JCIA Survey Expectations 2003 - KFSH&RC · JCIA Survey Expectations Quality Management Director...

JCIA SurveyJCIA SurveyExpectationsExpectationsExpectationsExpectations

Quality Management DirectorKFSHRC- 2011

What is JCIA?What is JCIA?

•• JCIAJCIA: JJoint CCommission IInternational AAccreditation•• JCIAJCIA: JJoint CCommission IInternational AAccreditation

• The accreditation process is designed to create a to create a p gculture of safety and quality withinculture of safety and quality within an organization an organization that strives to continually improve patient care processes and resultsand results.

A QuestionA Question

Accreditation is all about:Accreditation is all about:

A. Individual departments working alone

B A tifi tB. A certificate

C Continuous Improvement teamwork patient safety andC. Continuous Improvement, teamwork, patient safety and doing the right thing (Quality)

D. Departments competing against each other

Another QuestionAnother QuestionAnother QuestionAnother Question

How often are international surveys conducted?How often are international surveys conducted?

A. Once a year

B. Every 3 years

C. Every month

D E 5D. Every 5 years

What is Accreditation?What is Accreditation?

• An organizational survey which is conducted once every 3 years.

• Assessment of quality of care an organization provides using international standardsinternational standardsinternational standardsinternational standards

• Standards are developed using international consensus focusing on Patient Safety

•• Measurable elementsMeasurable elements are those requirements which a•• Measurable elements Measurable elements are those requirements which a score is assigned.

Accreditation Benefits?Accreditation Benefits?

• Improve public trust that the organization is concerned for patient safety and quality of carepatient safety and quality of care

• Provide a safe and efficient work environment that contributes to worker satisfactionworker satisfaction

• Listen to patients and their families, respect their rights, and involve them in the care process as partnersinvolve them in the care process as partners

• Create a culture that is open to learning from the timely reporting of adverse events and safety concernsof adverse events and safety concerns

What to expect?What to expect?

JCIA Survey 0909 13 April 201113 April 2011• JCIA Survey 0909--13 April 201113 April 2011• Opportunity to improve our performance.• Team of 4 surveyors (Nurse ClinicianTeam of 4 surveyors (Nurse, Clinician,

Physician & Administrator).

What to expect?What to expect?

•• Patient Patient Tracers: Tracers: can visit all areas of the organization. •• System Tracers: System Tracers: Medication, Infection Control, Facility

Management & Safety and Quality & Patient safetyManagement & Safety and Quality & Patient safety• Surveyors may visit any area of the organization

and may visit one area several times.y• Surveyor will visit the unit accompanied by escort and

scribe

JCIA S i itJCIA S i itJCIA Surveyors visitJCIA Surveyors visit

What to Expect? What to Expect? S• Surveyor will review the patient medical record with the direct care provider (Trace both knowledge and practice)

• Surveyors might request to interview the patient

• Surveyors will focus on Compliance with both:Surveyors will focus on Compliance with both: JCIA Standards Hospital Policies

S ’ F i “ P ti t S f t ”“ P ti t S f t ”• Surveyor’s Focus is “ Patient Safety” “ Patient Safety”

Why Accreditation?Why Accreditation?

• Creates a culture of QualityQuality and SafetySafety

• Supports continuous improvementcontinuous improvement

• Opportunity to learnlearn

• To improve systems/processes improve systems/processes of care and Patient outcomes

Why Accreditation?Why Accreditation?

• Assists with the implementation of Best Best PracticePractice through standards g

•• Internal improvement Internal improvement through survey preparationspreparations

• Unbiased review every 3 yearsevery 3 yearsy yy y

• Internationally recognizedrecognized

Focus AreasFocus Areas

• Patient safety.• Patients' rights• Patients rights.• Clinical Documentation.• Procedural sedation.• Pain management.• Privileges: (renewed every 2 years). • Orientation.Orientation. • Performance improvement activities.• Fire safety.• Disaster planning• Disaster planning.

Example of a Patient tracerExample of a Patient tracer

DEMDEM

Admitting processPain managementCommunication

CC33 LABLAB

DEMDEM

ProcessingCritical Lab

ResultsPI activities

Pain managementNutritional referrals

Falls preventionV.O / TO ordersClinical Pathway

PATIENTPATIENT C t

y

Food Food ServicesServices

OROR

PATIENTPATIENT Consent processTime out

Anesthesia useInfection control

Process for Process for preparation of preparation of food Special food Special

diets/referralsdiets/referrals

ICUICU RRRR Pain managementProcess for discharging

Blood administration Restraints use Verbal Orders Process for discharging

CommunicationHand Hygiene practices

Verbal Orders Communication

Infection control PI activities

Patient TracerPatient TracerIVF Cli i IVF Cli i P d l S d iP d l S d iIVF Clinic IVF Clinic –– Procedural SedationProcedural Sedation

•• Review the medical record with the direct care Review the medical record with the direct care provider.provider.

