JCIA Q & A

JCIA Survey

Specially Trained Surveyors Will Visit & Evaluate Each Health Care Organizations Compliance And Identify Strengths And Weaknesses. The Surveyors Goal Is Not Merely To Find Problems, But Also To Provide Education And Consultation So Health Care Organizations Can Improve.

Best Motto: Stay Prepared

Its very important that you have to be ready for the survey

Keep up-to-date & thorough with all the standard procedures involved in your assigned job & related medical records procedures. Seek your direct supervisors help & clarify your doubts

Tips to get educated

Try to review your departmental announcements & policy / guidelines information from outlook public folder

What do I say if I dont know the answer to a Joint Commission surveyors question?

Inform him/her where you would go to find the answer (e.g., I would ask my supervisor, reference a specific policy manual, etc.). NEVER RESPOND, "I DONT KNOW."

ACCESS TO CARE & CONTINUITY OF CARE

How do you provide for continuity of care throughout the patients hospital stay?

How do you assure that one level of care is provided for operative and other procedures throughout the facility?

Does the clinic provide the patient and their family with information about continuing care, treatment or services and how to access the resources?

Does the clinic/ambulatory setting explain treatments and follow-up care to discharged patients?

How do you provide for the exchange of appropriate patient care and clinical information when patients are admitted, referred, transferred, or discharged?

Do patients with alike healthcare problems and needs receive the same quality of care throughout the hospital? How are you sure of this?

Do you have a Discharge planner?

What is Nursings role in the patient admitting process?

How are you sure that a patients discharge is based upon his/her assessed needs and that care will continue as necessary in the home environment?

How do you arrange for home care and/or home equipment for patients discharged unexpectedly during off hours?

Who conducts discharge planning activities during the weekend?

If a physician refused to respond to an emergent call from staff regarding a patient, what is your process to arrange for care for the patient during off hours?

Describe the process (es) for referral, transfer, or discharge of a patient.

How do you provide for the exchange of appropriate patient care and clinical information when patients are admitted, referred, transferred, or discharged?

What type of patients do you routinely transfer to outside facilities? Why?

What is done with mental health patients? How are they managed if you do not have a psychiatric component of your facility?

What type of circumstances slow the progress of ED patients? Why? What is being done to improve in these areas?

How do you handle primary care referral sources?

Within what time frame are patients seen and examined by a physician? What do your medical staff bylaws or ED rules and regulations require?

Has this unit ever transferred one of your postoperative patients to an ICU as an unplanned event?

What would PACU staff do if an unplanned admission to ICU from the PACU was necessary and the ICU was full to capacity?

Can patients be discharged without a physicians order? If this center uses discharge criteria, describe the elements of the criteria

What is the process if a patient scheduled for an outpatient procedure must be converted to an inpatient?

Tell me about planning?

your

discharge

What has been done to accommodate patients and visitors with disabilities?

What has been done to accommodate culturally diverse patients and visitors?

PATIENT & FAMILY RIGHTS

How is the patients right to treatment or service respected and supported? How does your hospital respond to requests for care that it cannot provide based on its capacity, stated mission and philosophy, and relevant laws and regulations?

How does your hospital demonstrate respect for the following patient needs in this setting: Confidentiality; Privacy; Security; Resolution of complaints; and Communication?

Describe how patients are involved in the following 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 lifesustaining treatment;

Describe the medical staffs role in developing the hospitals code of ethical behavior:

Describe the medical involvement in the Committee:

staffs Ethics

Describe the medical staffs role in developing and implementing processes related to patient rights

What was the medical staffs participation in the development of policies regarding procurement and donation of organs/tissues?

What access is available to knowledge-based information that may be required in patient care activities, research and other clinical activities?

When and how do you obtain consent?

What happens if the patient is unable to sign the consent form?

What procedures need obtaining an informed consent?

How do you manage patients complains?

What rights and responsibilities do our patients have?

How is the patient informed about is/her rights?

What is your role in obtaining informed consent?

What structures are in place to address end of life decisions

How do we evaluate the need for restrictions such as telephones, visitors, etc.?

How does the organization ensure patients care is not negatively affected if a staff member asks not to participate in an aspect of care due to personal, Ethical, cultural or religious values?

If you have an ethical question on any aspect of patient care delivery, what resources are available to discuss the situation?

How are you as a staff member made aware of the ethical issues surrounding patient care and the hospitals policies governing these issues?

What is your departments role in the development and implementation of the mechanisms designed to address patient rights?

How is the managed?

patient

complaint

How are patients (spiritual) needs met?

How do inform other departments that a patient being transportation to their area has valid DNR orders?

What rights do patients have regarding pain management?

How do you involve the patient in participating in care decisions? How do you involve the patients family?

What is the nurses role in addressing ethical issues in the patient care process?

What is Nursing Services involvement with the Ethics Committee? Are nursing personnel assigned as Ethics Committee members?

What is the nurses role when an advance directive calls for discontinuing life support, but the family member objects?

Do we have a Complaint Management Policy?

What type of ethical issues do you deal with in your department?

What is the mechanism your department follows if there is a conflict between family members as to whether someone should be made a No Code?

What are the patients responsibilities and rights related to patient safety?

How is confidentiality of patient information maintained at your registration desk?

Does housekeeping staff have access to your department after hours? If so, how do you maintain confidentiality of patient information

What does your staff do if there is no informed consent for a procedure on the patients record prior to the procedure?

What mechanism does the patient care unit staff have in place to access the Ethics Committee? How are patients and their families informed about their right to access the Ethics Committee?

The ED environment by nature tends to be close. How do you maintain confidentiality of patient information?

How does your hospital demonstrate respect for the following patient needs: Response to patient and family requests for pastoral services? Communication of information in a way and language understood by those making care decision?

Describe the informed consent process on your unit. Who must inform the patient about operative and other procedures, and what must the patient understand prior to signing an informed consent?

What process does your hospital have in place to support the patients right for DNR intraoperatively?

