, ordering, preparation,administration and medicationeffect on the patient as part of your performance improvement
program:
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How do you knowyour Pharmacy issecure?
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Describe your controlled
substance protocol
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How are controlled substancesused by anesthesia tracked?
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Do storage, distribution,and control of medicationsreflect policies andprocedures?
Has the organization planned for emergency medications to be
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located in ambulatory or outpatientclinics? When present, what is the
procedure used to prevent abuse,theft, or loss of the medication?What is the process to replaceemergency medications when used,damaged, or out-of date?
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How do you determine if patients are usingalternative medicines(herbals, etc.)?
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What do you do toobtain medicationsafter hours?
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Do you as staff members feelcomfortable reportingmedication errors?
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How do you managepediatric medicationdosing in an emergencysituation?
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How often is your resuscitation cart checked?
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How do you comply with therequirement that medicationorders are to be reviewed by apharmacist prior to patientadministration when the
Pharmacy is closed?
How do you assure that only medicationsthat are needed for emergent or urgent
d b d d
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patient needs are obtained andadministered when the Pharmacy isclosed (i.e., when a patient is admitted at2:00 AM. with orders for medications andthe Nursing Supervisor fills these orders,how are you sure only those medicationsthat are of urgent/emergent need areobtained)?
Do you monitor illegible
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handwritten physicianorders? Have you identified
any problem areas? If so,have you been able toachieve improvements in thisarea?
ib i i d d i
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Describe training and educationprovided regarding
cardiopulmonary resuscitation of patients and the Pharmacy staff s involvement with this
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Who is responsible for checking
medication refrigerators?
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What is the PharmacyDepartment s role in painmanagement?
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How medication recalls are handled?
Wh i di i
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Who monitors medicationswasted in anesthesia? How
are controlled drugs managedin the Surgical Services area?
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H di i
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How are medicationerrors being tracked
and does this processinclude prescribingerrors?
Wh t ti
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What are your narcoticdiscrepancies during the last sixto twelve months? Have younoted any trends? What is thePharmacy Department doing to
improve discrepancies?
H di ti
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How are medication useprocess organized throughoutthe organization? What is theprocess for overseeingmedication use in the
organization?
D h li t f
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Do you have a list of medications stocked in theorganization? What is themethod for overseeing thelist?
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How do you obtain neededmedications not stocked or normally available to theorganization?
Are written policies andd d id
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procedures used to guideprescribing, ordering,
administration, and monitoring of medications? Are the uniformlyused throughout the organizationwhere medications are used?
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Describe the hospital s use of verbal medicalorders?
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Who is permitted toprescribe and order medications?
Is the self administration of
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Is the self-administration of medications permitted in the
organization? How do youensure that it is done safely,when permitted?
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What is done with anymedications that are brought
into the organization for or bythe patient?
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Who is responsible for supervising the storage,
preparation, and dispensingof medications?
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How do you ensure thatmedications are dispensed in
a form requiring minimalmanipulation?
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How do you identify patientsbefore medications areadministered?
How are medication errorsreported? What time frame must
di ti i t d? Wh t
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medication errors is reported? Whathave you learned from the
aggregation and analysis of medication error data? What, if anychanges have been made in themedication use processes from useof this information?
Wh t ld d if
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What would you do if youfound that the emergency
box or crash cart wasunlocked?
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Describe how the medicationorders are processed for your hospital.
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How are drug storage areas checked?
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Is there an automaticstop policy at your
hospital? How does itwork?
Who is approved to mix Kcl?Who is approved to administer
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Who is approved to administer this drug and monitor the patient?
How do you know that staff member is competent to managethe type of patient who requires
this medication?
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What is your policy for use of multi-dose vialsof medications?
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How do policies and procedures
support safe medicationprescription and ordering?
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How are adverse
medication effects noted inthe patient s record?
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U d h t i t
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Under what circumstances maythe inpatient nurse give a first
dose of medication to a patientprior to the pharmacist review of the medication order?
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PATIENT & FAMILY EDUCATION
H d h i
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How do you assess the patient s and familys education needs,
their ability and readiness tolearn?
When appropriate, are patientsgiven instruction on the safe and
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given instruction on the safe andeffective use of medications,including potential interactionsbetween medications and food,nutritional guidance, safe use of
medical equipment, andrehabilitation techniques?
