JCIA QA

JCIA Q & A

JCIA Survey

Specially Trained Surveyors Will Visit & Evaluate Each Health Care Organization’s Compliance And Identify Strengths And Weaknesses. The

Surveyor’s Goal Is Not Merely To Find Problems, But to score Health Care

Organizations for their Improvement .

Preparation for Accreditation

It’s 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 Education Is A Big Piece of the Puzzle:

Try to review your departmental announcements & policy / guidelines information from the intranet "hospital portal”

Maintain competency in all your tasks.

The training manuals are readily available in your respective stations –

Use it as your regular reference guide.

This is the Key

Be organized (in your respective areas) And Surveyors Are Less Likely To Dig Deep.

Always Have Key Information Handy

Demonstrate Improvement – Surveyors Will Want To See Whether Your Area is undergoing any improvement.

Question

What is the mission of Madinat Zayed Hospital?

To provide high quality healthcare services, that is accessible to all people we serve in the Western region

JCIA Questions/Answers Cont’d …

Question

What is the vision of Madinat Zayed Hospital?

The vision of Madinat Zayed hospital is to be a leader in the provision of excellent, compassionate, rural healthcare


JCIA Questions/Answers Question

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 to find the answer (e.g., I would ask my supervisor, reference a specific policy manual, etc.).

NEVER RESPOND, "I DON’T KNOW."


Question

What do you do in case of fire?

RACE see printed cards in all units

PASS see printed cards in all units

CALL 666.

JCIA Questions/Answers Cont’d … Question

A. Where are the fire extinguishers in your work area? (Individual to each area)

B. List the 2 types of extinguishers and the types of fires they may be used on.

Type 1 – Carbon dioxide (CO2) in black cylinder. Use on flammable liquids and electrical fires. Type 2 – A multi-use dry chemical extinguisher in a red cylinder.

Question

If there is a fire, where are patients moved?

Please review the unit map and the evacuation route and fire exits in your unit. Please locate the

closest assembly point (recently placed outside the hospital building)


Question

If there is a fire, where are patients moved?

Move patients laterally beyond one set of fire doors if the fire is in your area. If not possible to evacuate horizontally, evacuate vertically using

fire safe stairwells. Do not use elevators.


Question When the fire alarms are ringing, how do you know if the fire is in your area?

Over head address systemContinuous alarm means the fire is in the area


Question

How do you report an emergency security incident such as an assault?

Activate Code White( violent person) by dialing switchboard on (0).

Fill out OVR.


Question

What is the Madinat Zayed hospital smoking policy?

MZH is a smoke free zone


Question

How do you report suspected infant abductions?

Immediately activate Code Yellow (Missing Patient by dialing the switchboard.


Question

What is an MSDS sheet and where are they located?

MSDS is the acronym for Material Safety Data Sheets. They describe products, safety measures and precautions that should be considered when

using products, and procedures for hazardous exposure. MSDS information can be found on

each ward.


Question

A chemical you don’t know about is on the floor. What do you do?

Refer to the MSDS manual.


Question

What is the proper method of needle disposal?

Do not recap Dispose in the sharp box


Question

What are Standard Precautions?

Precautions used for all patients and are designed to reduce the risk of transmission of

microorganisms from recognized and unrecognized sources or infections in the hospital. Use personal protective equipment appropriate for

the situation to avoid any exposure. See the Infection Control Manual


Question

Do we need to screen patients for

HIV and hepatitis before surgery?

No

We follow standard precautions which means that same precautions are taken regardless of HIV status


Question

How do you dispose of infectious waste?

Red plastic bags and refer to the Infection Control Manual.


Question

What are the infection control indicators at MZH:

1-Compliance with hand hygiene

2-Ventilator associated pneumonia (ICU)

3-Catheter related blood stream infection (ICU)

4-Urinary catheter related infection (ICU)

5- Surgical site infection


Question

What are the infection control indicators at MZH:

6-Compliance rate with Ventilator associated pneumonia and central line bundles of care

7-Compliance rate with the surgical site infection bundle of care


Question

What is the best resource for infection control issues?

The infection control manual and the infection control nurse

Ext:560


Question

How do you report a Code Blue and code pink?

All Code Blue’s should be reported by dialing “222“ followed by Overhead bagging


Question

What happens in the case of an electrical shutdown?

Emergency generator power will come on within seconds after losing power.


Question

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

Via e-mailsMobile telephonesPorters


Question What would you do if the medical gas system were disrupted? What gases are available in your area?

Use portable oxygen tanks as necessary until the system is restored and then have tanks

refilled in hospital there is oxygen in all

wards/department but in some specific areas nitrous oxide is present.


Question

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

Inform engineering department.The hospital has an alternative source of

clean water in case of emergency.


Question How is a patient’s Do Not Resuscitate (DNR) order communicated to all caregivers?

DNR is not accepted by UAE lawConflicts related to that can be referred to the

hospital Ethics committee


Question How are patients and families involved in planning care?

The patient’s plan of care is discussed with the patient and family upon admission and periodically throughout the hospital stay or

ambulatory visit.