Do you require housekeeping staff to sign confidentiality statements (as there is a potential for access during off-hours when cleaning is performed)?

Can you list some of the rights that both the JCIA and the federal government require healthcare institutions to extend to patients?

What is meant "informed consent?

by

How are patients informed of their rights as a patient?

Do you have access to other religious sects

ASSESSMENT OF PATIENTS

What is your process nutrition screening?

for

What are the criteria you use for identifying patients at nutritional risk?

What are the criteria for developing a plan for nutritional therapy?

Is there a Nutritional Care Manual? Who has copies? Is there a copy available on each patient care unit?

Describe the assessment process

functional

What elements are assessed when a functional assessment is performed?

Describe your interdisciplinary approach to nutritional care

When patients enter the same day surgery area, does the nurse perform the same assessment as he/she would on an inpatient?

Does the initial patient assessment include an evaluation of physical, psychological, social, and economic factors, including, a physical examination and health history?

Describe the initial assessment process, including which disciplines are involved in assessing the patient, the scope of their assessment, and the time frame to complete the assessment.

In the initial assessment, how is the patients pain identified?

Are the initial assessment, medical history, and physical examination competed in a timely fashion, as defined by hospital policy or the standards?

How is the assessment process for special populations, such as infant, child, or adolescent patient individualized?

Do you periodically reassess patients at appropriate intervals to determine their response to treatment and to plan for continued treatment or discharge?

How is a patients pain assessed and managed?

What waived testing procedures are your nurses allowed to perform? What type of treatment is based on the results of the waived tests? What is your policy on this?

Who evaluates or deals with the psycho social needs.

How do you provide for services not available at this facility during off hours (i.e., mobile MRI)?

What is your turn-around-time on laboratory tests ordered as routine? Does this time vary during the evening or night shifts? Can you provide documentation supporting your answer?

What is your turn-around-time on diagnostic radiology films ordered STAT during off hours? Can you provide documentation supporting your answer?

What do you do in the event of a reagent recall?

What is the turn-around-time for STAT laboratory orders? Can you provide documentation to support your answer?

What types of tests are batched?

What percentage of collected specimens must be rerun due to human error? Due to technical (equipment) error?

What process is followed for providing STAT and urgent testing in the event of laboratory equipment failure?

How are medical and nursing staff informed of critical or panic laboratory values?

What is the Laboratorys process for taking orders from physicians over the telephone? Where is the documentation kept?

How does the Laboratory protect confidential patient information?

What type of staff safety equipment is available in the Laboratory?

How are blood/blood product ordering patterns established?

How blood reactions are monitored?

What is your process when blood is not available?

Do you monitor cross match to transfusion ratios? What is being monitored to assure appropriate utilization of blood/blood products?

What is the role of the Medical Director of the Clinical Laboratory? Does he/she review abnormal results prior to final printing of result?

Have you ever had an incident or near miss related to blood dispensing?

What is the process used to evaluate and select reference laboratories and contract services used by your laboratory?

Does your Laboratory perform proficiency testing? If so, what is your rate?

Who performs the tests on proficiency samples? Do these personnel also test patient samples?

Are there tests that are not included in a proficiency testing program? If so, what means do you have of verifying their accuracy and precision?

What is your process for reviewing quality control and patient results and where is this review process documented? Who performs the review?

What are your policies regarding unacceptable quality control results, and how do you document remedial action when this occurs?

Describe how your hospital provides pathology and clinical laboratory services and consultation, whether on the premises or in a contact laboratory.

Do you have set time frames for communicating laboratory results to patient care staff? Please provide an example?

How do staff members determine what is a normal range for a test?

Describe how your laboratory safety program is coordinated with the organizations safety management program.

How are reagents that are used to provide laboratory services periodically evaluated for accuracy and results?

How are procedures for collecting, identifying, handling, safely transporting, and disposing of specimens developed and implemented?

Who is responsible for reviewing the quality control results for all outside sources of laboratory services?

Does the organization have access to experts in specialized diagnostic areas, such as parasitology or virology, when necessary?

Who draws blood phlebotomists?

besides

How does this work with nursing drawing blood? How do they maintain competency if they are drawing blood very often?

How do you assure right person is getting right blood at right time?

Describe the reassessment process. What are the components of a reassessment? When are reassessments performed? Do you have criteria for this?

Describe the process for blood transfusions from order to completion of transfusion:

Have assessment activities been defined in writing?

What are the time frames established by the organization for initial assessments performed by each discipline?

What process is in place t identify those patients that need discharge planning?

Does a physician reassess all patients daily during the acute phase of their care or treatment?

Does the organization have a policy that defines the types of patients or circumstances that a physician reassessment can be less than daily? Describe the circumstances.

What is your triage process?

Explain the difference between triage and medical screening

Who can perform triage activities? Who conducts medical screening examinations?

How do you know you are assessing pain accurately?

Is blood stored in the surgical services environment? What is your policy on this?

Describe the preoperative and intra-operative nursing assessment process

What type of assessment occurs in the PACU? When are reassessments conducted?

Do you perform blood draws in the center? If so, how do you know staff is competent? Do you monitor laboratory requests for redraws? Do you monitor hematomas after blood draw?

What is the policy for pain assessment in Adults (inpatient settings)?

Are ambulatory clinics required to conduct pain assessment on all patients?

What point of care testing are you doing?

CARE OF PATIENTS

How do you know whether or not your patients like the food they receive as inpatients?

What is your policy on restraint and seclusion?

How the staff members are educated and trained on restraint use?

What are some of the alternative measures youve employed to reduce restraint use?

How are patients assessed while in restraint/seclusion?

What measures are in place to assure all patients have access to resuscitative measures?

How do you monitor resuscitation outcomes?

What processes are in place to optimally manage patient pain?

Have you addressed the special needs of patients who are possible victims of alleged or suspected abuse or neglect?

How do you plan care to ensure that it is appropriate to the patients needs?

How the same level of care is consistently assured?