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How do you identify thepatient/family need for education?
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How do pharmacy and nutritional
services work together in patientand family education?
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How the family is educated on
how to assure compliance andcontinued care?
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What questions can you ask your patients to determine their level of understanding
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When do you start to educatethe patient?
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How are patients educated about
Food Drug Interactions?
Are the patients given
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Are the patients giveninstructions on the safe and
effective use of medicalequipment, when required?
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How do you educate thepatient s family about restraintuse?
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How do you know
patient/family teaching hasbeen effective?
H i d d
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How are patients educatedregarding their responsibility insafety issues pertinent to their care?
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At time of patient discharge, whatis done in terms of educating thepatient/family?
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What type of pre-procedureeducation is provided to thepatient?
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What type of post-procedure
education is provided to thepatient?
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Describe your patient educationprocesses, including preoperativeand postoperative education
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How does staff on this unit assessthe learning needs and barriers of the patient?
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QUALITY IMPROVEMENT &PATIENT SAFETY
b h h l l
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Describe the hospital s sentinelevent policy and the procedure for reporting events to the JCI.
H h d ti l t
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Have you had a sentinel event or near miss occurrence? Whatprocedural changes have youinstituted following an event?
Does the unit get information back
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gfrom indicators? If yes how do you
use the information? What impacthas the data had on your operations?
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What information is available
relative to patient satisfaction withthe services provided?
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How have leaders
implemented a patient safetyprogram?
Does the organization have a
process to intensively assess datawhen significant unexpected
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p ywhen significant unexpectedevents and undesirable trendsand variation occur?Describe which types of eventswould be included in this intensiveanalysis.
How do the selected KPI
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measures focus on your
organization s mission, visionand improvement planningstrategies?
How was your organization s staff
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y gtrained on the KPI initiative?(This question includes collectionof data, analysis and use of data.)
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How measure selections were
communicated to staff?
Outline your organizational
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Outline your organizationalperformance improvement
program (how program isimplemented and how it works)
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What is your method or model
of performance improvement?
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Explain how your organization
plans and designs new or redesigns, existing processes
Explain the types and methods of
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Explain the types and methods of data collection you perform for
performance improvementpurposes
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When does Leadership analyzecurrent performance? How is thisconducted?
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Describe actual improvements
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Describe actual improvementswithin the facility or community asa result of performanceimprovement activities
Are quality Improvement and
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q y ppatient safety activities carried out
in a collaborative fashion amongdepartments and disciplines?
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How do leaders prioritize the
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processes to be monitored? How
do leaders prioritize thoseprocesses and activities to beimproved?
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What data are collected about
the Patient assessment?
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What data are collected
about the use of anesthesia?
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Do you monitor the use of
blood and blood products?
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Do you monitor staff
expectations and satisfaction?
Have you identified any issuesform monitoring patient and family
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g p yexpectations and satisfaction of
their care? What if anything, haveyou changed as a result of thisinformation?
Wh if hi h l d
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What if anything, have you learned
from monitoring the use of antibiotics and other medications?
d k h
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How do you know that
improvements in quality and safetyis achieved and sustained?
H d h i t h t
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How do you have input on whatshould be improved in your area?
Wh t f th
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What were some of theaccomplishments in the pastyear?
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What is everyone s responsibility
in data collection?
If our hospital should need toscale down its efforts for any of
i h i i
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various reasons, what criteria
would the performanceimprovement and patient safetycouncil use to prioritize the
minimal efforts to be continued?
What are clinical guidelines and
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What are clinical guidelines andhow do they affect the outcome of the patient?
What are some examples of
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pclinical protocols at our facilitythat have been successfullyimplemented?
What are some clinical protocols
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that we are working on and
planning to implement within thecoming year?
What types of outcome indicators
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What types of outcome indicatorsare being monitored by NursingServices?
How have departmental staffs
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How have departmental staffsbeen educated about sentinelevents?
Wh t l d
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What role does your
department play in improvingpatient safety?
Do the members of your d f l f bl
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department feel comfortable
reporting medical/health careerrors?
H d h d
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How and when do you report
a medical/health care error?