QuestionQuestion

How should patient complaints be handled?How should patient complaints be handled?All the complaints will be handled as per the All the complaints will be handled as per the

compliant policy and the flow process. compliant policy and the flow process. verbal complaints are handled by the staff/HODs verbal complaints are handled by the staff/HODs

in the units /ward or by the patient affairs office.in the units /ward or by the patient affairs office.Written complaints are handled by QMDWritten complaints are handled by QMD

And patient affairs department. And patient affairs department.

Question How are patient’s rights to privacy protected?

Privacy is maintained by drawing curtains or closing doors when appropriate, refraining from conversations

regarding patients in any public area, knocking on closed doors, announcing yourself prior to entering, and placing

any census listing or appointment schedule where it is not readily viewed by those not engaged in patient

service activity.


Question How are the patient’s rights to confidentiality

protected? Confidentiality of patient information is maintained by

storing patient records only in restricted access areas of all patient care areas and offices. The MEDICOM system required authorized users to log on for each session.

Media requests for information are referred to the hospital Director office.

Encourage a patient’s family and friends to designate a spokesperson to relay information. Health care workers

should exercise extreme discretion when asked for patient information via telephone.


Question What is meant by "informed consent?“

Patient are entitled to information concerning the medical necessity, possible risks, and known

alternatives prior to the initiation of care, unless emergent in nature. IN some instances, MZH consent

policies require this process be documented by a written consent form. (refer to consent policies)


Question How do you address ethical issues of patient care or clinical practice if you have questions or concerns?

First discuss your concerns with your immediate supervisor. Refer to other Administrative channels for

your department as needed. MZH has an ethics committee chaired by medical

director and activated when needed. For example, we had 2 ethics committee meetings this year to discuss

patient requests for cord blood collection.


Question

How are patients informed of their rights as a patient?

MZH provides a pamphlet titled "Patient Rights and Responsibilities" to all admitted patients and

outpatients. This document outlines the individual rights as a patient. Posters of the same will be found

in key areas in the hospital, also the patient information Handbook includes them.


Question How did you receive training to operate the

equipment in your area?

Training should be received at initial orientation and through in-services. The operating manual should be accessible. Staff are also trained on new technology and equipment when they are introduced to their units.

Biomedical engineering department arranges training when requested


Question

How does MZH assure that equipment is safe for use?

Equipment are checked regularly by biomedical engineering department as per their specification and stickers are maintained on the equipments to indicate the date of last preventive maintenance and date of next maintenance.


Question What is "restraint?“

A physical or mechanical device or medication used to involuntarily restrict the

movement of the whole or a portion of a patient’s body as a means of controlling

his/her physical activities in order to protect him/her or others from injury.


Question

Are handcuffs used for prisoners considered restraints?

Devices used by corrections officers do not fall under the MZH policy on the use of

restraints.


Question

Who may initiate the use of restraints on medical/surgical areas?

Restraints may be initiated by competent staff after an order is obtained.


Question

Can a physician write a PRN order for restraints?

No. PRN orders cannot be written for restraints. Each order must be based on the assessed needs of the patient and include the reason for restraint, and the type of restraint.

Length of restraint time allowed depends on the circumstances and the results of patient reassessment.

Restraint orders are valid for a maximum for 24 hours only according to MZH policy.


Question

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

The patient is assessed for hygiene, elimination, hydration, nutrition and comfort needs including

neurological checks and skin integrity checks depending on the reason for restraint, as per the

approved policy .


Question

How are staff trained in the proper use of restraints?

Orientation is provided to all concerned staff and the restraints' policy is accessible to all in the hospital portal.


Question

What is the governing body at Madinat Zayed hospital?

Senior management Committee which is chaired by Mr. Salem Al Mazroei and include

the senior leaders from the WMR and MZH


Question

Who established the hospitals` mission statement?

The Senior management committee.


Question

What do you do if a sentinel event occurs?Sentinel event is unexpected occurrence involving death or

serious injury. Serious injury specifically include loss of limb or function. Examples: wrong site surgery, infant abduction.

-Follow MZH sentinel event policy: inform head of department, manager or nursing supervisor who will inform immediately other senior leaders.


Question Who should fill out Occurrence of Variance Reports (OVR) ?

Any MZH staff member who witnesses an accident or unusual incident involving a

patients or visitor .Any staff member who is injured or involved in

a work related accident.


Question

To whom do you report incidents?

The immediate supervisor on duty.


Question

Where do you find out information about hazardous materials?

Ask supervisors. Look at MSDS information sheet available in your department.


Question

What do you do if a Disaster is announced?

Refer to the hospital Disaster Plan. Check your department and unit responsibilities and

the action card .


Question As you answer a telephone call, a news media representative asks questions about a patient receiving care at MZH. What should you do?

The caller should be asked to contact the Hospital director office.


Question

How do you report a blood exposure (via needlestick, splash, etc.)?Fill an OVRSee Infection control manual

(Employee health policies)


Question

What is the major infection control measure that you can use to decrease the

transmission of organisms?Hand washing.

When should you wash your hands?Before each patient contact, before and after

removing gloves, after using the restroom, blowing your nose, before eating.