Explain the medical staffs role in the 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 safe and effective alternatives to restraint:

What type of performance improvement activities are conducted related to restraints?

How do you provide for special nutritional requests of the patient when the kitchen is closed?

Who monitors food preparation, safety and storage and how are these processes monitored?

What guidelines are in place for counseling patients about significant changes in their diet?

What has the Nutritional Care Services Department done to improve the provision of food and nutrition to the patient population?

What has the Nutritional Care Services Department done to improve the meal service provided?

How do you ensure that members of the Nutritional Care Services Department, Pharmacy, Nursing and the medical staff find out promptly when a patient is on a drug in which there is a potential interaction with food?

Are dietitians available on weekends?

Describe how patients are involved in the assessment and management of pain?

Do you periodically evaluate patients progress against care goals and the plan of care? Are the plans or goals revised when indicated?

How do you provide for coordination among the health professional(s) and service(s) or setting(s) involved in patient care?

Describe the informed consent process on your unit. Who must inform the patient about operative and other procedures, and what must the patient understand prior to signing an informed consent?

Is there a discharge planner available on the weekends and holidays? If not, what education has your staff received regarding ordering of home health supplies? How does the discharge process work in this instance?

Who on this patient care unit is approved to take verbal or telephone orders? When must the order be signed by the ordering physician?

What procedures are used to guide the care of patients in restraint and seclusion? How do you know that staff members follow the guidelines, when restraint and seclusion are used in the care if a patient?

Can restraints be initiated by an R.N?

What must the physician order include for the use of restraints?

How long is an order for Medical/Surgical restraint on a patient valid?

if a patient is restrained for sudden aggressive behavior, how soon must the patients is assessed faceto-face by the physician and how long is the restraint good for?

Who is responsible for monitoring resuscitation (Code Blue) outcomes and how often is this performed?

How can you be certain that a crash cart on a different unit is stocked the same as the cart on your unit?

How often do the Nurses check the contents of all crash cart?

What is your visitation policy?

What is the process if you suspect a patient is an abuse victim?

Do you have access to nutrition for patients after dietary is closed?

Describe what steps are taken in the care of the immunosuppressed patient

Describe the process for performing a test or procedure on a patient with a behavior management problem?

What is your hospitals policy regarding organ donation? What tissue bank do you report to?

If your facility does not treat patients suffering from mental illness/behavior problems, what would staff do if it became apparent that a patient with a medical/surgical illness was in need of mental health care?

Can a physician write a PRN order for restraints?

How are patient rights, dignity and well-being protected during an episode of restraint?

Where are patient assessments/interventions related to restraints documented?

How staff are trained in the proper use of restraints?

What is available for food preferences for patients of other cultures/religions?

ANESTHESIA & SURGICAL CARE

What do you do if you discover the patient does not have a signed, informed consent in the medical record prior to surgical procedure (a scenario where the patient is in the surgical preoperative holding area):

Where is IV conscious sedation given? Are patients receiving conscious sedation recovered the same as surgical patients?

Are medical staffs privileged to give conscious sedation? If not, how are you sure they are competent to provide this service?

Do you document informed consent for anesthesia? How are you sure the patient has been given information about all risks, options and alternatives?

Where is the evidence that a reevaluation of the patient is performed immediately prior to anesthesia induction?

How do you know which procedures present a potential for blood transfusion?

What are the criteria for discharge from the PACU?

How are surgical cases reviewed? Who determines the criteria used in the review?

Are individuals administering sedation and anesthesia qualified?

Is pre anesthetic evaluation preformed prior to administering sedation or anesthesia?

Is anesthesia care of each patient planned and documented in the patient record before the patient receives the anesthesia? What information is included in the anesthesia plan of care?

Are anesthesia risks, potential complications, and options discussed with patients and their families prior to administering anesthesia?

Is each patients psychological status during anesthesia administration continuously monitored and documented in the patients record?

Describe the process for monitoring patients during the post-anesthesia recovery area?

If moderate and deep sedation considered a high-risk procedure in your organization? If so, are data collected and intensively analyzed from a risk management prospective, when significant unexpected events and undesirable trends and variation occur?

How do you recover patients if they have received conscious sedation?

Are all physicians allowed to order and administer moderate to deep sedation (conscious sedation)?

What policies and procedures have been established to guide the care of those patients undergoing moderate or deep sedation, if used in the area?

What are the qualifications of the individual responsible for monitoring the patient undergoing moderate or deep sedation?

Why is it important to assess reversal agent use?

How do you know the physician performing the endoscopy procedure is privileged and competent?

What processes are in place to prevent surgery on the wrong body part or wrong side of the patients body?

What is your policy on allowing representatives from equipment manufacturers into the Surgical Services Department? Are these individuals allowed to observe procedures? Are they allowed to participate in procedures?

What are the minimal preoperative testing requirements for all surgical patients?

Is a plan of anesthesia care formulated and communicated among care providers prior to administering anesthesia?

Are anesthesia options and risks discussed with patients and their families prior to administering anesthesia?

Are patients assessed on admission to and before discharge from the postanesthetic recovery area?

Are patients discharged from the post anesthetic recovery area by an anesthesiologist or other qualified individual or by a qualified individual who applies criteria and discharges the patient?

Describe how you monitor patients during the postprocedure period.

How is pain managed for the PACU patient? How can staff determine if the patient just emerging from anesthesia is truly having pain?

Are patient family members allowed in the PACU? Are there ever any special circumstances regarding this?

Who is responsible for assessing and/or reassessing the patient immediately prior to administering anesthesia when a nurse anesthetist is not involved in the procedure?

MEDICATION MANAGEMENT & USE

What is your policy on medication samples? Are they controlled?

What has the medical staff done with ADR reports to improve the care of patients?

What ADR trends have you identified? What type of followup do you do? What is your ADR rate?

How are medication errors reported?

What is your medication error rate? How does this compare with other organizations?

How are food-drug interactions reported?

How do you educate patients about food-drug interactions? When do you provide the education?