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What is a sentinel event?
Who has responsibility for the
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Who has responsibility for theimplementation of the QualityManagement System?
How often is the Quality Management
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Q y gSystem reviewed and what were theresults of your last review?
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What is OVR?
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How do you report incidents?
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Who should fill out Incident Reports?
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To whom do you report incidents?
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What is a "Near Miss"
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PREVENTION & CONTROL OF
INFECTIONS
What procedures are in place to
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p preport infections when they havebeen identified?
What action has the hospital taken
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pto reduce the risk of or preventnosocomial infections?
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Is surgical site surveillance conducted?
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What has been improved as a
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result of your infection control andsurveillance program efforts?
ff d d b
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How are staffs educated about
categories of isolation?
What is the most common isolation
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category implemented in thisinstitution?
What type of education has beenprovided to staff regarding the
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p ov ded to sta ega d g t eBlood borne PathogensStandards and the Needle StickPrevention Act?
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What is your staff needle stick rate?
How infectious diseaseconsultations are managed? Ish ifi i i i
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there a specific criterion or triggers,
or is the process dependent uponspecific request by the InfectionControl Nurse?
What types of prevention activities
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What types of prevention activities
are currently in process?
What role does the InfectionControl Nurse, program and/or
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committee play in relationship topatient safety activities conductedat this institution?
As the Infection Control
Nurse/Epidemiologist do you workfull time? If not, how many hours
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, yper week do you work? How didyou arrive at this ratio of hours?How do you know it is sufficient for
the facility?
Has this institution experienced
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pany outbreaks during the past 12months?
Have you treated any patients with
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Have you treated any patients with
tuberculosis?
How many negative airflow rooms
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How many negative airflow rooms
do you have?
How is Employee Health related
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p yto the Infection Control Program?
How do you prevent
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transmission of infections frompatients to staff?
Describe your waste managementprogram as it relates to the handling
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program as it relates to the handling
of infectious waste?
Describe how your infectioncontrol activities are integrated
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control activities are integrated
with the hospital s performanceimprovement activities
Describe the resources availableto you, such as professionaljournals related to infection
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journals related to infection
control, internal and externaldatabases, professional library,CDC and APIC data
Why is there an infection control
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Why is there an infection control
program?
What single action is recognizedby the CDC (center of diseasecontrol and prevention) as the
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control and prevention) as the
most effective means of preventing the spread of infection within a facility
What does the term of Standard
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What does the term of Standard
Precaution mean?
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What is personal protectiveeq ipment? Name an e ample and
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equipment? Name an example and
when you should use.
If a patient has an infection whichrequires isolation where would
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requires isolation, where would
you find information regarding thetype of isolation required?
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What immunizations are available
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to our employees?
What precautions are taken for
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patients with known or suspectedTB?
D dl ?
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Do you recap needles?
H d di f h ?
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How do you dispose of sharps?
Who is on your infection controlcommittee? How do you utilize
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committee? How do you utilize
these persons?
What types of surveillance, other
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than infections, are you doing?
Have there been any areas of concern for possible infectionsin the last year such as
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in the last year such as
construction and what did youdo about it?
H IC P g d l d?
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How was your IC Program developed?
What is the most prevalent infectionseen in your hospital? How is it
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seen in your hospital? How is it
addressed?
What do you do with theinformation (re infections) you
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information (re. infections) you
gather?
Where do you get the data (re:infections within the hospital,
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nosocomial and communityacquired)?
What hand hygiene training is
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provided to staff and patients?
Is there a competency for handwashing/use of alcohol
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washing/use of alcohol
agents?
What preventive efforts ared i i l h l h?
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you doing in employee health?
What questions do you ask onyour employee medical
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your employee medical
assessment?
What is your program in preventinginfections in donated organs and
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g
with organ procurement.
How do you report to theHealth Department and
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Health Department andwhat/when etc.
How is infection data presented
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up and down in the institution?
What is your action if youprick yourself with a dirty
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prick yourself with a dirty
needle?
Have you had any sentinelevents related to infection
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events related to infection
control?
Where are your hot spots? Whatinterventions did you use toreduce the risk of infections? Who
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was involved? Are you monitoringthe changes?