Question

What do you do if a patient is suspected of having TB?

See Infection Control manualWe have special room with negative pressure

for airborne isolation which is required for patients with Tuberculoses.


Question

How do you handle soiled linen?

It is handled minimally, placed in a white bag at the point of generation and sent to the

laundry.


Question

What is the hospital’s policy on the use of drug samples?

Not permitted at MZH. Refer to the pharmacy policy in the portal.


Question

How do you respond to orders that permit a patient’s own supply of medications to be

used while he/she is in the hospital?

Refer to pharmacy policy n hospital portal. It is permitted in certain situations and under

certain conditions.


Question

What is the hospital’s process for monitoring, detecting and reporting

adverse drug reactions (ADRs)?

Fill the ADR form and send to pharmacy refer to the ADR policy.


Question

When a patient is sedated for a procedure what elements need to be assessed and

documented during the procedure?

See conscious (moderate) sedation

policy


Question Under what circumstance and from whom may the nurse

take verbal orders? What information must the nurse include when the verbal order is written and in what time

frame must it be co-signed? Refer to the verbal orders policy. Verbal order is permitted during emergencies and

must be signed within 24 hours


Question

How are medications stored securely outside the Pharmacy?

Medications must be stored in a secure places like:

locked cabinet/refrigerator; in a closed room; or within sight of a Nursing desk that is continuously staffed

around the clock;


Question

How should narcotic substances be stored?

Narcotic substances must be separated from non-restricted ward stock medications behind

a separate double lock cabinet.


Question

What is the MZH structure for reporting safety issues?

Staff are required to complete an OVR


Question What is a "Near Miss" and do we report these events?

"Near Miss" are for example category A &B medication errors “which are medication error happened but not reaches the

patient”, yes we have to report these type of error to be used as an education tools.


Question

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

All patients will be individually assessed for pain. Patients will receive interventions (pharmacological and non-pharmacological) that reduce or eliminate pain associated with their diagnosis, procedure or treatment, and will be reassessed

for the effectiveness of the intervention. An explanation of the pain management assessments,

interventions and outcomes will be given to the patient and family.

Refer to pain management policy


Question

What pain scales should be used to assess pain?

The Faces Pain Rating Scale, in which you have the patient choose (point) to the face

that represents their pain, for use in patients cannot do the Verbal Numeric Scale.


Question Are OPD clinics required to conduct pain

assessment on all patients?

All patients need to be assessed for pain. Healthcare providers share the responsibility of assessing pain, response documented, intervention if applicable and

follow-up.


PATIENT AND FAMILY EDUCATION (PFE) Q&A

Question Does the hospital have a written plan for

patient/family education?

Answer: Yes, Hospital Policy (patient and family education policy) , and Hospital form

(Interdisciplinary PFE Record). The hospital supports patient education by

providing multiple educational brochures.

PFE Q&A continued..

Question: How do we educate patients concerning pain management?

Answer: Patient education about pain management is taught by different disciplines at MZH (physicians,

nurses, pharmacists, and others). Hospital (Pain Management)

Policy outlines the process of pain management and considers patient education about pain.

PFE Q&A continued..

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

Needs are identified by performing ongoing patient assessment of educational needs

which includes initial assessment, and ongoing reassessments by healthcare providers involved in the care process.

PFE Q&A continued..

Question: Where is patient education documented?

Patient Education is documented on the Interdisciplinary Patient/Family Education

form.

PFE Q&A continued.. Question: How do you assess readiness to learn?

Answer: The patient/family is interviewed prior to education and is reassessed throughout hospitalization. Readiness to

learn is demonstrated by alert state, verbalization and ability to retain knowledge. Educators should choose the

most “teachable moments” to educate patients. Outpatients are assessed at each clinic visit. The Interdisciplinary

Patient /Family Education Record, allows the documentation of patients` readiness to learn

PFE Q&A continued..

Question:How the family is educated on how to

assure compliance and continued care?

Answer: Written Discharge Instructions provide patient specific instructions as well

as future appointments. Discharge planning teams help educating patients about

continuity of care at home

PFE Q&A continued..

Question:What questions can you ask your patients to

determine their level of understanding regarding Patient Education?

Answer: Ask them to repeat instructions back to you, ask them for details about their medications,

and ask them for return demonstrations. The IPFER helps to document patient's`

understanding.

PFE Q&A continued..

Question:

When do you start to educate the patient?

Answer: The education process begins with initial patient contact and continues

throughout the continuum of care.

(PFR) Q&A continued..

Question: How do you inform patients about complaints?

Answer: posters, visitor guidelines handbook.

Question :What procedures needs obtaining an informed consent?

Answer: mainly before surgery, anesthesia, use of blood and blood products and other

high risk treatments.



Question: How do patients know the hospital mission?

Answer: The hospital mission, vision and values are posted in key areas, they are

available in the patient booklet also.

Cardiac Arrest Code Blue

Fire Code Red

External Disaster Code Orange

Internal Disaster Code Green

Violent Person Code White

Missing Person Code Yellow

Hazardous Spill Code Brown

Bomb Threat Code Black

JCIA QA

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