Are patient profiles from the Pharmacy available to all caregivers?

How does nursing staff obtain needed medications when the Pharmacy is closed?

What is your policy on selfadministered drugs by patients?

Describe how you monitor selection, ordering, preparation, administration and medication effect on the patient as part of your performance improvement program:

How do you know your Pharmacy is secure?

Describe your controlled substance protocol

How are controlled substances used by anesthesia tracked?

Do storage, distribution, and control of medications reflect policies and procedures?

Has the organization planned for emergency medications to be located in ambulatory or outpatient clinics? When present, what is the procedure used to prevent abuse, theft, or loss of the medication? What is the process to replace emergency medications when used, damaged, or out-of date?

How do you retrieve and safely dispose of discontinued and recalled medications?

How do you determine if patients are using alternative medicines (herbals, etc.)?

What do you do to obtain medications after hours?

Do you as staff members feel comfortable reporting medication errors?

How do you manage pediatric medication dosing in an emergency situation?

How often is your resuscitation cart checked?

How do you comply with the requirement that medication orders are to be reviewed by a pharmacist prior to patient administration when the Pharmacy is closed?

How do you assure that only medications that are needed for emergent or urgent patient needs are obtained and administered when the Pharmacy is closed (i.e., when a patient is admitted at 2:00 AM. with orders for medications and the Nursing Supervisor fills these orders, how are you sure only those medications that are of urgent/emergent need are obtained)?

Do you monitor illegible handwritten physician orders? Have you identified any problem areas? If so, have you been able to achieve improvements in this area?

Describe training and education provided regarding cardiopulmonary resuscitation of patients and the Pharmacy staffs involvement with this

Who is responsible for checking medication refrigerators?

What is the Pharmacy Departments role in pain management?

What would the Pharmacy Department do if there was an electrical failure and various medication refrigerators throughout the institution were without power? How would you know the refrigerated medications were still viable?

How medication recalls are handled?

Who monitors medications wasted in anesthesia? How are controlled drugs managed in the Surgical Services area?

How do you involve the patient in participating in care decisions regarding medication use? How do you involve the patients family?

How are medication errors being tracked and does this process include prescribing errors?

What are your narcotic discrepancies during the last six to twelve months? Have you noted any trends? What is the Pharmacy Department doing to improve discrepancies?

How are medication use process organized throughout the organization? What is the process for overseeing medication use in the organization?

Do you have a list of medications stocked in the organization? What is the method for overseeing the list?

How do you obtain needed medications not stocked or normally available to the organization?

Are written policies and procedures used to guide prescribing, ordering, administration, and monitoring of medications? Are the uniformly used throughout the organization where medications are used?

Describe the hospitals use of verbal medical orders?

Who is permitted to prescribe and order medications?

Is the self-administration of medications permitted in the organization? How do you ensure that it is done safely, when permitted?

What is done with any medications that are brought into the organization for or by the patient?

Who is responsible for supervising the storage, preparation, and dispensing of medications?

What procedures are in place throughout the organization to ensure that controlled substances are accurately accounted for?

How do you ensure that medications are dispensed in a form requiring minimal manipulation?

How do you identify patients before medications are administered?

How are medication errors reported? What time frame must medication errors is reported? What have you learned from the aggregation and analysis of medication error data? What, if any changes have been made in the medication use processes from use of this information?

What would you do if you found that the emergency box or crash cart was unlocked?

Describe how the medication orders are processed for your hospital.

How are drug storage areas checked?

Is there an automatic stop policy at your hospital? How does it work?

Who is approved to mix Kcl? Who is approved to administer this drug and monitor the patient? How do you know that staff member is competent to manage the type of patient who requires this medication?

What is your policy for use of multi-dose vials of medications?

How do policies and procedures support safe medication prescription and ordering?

How are adverse medication effects noted in the patients record?

What is the usual method for the nurse to verify that the pharmacist has reviewed a medication?

Under what circumstances may the inpatient nurse give a first dose of medication to a patient prior to the pharmacist review of the medication order?

PATIENT & FAMILY EDUCATION

How do you assess the patients and familys education needs, their ability and readiness to learn?

When appropriate, are patients given instruction on the safe and effective use of medications, including potential interactions between medications and food, nutritional guidance, safe use of medical equipment, and rehabilitation techniques?

What is the medical staffs role in patient/family education? Is this an interdisciplinary process?

Does the hospital have a written plan for patient/family education?

How do we educate patients concerning pain management?

How do you identify the patient/family need for education?

Where is patient documented?

education

How do pharmacy and nutritional services work together in patient and family education?

How the family is educated on how to assure compliance and continued care?

What questions can you ask your patients to determine their level of understanding

When do you start to educate the patient?

How are patients educated about FoodDrug Interactions?

Are the patients given instructions on the safe and effective use of medical equipment, when required?

How do you educate the patients family about restraint use?

How do you know patient/family teaching has been effective?

How are patients educated regarding their responsibility in safety issues pertinent to their care?

At time of patient discharge, what is done in terms of educating the patient/family?

What type of pre-procedure education is provided to the patient?

What type of post-procedure education is provided to the patient?

Describe your patient education processes, including preoperative and postoperative education

How does staff on this unit assess the learning needs and barriers of the patient?

QUALITY IMPROVEMENT & PATIENT SAFETY

Describe the hospitals sentinel event policy and the procedure for reporting events to the JCI.

Have you had a sentinel event or near miss occurrence? What procedural changes have you instituted following an event?

Does the unit get information back from indicators? If yes how do you use the information? What impact has the data had on your operations?

What information is available relative to patient satisfaction with the services provided?

How have leaders implemented a patient safety program?

Does the organization have a process to intensively assess data when significant unexpected events and undesirable trends and variation occur? Describe which types of events would be included in this intensive analysis.

How do the selected KPI measures focus on your organizations mission, vision and improvement planning strategies?

How was your organizations staff trained on the KPI initiative? (This question includes collection of data, analysis and use of data.)

How measure selections were communicated to staff?