Tell me about your employeehealth program. Do you have
much TB in this area? Have youhad any conversions in the lastyear? What percentage of your
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year? What percentage of your staff had their PPD last year?What are the major issues inemployee health? Tell me aboutyour flu vaccine initiative.
Do you re-sterilize any single used i ? Whi h i ?
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devices? Which items?
Asked staff about blood spill kits,yearly Infection Control
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yearly Infection Control
education
How do you get information backfrom the physicians concerning
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p y g
post-op infections/SSIs?
Who do you network with locally?
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Who do you network with locally?
Where do you refer patients to or consult with concerning infectious
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g
disease?
Asked about prophylactic pre-operative antibiotic usage and
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p g
trends.
With so much out-patient surgerybeing done, how do you find out
h t t i f ti t
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what your post-op infection ratereally is?
In current literature, there has beennoted an increase of cross-contamination due to computer
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p
hardware. Have you come acrossthat?
Speaking to operating roomrepresentative: What do you
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representative: What do you
decontaminate?
What plans do you have for d t i ti
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decontamination
For clinical personnel, whatare o doing abo t nails?
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are you doing about nails?
What information do your employees have about blood
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p y
exposures?
How often do you do infectioncontrol rounds and with whom?
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control rounds and with whom?
For HIV text, how quickly do youget the results back?How and when do you start anexposed employee on prophylactic
di i ?
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medications?Going back to HIV, have you had toput exposed employees on
drugs? How were they exposed?
What is IC's role in construction?
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Monitoring of air quality and water
quality---who did it, how often,where was it reported, what wasb i d i thi d i
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being done in this area duringconstruction, did we have backupplans for disruption of services, etc.
Explain your process for
sterilization of equipment /instruments, including flasht ili ti Wh t t f
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sterilization. What type of documentation do you keepregarding sterilization?
How do you manage an infectiouspatient in the OR? Whatprecautions are undertaken to
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p
prevent spread of the infection inthe sterile environment?
What type of measures or policiesdo you have in place to preventnosocomial infections as a result
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nosocomial infections as a resultof food or nutrition?
What type of orientationregarding food safety is providedto new Nutritional Care Services
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to new Nutritional Care Servicesstaff?
How do you manage patients withinfections? How do you preventnosocomial outbreaks within the
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nosocomial outbreaks within thedepartment and hospital wide?
Do you ever use non-disposablesuture kits? If so, what is thel i d h d
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cleaning process and who doesthis?
Describe the following:
The process for reportinginformation about infections;and
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and Actions you have taken to reducethe risk of or prevent nosocomial
infections.
How are instruments cleaned?
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What type of personal protectiveequipment is used when cleaning
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equipment?
How are you sure the room wherecleaning is performed is safe for personnel and that they are not
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personnel, and that they are notexposed to chemicals?
Describe the disposalprocess for anatomical
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remains
What types of infectious patientshas staff dealt with in the PACU?What is the process for preventing
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nosocomial infection in thisenvironment?
Do risk reduction procedures and
processes address engineeringcontrols, such as positiveventilation systems biological
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ventilation systems, biologicalhoods in laboratories, andthermostats on water heaters?
What situations require the useof masks and gloves?
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g
Describe the processes for tracking nosocomial infection risks,
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rates, and trends?
How do you dispose of infectiouswaste?
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waste?
When should you wash your hands?
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How do you handle soiled linen?
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GOVERNANCE, LEADERSHIP &DIRECTION
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How is the hospital s mission and
vision communicated to all hospitaland medical staff? How do thehospital leaders know they have
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p yeffectively communicated themission/vision?
Describe your hospital s planningprocess and describe how thisrelates to your mission and vision
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ystatement
What patient outcomes have youbeen able to improve based on your
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KPI data measurements?
Describe how the hospital has
established processes that definethe qualifications, responsibilities,competencies and staffing required
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p g qfor supporting and maintaining itsmission
Do you have a conflict of interestpolicy? Describe your process for addressing conflict of interest in the
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gfacility
Describe how you are certain thatservices provided to patients relates
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to their identified needs
Describe how you have planned tocoordinate administrative withclinical decisions for patients that
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you may receive that are under legal or correctional restrictions
Describe how departments haveestablished goals and scopes of
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service
How was your hospital-wide planfor providing patient caredeveloped? Who was involved in
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the development? How did youimplement this plan?