Outline your organizational performance improvement program (how program is implemented and how it works)

What is your method or model of performance improvement?

Explain how your organization plans and designs new or redesigns, existing processes

Explain the types and methods of data collection you perform for performance improvement purposes

What are your criteria for prioritizing performance improvement activities?

When does Leadership analyze current performance? How is this conducted?

How do the medical staff, administration and clinical care providers interact within the performance improvement culture within the facility?

Describe actual improvements within the facility or community as a result of performance improvement activities

Are quality Improvement and patient safety activities carried out in a collaborative fashion among departments and disciplines?

Is there a written plan for an organization-wide quality improvement and patient safety program?

How do leaders prioritize the processes to be monitored? How do leaders prioritize those processes and activities to be improved?

What data are collected about the Patient assessment?

What data are collected about the use of anesthesia?

Do you monitor the use of blood and blood products?

Do you monitor staff expectations and satisfaction?

Have you identified any issues form monitoring patient and family expectations and satisfaction of their care? What if anything, have you changed as a result of this information?

What if anything, have you learned from monitoring the use of antibiotics and other medications?

How do you know that improvements in quality and safety is achieved and sustained?

How do you have input on what should be improved in your area?

What were some of the accomplishments in the past year?

What is everyones responsibility in data collection?

If our hospital should need to scale down its efforts for any of various reasons, what criteria would the performance improvement and patient safety council use to prioritize the minimal efforts to be continued?

What are clinical guidelines and how do they affect the outcome of the patient?

What are some examples of clinical protocols at our facility that have been successfully implemented?

What are some clinical protocols that we are working on and planning to implement within the coming year?

What types of outcome indicators are being monitored by Nursing Services?

How have departmental staffs been educated about sentinel events?

What role does your department play in improving patient safety?

Do the members of your department feel comfortable reporting medical/health care errors?

How and when do you report a medical/health care error?

What is a sentinel event?

Who has responsibility for the implementation of the Quality Management System?

How often is the Quality Management System reviewed and what were the results of your last review?

What is OVR?

How do you report incidents?

Who should fill out Incident Reports?

To whom do you report incidents?

What is a "Near Miss"

PREVENTION & CONTROL OF INFECTIONS

What procedures are in place to report infections when they have been identified?

What action has the hospital taken to reduce the risk of or prevent nosocomial infections?

Is surgical site surveillance conducted?

Outline your surveillance plan

What has been improved as a result of your infection control and surveillance program efforts?

How are staffs educated about categories of isolation?

What is the most common isolation category implemented in this institution?

What type of education has been provided to staff regarding the Blood borne Pathogens Standards and the Needle Stick Prevention Act?

What is your staff needle stick rate?

How infectious disease consultations are managed? Is there a specific criterion or triggers, or is the process dependent upon specific request by the Infection Control Nurse?

What types of prevention activities are currently in process?

What role does the Infection Control Nurse, program and/or committee play in relationship to patient safety activities conducted at this institution?

As the Infection Control Nurse/Epidemiologist do you work full time? If not, how many hours per week do you work? How did you arrive at this ratio of hours? How do you know it is sufficient for the facility?

Has this institution experienced any outbreaks during the past 12 months?

Have you treated any patients with tuberculosis?

How many negative airflow rooms do you have?

How is Employee Health related to the Infection Control Program?

How do you prevent transmission of infections from patients to staff?

Describe your waste management program as it relates to the handling of infectious waste?

Describe how your infection control activities are integrated with the hospitals performance improvement activities

Describe the resources available to you, such as professional journals related to infection control, internal and external databases, professional library, CDC and APIC data

Why is there an infection control program?

What single action is recognized by the CDC (center of disease control and prevention) as the most effective means of preventing the spread of infection within a facility

What does the term of Standard Precaution mean?

What would you do for an occupational exposure to blood borne pathogens (needle stick, splash or spray to eyes, nonintact skin)?

What is personal protective equipment? Name an example and when you should use.

If a patient has an infection which requires isolation, where would you find information regarding the type of isolation required?

Who monitors refrigerator temperatures in our facility and what action should be taken to correct an out of range reading?

What immunizations are available to our employees?

What precautions are taken for patients with known or suspected TB?

Do you recap needles?

How do you dispose of sharps?

Who is on your infection control committee? How do you utilize these persons?

What types of surveillance, other than infections, are you doing?

Have there been any areas of concern for possible infections in the last year such as construction and what did you do about it?

How was your IC Program developed?

What is the most prevalent infection seen in your hospital? How is it addressed?

What do you do with the information (re. infections) you gather?

Where do you get the data (re: infections within the hospital, nosocomial and community acquired)?

What hand hygiene training is provided to staff and patients?

Is there a competency for hand washing/use of alcohol agents?

What preventive efforts are you doing in employee health?

What questions do you ask on your employee medical assessment?

What is your program in preventing infections in donated organs and with organ procurement.

How do you report to the Health Department and what/when etc.

How is infection data presented up and down in the institution?

What is your action if you prick yourself with a dirty needle?

Have you had any sentinel events related to infection control?

Where are your hot spots? What interventions did you use to reduce the risk of infections? Who was involved? Are you monitoring the changes?

Tell me about your employee health program. Do you have much TB in this area? Have you had any conversions in the last year? What percentage of your staff had their PPD last year? What are the major issues in employee health? Tell me about your flu vaccine initiative.

Do you re-sterilize any single use devices? Which items?

Asked staff about blood spill kits, yearly Infection Control education

How do you get information back from the physicians concerning post-op infections/SSIs?

Who do you network with locally?

Where do you refer patients to or consult with concerning infectious disease?

Asked about prophylactic preoperative antibiotic usage and trends.

With so much out-patient surgery being done, how do you find out what your post-op infection rate really is?

In current literature, there has been noted an increase of crosscontamination due to computer hardware. Have you come across that?

Speaking to operating room representative: What do you decontaminate?

What plans do you have for decontamination

For clinical personnel, what are you doing about nails?

What information do your employees have about blood exposures?

How often do you do infection control rounds and with whom?

For HIV text, how quickly do you get the results back? How and when do you start an exposed employee on prophylactic medications? Going back to HIV, have you had to put exposed employees on drugs? How were they exposed?

What is IC's role in construction?

Monitoring of air quality and water quality---who did it, how often, where was it reported, what was being done in this area during construction, did we have backup plans for disruption of services, etc.

Explain your process for sterilization of equipment / instruments, including flash sterilization. What type of documentation do you keep regarding sterilization?

How do you manage an infectious patient in the OR? What precautions are undertaken to prevent spread of the infection in the sterile environment?

What type of measures or policies do you have in place to prevent nosocomial infections as a result of food or nutrition?

What type of orientation regarding food safety is provided to new Nutritional Care Services staff?

How do you manage patients with infections? How do you prevent nosocomial outbreaks within the department and hospital wide?

Do you ever use non-disposable suture kits? If so, what is the cleaning process and who does this?

Describe the following: The process for reporting information about infections; and Actions you have taken to reduce the risk of or prevent nosocomial infections.

How are instruments cleaned?

What type of personal protective equipment is used when cleaning equipment?

How are you sure the room where cleaning is performed is safe for personnel, and that they are not exposed to chemicals?

Describe process remains

the disposal for anatomical

What types of infectious patients has staff dealt with in the PACU? What is the process for preventing nosocomial infection in this environment?

Do risk reduction procedures and processes address engineering controls, such as positive ventilation systems, biological hoods in laboratories, and thermostats on water heaters?

What situations require the use of masks and gloves?

Describe the processes for tracking nosocomial infection risks, rates, and trends?

How do you dispose of infectious waste?

When should you wash your hands?

How do you handle soiled linen?

GOVERNANCE, LEADERSHIP & DIRECTION

How is the hospitals mission and vision communicated to all hospital and medical staff? How do the hospital leaders know they have effectively communicated the mission/vision?

Describe your hospitals planning process and describe how this relates to your mission and vision statement

What patient outcomes have you been able to improve based on your KPI data measurements?

Describe how the hospital has established processes that define the qualifications, responsibilities, competencies and staffing required for supporting and maintaining its mission

Do you have a conflict of interest policy? Describe your process for addressing conflict of interest in the facility

Describe how you are certain that services provided to patients relates to their identified needs

Describe how you have planned to coordinate administrative with clinical decisions for patients that you may receive that are under legal or correctional restrictions

Describe how departments have established goals and scopes of service

How was your hospital-wide plan for providing patient care developed? Who was involved in the development? How did you implement this plan?

Describe how hospital-wide policies are developed and who is involved in the development

Do patients with like healthcare problems and needs receive the same quality of care throughout the hospital? 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 care? Describe the medical staffs involvement in this process

Describe how performance improvement priorities are established

Describe which individuals are involved in the planning process for the operating budget and long term capital budget

Describe your hospitals approach to performance improvement. How are planning the improvement process, setting priorities and assessing performance in a systematic manner included?

Describe how your facility maintains achieved improvements

How were improvement established?

performance expectations

What important internal processes and activities are continuously and systematically assessed and improved throughout your facility?

How were the leaders in the organization educated regarding performance improvement approaches and methods?

Who establishes and evaluates the responsibilities of department/service directors? How is this done?

What types of resources are allocated for assessing and improving the hospitals governance, managerial, clinical and support activities?

Explain how the leaders assess the effectiveness of their contributions toward improving performance

Describe your process that assures that the competence of all staff members is assessed, maintained, demonstrated and improved on an ongoing basis

Describe your staffing plan, and explain how you assess actual staff provided against projected staffing

Describe how your facility promotes personnel selfdevelopment and learning

Describe the processes in place within your facility to support patient rights. How staff is made aware of these processes?

How are leaders involved in assuring that billing and marketing practices are conducted in an ethical manner?

How can you be sure your discharge and transfer practices are conducted in an ethical manner?

Have you started a new patient care service recently? Have there been any existing services that have undergone significant change recently? Describe the processes involved in implementing this new service/this recent change in service

Describe your restraint policy. How do the leaders of the facility ensure that only limited, justified restraint or seclusion use is conducted?

Describe the patient and family education processes in place in your institution

Explain the process you as leaders use to approve the policies and plans used to operate your organization.

What is a recent example of how the governance of this organization has supported and promoted quality management and improvement efforts?

How do you monitor the services offered by an outside organization with which you have a contract to provide services?

What is your process for identifying in writing the services provided by each department? How do you know the documents are current?

When did the organization last test its community-wide disaster plan? What changes, if any, did you make in the plan as a result of testing?

Discuss the processes for staff recruitment, retention and staff development and continuing education.

How do leaders support the oversight of professional ethical issues?

What is mission statement?

What does your hospital mission statement mean to you?

What is your definition of quality?

Who are your customers?

How do you decide on Board members?

How do you evaluate Board members? Do you have a formal process to evaluate the Board?

What have you done concerning ergonomics?

How do you protect the integrity of clinical decisions?

Tell me about your donation program

organ

How does the community let you know their needs?

How do you measure if you are meeting community needs?

Tell me about your population?

What are the job requirements of the medical director?

Asked medical director about performance improvement activities

What type of feedback do you get from patients?

What barriers make it difficult to obtain needed staff?

Does the hospital have an mechanism to ensure that independent practitioners within the scope of privileges?

effective licensed function granted

Explain your participation in the budgeting process

How are recommendations to appoint or reappoint practitioners made to the Governing Body?

What is the criteria for initial appointment and how was this criteria developed?

What are the criteria for granting, renewing and/or revising clinical privileges?

How are you sure that individuals with clinical privileges provide services within the scope of those privileges? Are privilege lists updated to reflect changes in privileges, technology or clinical practice?

Do decisions on reappointment or revisions or renewal of clinical privileges consider criteria that are directly related to quality of care? Explain

Describe your peer review process and how this impacts the credentialing function

What is the process if the Governing Body declines a medical staff recommendation for appointment or reappointment?