Describe how hospital-wide policiesare developed and who is involved
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in the development
Do patients with like healthcareproblems and needs receive thesame quality of care throughout the
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q y ghospital? How are you sure of this?
How do you assure that patients
requiring tests, services or procedures not provided by your hospital receive the necessary
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p ycare? Describe the medical staff s involvement in this process
Describe how performanceimprovement priorities are
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established
Describe which individuals areinvolved in the planning process for the operating budget and long term
7/27/2019 JCIA Q & A 2010
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p g g gcapital budget
Describe your hospital s approach to
performance improvement. How areplanning the improvement process,setting priorities and assessing
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g p gperformance in a systematic manner included?
Describe how your facility maintainsachieved improvements
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How were performanceimprovement expectations
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established?
What important internal processesand activities are continuously andsystematically assessed and
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improved throughout your facility?
How were the leaders in theorganization educated regardingperformance improvement
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p papproaches and methods?
Who establishes and evaluatesthe responsibilities of department/service directors?
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pHow is this done?
What types of resources areallocated for assessing andimproving the hospital s
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governance, managerial, clinicaland support activities?
Explain how the leaders assessthe effectiveness of their contributions toward improving
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p gperformance
Describe your process thatassures that the competence of all staff members is assessed,
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maintained, demonstrated andimproved on an ongoing basis
Describe your staffing plan, andexplain how you assess actualstaff provided against projected
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staffing
Describe how your facilitypromotes personnel self-
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development and learning
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How are leaders involved inassuring that billing and marketingpractices are conducted in an
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ethical manner?
How can you be sure your dischargeand transfer practices are conducted
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in an ethical manner?
Have you started a new patientcare service recently?
Have there been any existingservices that have undergonesignificant change recently?
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g g yDescribe the processes involved inimplementing this new service/this
recent change in service
Describe your restraint policy.How do the leaders of the facilityensure that only limited, justified
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restraint or seclusion use isconducted?
Describe the patient and familyeducation processes in place in
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your institution
Explain the process you as leadersuse to approve the policies andplans used to operate your
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organization.
What is a recent example of howthe governance of thisorganization has supported and
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promoted quality managementand improvement efforts?
How do you monitor the servicesoffered by an outside organizationwith which you have a contract to
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provide services?
What is your process for identifying in writing the servicesprovided by each department?
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How do you know the documentsare current?
When did the organization last testits community-wide disaster plan?What changes, if any, did you
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make in the plan as a result of testing?
Discuss the processes for staff recruitment, retention and staff development and continuing
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education.
How do leaders support theoversight of professional ethical
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issues?
What is mission statement?
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What does your hospital missionstatement mean to you?
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What is your definition of quality?
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Who are your customers?
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How do you decide on Boardmembers?
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How do you evaluate Boardmembers? Do you have a formal
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process to evaluate the Board?
What have you done concerningergonomics?
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How do you protect the integrityof clinical decisions?
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Tell me about your organdonation program
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How does the community let youknow their needs?
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How do you measure if you aremeeting community needs?
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Tell me about your population?
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What are the job requirements of the medical director?
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Asked medical director about performance
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improvement activities
What type of feedback do youget from patients?
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What barriers make it difficult toobtain needed staff?
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Does the hospital have an effectivemechanism to ensure that licensedindependent practitioners function
i hi h f d
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within the scope of grantedprivileges?
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How are recommendations toappoint or reappoint practitioners
d h G i B d ?
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made to the Governing Body?
What is the criteria for initialappointment and how was this
i i d l d?
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criteria developed?
What are the criteria for granting,renewing and/or revising clinical
i il ?
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privileges?
How are you sure that individualswith clinical privileges provideservices within the scope of thoseprivileges? Are privilege lists
d d fl h i
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updated to reflect changes inprivileges, technology or clinicalpractice?
Do decisions on reappointmentor revisions or renewal of clinicalprivileges consider criteria that
di tl l t d t lit f
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are directly related to quality of care? Explain
Describe your peer reviewprocess and how this impacts
th d ti li f ti
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the credentialing function
What is the process if theGoverning Body declines amedical staff recommendation for
i t t i t t?