Does the competency review at time of reappointment include the practitioners ethical behavior patterns?

What mechanism does your medical staff have in place to assure all practitioners are treated fairly?

How do you know the members of the Credentials Committee are competent and knowledgeable to perform their duties as a committee member?

How often your privilege lists are revised?

What process does your medical staff have in place to accurately assess outcomes from a statistical standpoint? (i.e., for those requesting surgical privileges, at time of reappointment do you list number of procedures performed versus number of complications)

How you are sure information regarding any medical malpractice judgments is communicated at time of appointment or reappointment?

What does a department director do if he/she has no personal knowledge of an applicant for reappointment and there are no members with knowledge of the practitioner on the committee reviewing privilege requests, to make a determination regarding the practitioners competence?

How is Nursing Leadership involved in the budget process?

How is Nursing Leadership involved in improving patient satisfaction?

How much input does Nursing Services have in hospital wide decision-making processes?

How do you contain and control departmental costs?

How is peer review for the Medical Director of the Clinical Laboratory performed?

How do your leaders define the following: The qualifications and responsibilities of staff working in this setting; A system to evaluate how well staff responsibilities are met; and The number of staff needed to fill the settings mission?

How does the department manager determine if staff is competent to perform assigned duties, and when appropriate, provide care for the special needs and behaviors of specific age groups?

FACILITY MANAGEMENT & SAFETY

Have staff educated and trained about their roles in providing a safe and effective patient care facility, including their roles in the organizations plans for fire safety, security, hazardous materials, and emergencies?

Have you maintained, tested, and inspected medical equipment in this setting?

How have the ambulatory care/outpatient clinics been involved in the risk assessment and planning activities for utility systems, including the identification of areas and 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 material is located where?

What has the Safety Officers role been in developing department and organization safety policies, procedures and performance measures?

Has the safety officer worked with appropriate staff to implement recommendations and monitor their effectiveness?

What performance measure has been prioritized by the Safety Committee for recommendation to the Performance Improvement Committee?

How does the Safety Committee interact with other hospital committees?

How is information on incidents handled? How does information get to the Administrator/CEO? How does information get to the Governing Body?

Describe how the organization provides for the security of patients and personnel

Describe your most challenging security issue: How are you meeting this challenge?

What is the process for selection of hazardous materials for use in the organization? Who approves these materials?

What are the hazardous chemicals used in the hospital? Who is responsible for training the employees? How do you know training has occurred and is effective?

Where is the master list of MSDSs kept? Are unit specific MSDSs kept on individual units? (Surveyor may request specific MSDS and time staffs response.)

What is the hospitals role in communitywide emergency preparedness/management?

What is the procedure you follow when a bomb threat is received?

How are physicians oriented and educated about life safety? (Surveyor may ask for documentation verifying physician education.)

Describe the emergency procedures that are in place in the event of a utility system disruption or failure

What are the PM completion rates?

What is your average turn-around time for repairs?

How is incoming equipment screened?

Where does frequency testing come from?

of

What is the process for acquiring new equipment?

What happens when a vendor brings in a piece of equipment? What are the safeguards that prevent the piece of equipment from being used by staff or physicians?

Describe the testing of the emergency power system, as required by the services provided

What processes are in place for managing pathogenic biological agents in cooling towers, domestic hot water and other aerosolizing water systems? What departments were involved in developing these processes?

How does the Plant Services Director determine if staff is competent to perform assigned duties, and when appropriate operate specialized equipment and utility systems?

What do you do on discovering a fire?

What are the types of Fire Extinguishers in the Hospital?

How to use the Fire Extinguisher?

Do you know the location of fire Alarm in your area?

Do you know the location of the Fire Extinguishers in your area?

Do you know the location of the fire floor plan in your area?

Do you know the location of the Medical Gas valve (if available) in your area?

Do you know the Fire Exits in your area?

Do you know the designated Assembly Points for your area?

Do you have a no-smoking policy in the hospital?

A chemical can't be identified on the floor. What do you do?

What does MSDS refers to?

What are the Emergency Codes in the hospital?

What is your action in the case of chemical spill?

What spill kit and its components are?

Do we have a disaster plan?

What is your role in case of disaster?

Who is responsible for safety at the hospital?

What is included in your hospital safety program at your hospital?

What is the goal of the safety program?

What should you do if you see smoke coming from a patient room, a fire in a Wastebasket or any other signs of a fire?

Which extinguishers can be used for extinguishing fires involving burning cloth, paper, or wood?

Which extinguishers can be used for electrical equipment motors, switches, and flammable liquids?

Which fire extinguishers should not be used on electrical equipment motors, switches, and flammable liquids?

How would you respond if told, A FIRE HAS BROKEN OUT?

How often do you have fire drills?

What is the hospital code for a Fire?

Where do you find information regarding employee responsibilities during a disaster?

What information should one attempt to obtain from someone calling in a bomb threat?

Who should be contacted upon receiving a bomb threat?

What do you do if someone becomes extremely agitated or violent?

What is the hospital code for Cardiac Arrest?

What is the center code for a chemicals spill or blood body fluid spill?

How do you report equipment malfunction?

an

Whose responsibility is it to be certain the equipment you using is functioning properly?

Who is authorized it shut off the oxygen valves in the event of a fire or another emergency?

What happens in the event of a utility failure (i.e. electric, water, gas, medical gas, or telephone)?

Other than the Material Safety data Sheet ( MSDS), where can the hazardous material name and hazard warning for that material be found?

What first aid measures are necessary when working with the hazardous chemicals found in your department?

How are the safety activities reported to Administration and the Board?

How do you report an employee incident?

How do laboratory staff members safely handle hazardous and infectious materials?

Describe the inspecting and testing procedures for laboratory equipment. What documentation is maintained to show that testing, maintenance, and calibration of equipment is done?

What types of fire hazards are specific to the kitchen area?

How often are your scales calibrated to assure accuracy?

What would staff do if the lights went out during a surgical procedure? Assuming your department has a back-up lighting system, what would staff do if that system also failed?

Describe storage and management requirements for gas and nitrogen used in the surgical environment

What steps does the PACU staff take if biomedical equipment malfunctions or is unable to be used for patient care? How is replacement equipment obtained?

How are communications maintained in the event of a telephone outage?

What would you do if the water supply were cut off?

What do you do in the event of a mercury spill and where is the information found to guide healthcare workers with this?

How do you know this fire extinguisher has been checked?

What type of provisions does the Nutritional Care Services Department keep on hand in the event of a disaster?

How can you be sure you will have enough food and water to provide for the basic nutritional needs of both the staff and the patient population in the event of a disaster?

STAFF QUALIFICATION & EDUCATION

How do you know your staff is competent to perform patient care?

Have leaders identified those staff members to be trained in cardiac life support? How often is the desired level of training for each individual repeated?

Do department directors determine the desired education, skills, and knowledge of each staff member assigned responsibilities in the department?

How do you encourage and support staff selfdevelopment and learning?

Do staff members receive an orientation to the department and initial job training and information?

How do you assure that competence is the same at all times?

What type of information from the Human Resources Department is collected for performance improvement purposes?

Do you use float staff? Do you have a float staff policy that defines orientation and minimum competencies? How do you know the staff floating to different units is as qualified to provide care as the routine Patient Care Unit staff?

How do you promote recruitment, retention, development and recognition of staff members?

If you have to use staff from other departments to cover for staff members that have called in sick, how do you assure this staff members competence?

How do you adjust staffing needs to a fluctuating patient census?

Who evaluates the clinical competency of the Nurse Executive? (Relevance -need for Nurse Executive to remain current in clinical theory to allow for appropriate decision making)

How is staff oriented to the organization, job responsibilities and performance expectations?

What staff learning needs have been identified by your Governing Body through their review of your staff competency reports?

How are Human Resources involved in the budget process?

How are Human Resources involved in assessing the needs of the community?

How Human Resources is involved in improving patient satisfaction?

What continuing education does staff receive?

How do you analyze, assess and respond to the educational needs of your staff?

How are your job descriptions developed? Do your job descriptions match your performance evaluations?

Explain your criteria for development of clinical competency assessments

How do you know if a nurses current licenses or certifications have been verified? What is your process?

As appropriate to your organizations priorities, what aspects of the Human Resources function do you measure, assess and improve?

Do you use contracted staff? How do you assess the competency of these individuals?

How do you maintain your competency/ skills in order to perform your job?

Did you receive training during department orientation on equipment used in your area?

What age of patients do you care for? Have you received age-specific instructions and care for all of these ages?

Do you have access to educational materials related to your profession?

How do you do Primary source verification? Do you have approval and a budget for payment for verifications?

Tell us about BLS training for staff

What data do you have to assure you have adequate staff?

Describe training and education provided regarding cardiopulmonary resuscitation of patients. Describe your resuscitation outcomes monitoring program. Have you identified any opportunities to improve your resuscitation processes?

What is your training on identification and reporting of victims of abuse?

Do you ever use locum anesthesiologists? If so, how do you know they are qualified to provide anesthesia?

MANAGEMENT OF COMMUNICATION & INFORMATION

Describe your organizations information management needs assessment process and how this relates to your mission and vision statement

Explain the processes your organization uses to conduct an ongoing review of medical records for completeness, accuracy and timely completion of medical records

Does your medical staff suspend physicians due to medical record delinquencies? Describe how this process works

Describe how your hospital is collecting and reporting KPI data related on any of the Information Management Function processes

What medical record improvements have you been able to implement based on your medical records review process?

How do you define completeness, accuracy and timelines in the review of medical records?

Who are the members of the group responsible for the ongoing review of medical records? How were the members determined?

What has the medical staff done to improve the content, timeliness or completion of the medical record?

Are medical records available on a 24-hour basis? How are they accessed?

What is your organizations policy related to the use of H&P information gathered in physician offices within 30 days prior to admission?

What is the extent of history and assessment when a patient is readmitted to the organization?

Describe the coding and retrieval system for medical records by diagnosis and procedure

How do you maintain security and confidentiality of data when contributing to or using an external database?

How are medical records and other data protected against tampering or falsification?

How are medical records and other data protected against destruction, damage or loss?

What type of measures do you have for assuring security of patient information when computerized systems are used?

What is your organizations policy regarding unscheduled computer system interruption?

What resources are available to both the medical and hospital staff related to knowledge-based information

What is the organizations policy on use of the Internet?

How do you know your information management processes and systems satisfactorily meet the needs of the institution and the patient population?

Describe the system for making information available to staff who need it to carry out their responsibilities.

How do you ensure that the confidentiality, security, and integrity of data and information are maintained?

How does your hospitals information management process support your processes to provide continuity over time among the assessment and diagnosis, planning and treatment phases of patient care?

Has the organization established standardized diagnosis codes, procedure codes, symbols, and definitions? How were they established?

Explain the written protocol defining the requirements for developing and maintaining policies and procedures. Describe the method for identifying and tracking all policies and procedures in circulation

One of your co-workers has forgotten her computer password and ask to use your password so she can get her work done complete. What do you do?

You learn, as a result of your work, that a close friend is on the surgery schedule. Another friend asks you what you know about the patient. How do you handle the situation?

How are you informed of policy and procedures changes?

Who can look in a medical record?

Describe how communication takes place across the organization. What are the communication avenues open to individual departments

How are surgical complications documented? How and to whom are these reported?

When does the medical record have to be complete?

What process is in place to ensure that the patients record is available to those providing care and services?

What elements are required on a written H&P prior to operative procedure?

What elements are required to be documented in the medical record prior to patient discharge from the PACU?

Under what circumstance and from whom may the RN take verbal orders? What information must the RN include when the verbal order is written and in what time frame must it be co-signed?