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appointment or reappointment?
Does the competency review attime of reappointment include thepractitioner s ethical behavior
tt ?
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patterns?
What mechanism does your medical staff have in place toassure all practitioners are treatedf i l ?
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fairly?
How do you know the members of the Credentials Committee arecompetent and knowledgeable to
f th i d ti itt
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perform their duties as a committeemember?
How often your privilege listsare revised?
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What process does your medicalstaff have in place to accurately
assess outcomes from a statisticalstandpoint? (i.e., for thoserequesting surgical privileges, attime of reappointment do o list
7/27/2019 JCIA Q & A 2010
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time of reappointment do you listnumber of procedures performedversus number of complications)
How you are sure informationregarding any medicalmalpractice judgments iscommunicated at time of
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appointment or reappointment?
What does a department director doif he/she has no personalknowledge of an applicant for reappointment and there are nomembers with knowledge of the
practitioner on the committee
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practitioner on the committeereviewing privilege requests, tomake a determination regarding thepractitioner s competence?
How is Nursing Leadershipinvolved in the budget process?
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How is Nursing Leadershipinvolved in improving patient
satisfaction?
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satisfaction?
How much input does NursingServices have in hospital wide
decision making processes?
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decision-making processes?
How do you contain and controldepartmental costs?
7/27/2019 JCIA Q & A 2010
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How is peer review for theMedical Director of the Clinical
Laboratory performed?
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Laboratory performed?
How do your leaders define thefollowing:
The qualifications andresponsibilities of staff working in
this setting;
A system to evaluate how well
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A system to evaluate how wellstaff responsibilities are met; andThe number of staff needed to fill
the setting s mission?
How does the departmentmanager determine if staff iscompetent to perform assignedduties, and when appropriate,
provide care for the special needs
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provide care for the special needsand behaviors of specific agegroups?
FACILITY MANAGEMENT &SAFETY
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Have staff educated and trainedabout their roles in providing asafe and effective patient carefacility, including their roles in theorganization s plans for fire safety,
it h d t i l d
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security, hazardous materials, andemergencies?
Have you maintained, tested, andinspected medical equipment in
this setting?
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this setting?
How have the ambulatorycare/outpatient clinics been involvedin the risk assessment and planningactivities for utility systems, includingthe identification of areas and
services at greatest risk when powerf l d
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services at greatest risk when power fails or water is contaminated or interrupted? How have the risks of
such events been reduced?
Information on hazardous materialis located where?
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What has the Safety Officer s rolebeen in developing departmentand organization safety policies,
procedures and performance?
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procedures and performancemeasures?
Has the safety officer worked withappropriate staff to implementrecommendations and monitor
their effectiveness?
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their effectiveness?
What performance measure hasbeen prioritized by the SafetyCommittee for recommendation
to the Performance ImprovementC itt ?
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to the Performance ImprovementCommittee?
How does the Safety Committeeinteract with other hospital
committees?
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committees?
How is information on incidentshandled? How does informationget to the Administrator/CEO?How does information get to theGoverning Body?
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Governing Body?
Describe how the organizationprovides for the security of
patients and personnel
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patients and personnel
Describe your most challengingsecurity issue: How are you
meeting this challenge?
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meeting this challenge?
What is the process for selectionof hazardous materials for use inthe organization? Who approvesthese materials?
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these materials?
What are the hazardous
chemicals used in the hospital?Who is responsible for trainingthe employees? How do you
know training has occurred and
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know training has occurred andis effective?
Where is the master list of
MSDSs kept? Are unit specificMSDSs kept on individual units?(Surveyor may request specificMSDS and time staff s
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MSDS and time staff s response.)
What is the hospital s role incommunitywide emergency
preparedness/management?
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537/674
preparedness/management?
What is the procedure youfollow when a bomb threat isreceived?
7/27/2019 JCIA Q & A 2010
538/674
How are physicians oriented andeducated about life safety?(Surveyor may ask for
documentation verifying physician
7/27/2019 JCIA Q & A 2010
539/674
documentation verifying physicianeducation.)
Describe the emergencyprocedures that are in place inthe event of a utility systemdisruption or failure
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disruption or failure
What are the PM completion rates?
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What is your