•• Request to interview the patientRequest to interview the patientRequest to interview the patient.Request to interview the patient.

•• Focus on : Focus on : JCIA StandardsJCIA Standards•• JCIA Standards JCIA Standards

•• Hospital Policies Hospital Policies

E i t l Ob tiE i t l Ob tiEnvironmental ObservationsEnvironmental Observations


How to behave? How to behave? • Do not run away !!!!!• Do not run away !!!!!

• Welcome the surveyor to your area

• Relax & enjoy the educational experience

• Introduce yourself, explain your position & how long you’ve been y p y p g yworking in the hospital

• The surveyor wants to hear about your everyday practice (safe & (safe & competent care)competent care)competent care)competent care)


How to behave? How to behave? • Reply to surveyors’ questions directly & concisely. Don’t embellish

answers

• Answer questions with confidenceconfidence

• Ask for clarification if you do not understand the questionAsk for clarification if you do not understand the question

• Don’t use phrases such as, “most of the time”, “we usually”, “well, sometimes we do”sometimes we do .

• If unsure of the answer, the safest response is “I will check the policy or ask my supervisor”

• Answer onlyonly what you’re asked. Don’t give surveyors more information or documents than they ask for

International Accreditation International Accreditation Standards for Hospitals 2011Standards for Hospitals 2011

What's inside that Book ?What s inside that Book ?

Patient Centered StandardsPatient Centered Standards

• Access to Care and Continuity of Care - ACCy• Assessment of Patient – AOP• Care of Patient- COP• Anesthesia & Surgical Care – ASC• Medication Management & Use - MMU• Patient & Family Education – PFE• Patient & Family Rights - PFR

Health Care OrganizationHealth Care OrganizationHealth Care Organization Health Care Organization Management StandardsManagement Standards

• Quality Improvement & Patient Safety - QPS

• Prevention and Control of Infections - PCI

• Governance, Leadership & Direction - GLD

• Staff Qualification & Education - SQE

• Management of Communication & Information - MCI

What'sWhat's NEWNEW in thein theWhat s What s NEWNEW in the in the 2011 2011 Standards Standards

PCI.7.1.1 Process to manage expired supplies and g p ppconditions for re use of single use devices.

MMU 4 Initial medication orders are compared withMMU.4 Initial medication orders are compared with medication taken prior to admission.

GLD.3.3.1 Contracts are included as part of the organization quality improvement and patient safety programp g

What'sWhat's NEWNEW in thein theWhat s What s NEWNEW in the in the 2011 Standards 2011 Standards

QPS.5.1 Internal process for data validationQPS.5.1 Reliability of data that is published

Wh t' i lWhat's in place:

Data validation processData validation process Hand Hygiene data validatedReadiness Tip # 15p


ACC.3.5 Process for management and follow up patient who leave against medical adviceleave against medical advice

Wh t' i lWhat's in place:

• Developed IPP• Developed IPP• Revision of form • Follow up processp p


PFR.2 Right to seek a second opinion second opinion without fear f C iof Compromise

PFR.6.1 Request for additional informationadditional information

What's in place:

Included in the Patients Bill of RightsMCO website (Physicians Privileging)

JCIA Standards are included in our JCIA Standards are included in our Hospital PoliciesHospital PoliciesHospital Policies Hospital Policies

International Patient Safety GoalsInternational Patient Safety GoalsInternational Patient Safety Goals International Patient Safety Goals 20112011

• Have you heard about them?y

• Do you know how many there are?

• Do you know why they are important?

What two identifiers are used at KFSH&RC to What two identifiers are used at KFSH&RC to a o de e s a e used a S & C oa o de e s a e used a S & C ocorrectly identify patients?correctly identify patients?

A R /B d bA. Room/Bed number

B Home addressB. Home address

C. Weight & heightC. Weight & height

D. MRN & full name

International PatientInternational PatientInternational Patient International Patient Safety GoalsSafety Goals

1. Identify Patients Correctly1. Identify Patients Correctly

2. Improve Effective Communication2. Improve Effective Communication

3. Improve the Safety of High Alert Medications3. Improve the Safety of High Alert Medications

4. Ensure Correct Site , Correct Procedure, Correct Patient Surgery

5. Reduce the Risk of Health Care Associated Infection5. Reduce the Risk of Health Care Associated Infection

6. Reduce the Risk of Patient Harm Resulting from Falls6. Reduce the Risk of Patient Harm Resulting from Falls6. Reduce the Risk of Patient Harm Resulting from Falls6. Reduce the Risk of Patient Harm Resulting from Falls

#1 Identify Patients Correctly#1 Identify Patients Correctly

Requirement:

• Patients are identified using two patient identifiers before: giving medications, blood/blood products, taking blood samples/specimens, providing treatment or procedures

• Patients full name and MRN#• Patients full name and MRN#

• Never use room/bed number

#2 Improve Effective Communication#2 Improve Effective Communication

Requirement:

• Document verbal/telephone orders and critical lab results and then“READ BACK”“READ BACK”“READ BACK”“READ BACK”

#3 Improve the safety of high alert#3 Improve the safety of high alert#3 Improve the safety of high alert #3 Improve the safety of high alert medicationsmedications

Requirement:

• Remove all concentrated electrolytes from patient care units ( i e potassium chloride)units ( i.e. potassium chloride)

• Clear labeling of HIGH ALERT medicationsClear labeling of HIGH ALERT medications

#4 Eliminate wrong#4 Eliminate wrong--site wrongsite wrong--#4 Eliminate wrong#4 Eliminate wrong site, wrongsite, wrongpatient, wrongpatient, wrong--procedure surgeryprocedure surgery

Requirements• Mark the precise site

• Use “Time Out” “Time Out” just before starting the procedure

Ensure all documents and equipment are on hand• Ensure all documents and equipment are on hand before surgery begins

##55 Reduce the risk of health careReduce the risk of health care##5 5 Reduce the risk of health care Reduce the risk of health care acquired infectionsacquired infections

Requirements

• Comply with recognized effective hand hygiene guidelinesguidelines

• All infection control related IPPs are posted on the Info Gateway

##66 Reduce the risk of patient harmReduce the risk of patient harm##6 6 Reduce the risk of patient harm Reduce the risk of patient harm resulting from FALLSresulting from FALLS

Requirements:Requirements:

• Assess and reassess patients risk of falls and take pactions

How are patients informed of their rights?How are patients informed of their rights?

A. In the Sand script

B. In the newspaper

C. Bill of Rights, Informed Consent process, education

D. On the internet

When would you share your ICISWhen would you share your ICISWhen would you share your ICIS When would you share your ICIS password?password?

A. When my friend forgets his/her password

B. When my boss asks me for it

C. In a code situation

D. Never

In the patient care area, the best place In the patient care area, the best place t e pat e t ca e a ea, t e best p acet e pat e t ca e a ea, t e best p aceto keep the medical record chart is:to keep the medical record chart is:

A. In the patient’s room

B. In an area locked or under constant observation

C. In the corridor

D. In the reception desk

P ti t & F il Ri htP ti t & F il Ri htPatient & Family RightsPatient & Family Rights

Patients & families are informed of their rights by:• Bill of Rights provided during admission g p g• Bill of Rights posted in patient rooms and in public

areas• Patient handbook• Posted on hospital web site

Patients are informed during:• Informed consent process• Informed consent process• During patient and family education

Bill of RightsBill of Rights

How are patients and families informed of their rightsHow are patients and families informed of their rights?

They are informed of their rights by the following:

A f th Bill f Ri ht i id d d i d i i• A copy of the Bill of Rights is provided during admissionprocess

• Addressed in the Patient Handbook Addressed in the Patient Handbook • Posted in patient rooms and in public areas • Posted on the Patient Information site on KFSH&RC website.

Bill of Rights

New StandardsNew StandardsNew Standards New Standards Patient Family RightsPatient Family Rights

PFR New Standards 2011• To seek additional professional information about theadditional professional information about the• To seek additional professional information about the additional professional information about the

ConsultantConsultant responsible for their care• To be provided with a statement documenting their

h it li ti d/ di l l ti t t khospitalization and/or medical evaluation to use to seek a second opinionsecond opinion, if desired without fear of any negative impact on their continuity of care at KFSH&RC

• Patients Bill of Rights has been revised to include these new standards

Ref: KFSH&RC Patients Bill’s of Rights MCO-MC-ADM-01-004 42

standards

ConfidentialityConfidentiality

Confidentiality of patient information is maintained by:

• Confidentially statement

• Code of professional conductp

• ICIS security privileges

P t ti f di l d• Protection of medical records

• Use of single rooms

Maintain Patient’s Maintain Patient’s confidentiality & Privacyconfidentiality & Privacy

Do not discuss patient information in publicDo not discuss patient information in public. Log off ICIS .Dispose temporary patient information.p p y pUse bed curtains/ close doors during exam.Only allow necessary staff to attend patient examinationexamination.

Informed Consent ProcessInformed Consent ProcessInformed Consent ProcessInformed Consent Process

Informed consent must be obtained for:

• General Treatment

• Surgery

S i l P d• Special Procedures

• Blood/blood product transfusion

• Critical Care invasive procedures

• Procedural SedationProcedural Sedation

• Participation in research

Informed Consent Informed Consent

– The physician shall explain the following:Patient’s conditionProposed procedure(s)/ treatment(s)Proposed procedure(s)/ treatment(s)Who is authorized to perform themPotential benefits & risksPossible alternatives and their outcomesPossible alternatives and their outcomesLikelihood of success

Complete Consent Form includes:Complete Consent Form includes:Specific procedure / treatment to be performed written fully and clearlySignature of the patient or guardian Signature of two (2) witnessesSignature of two (2) witnesses

47Ref: APP – 1431-07 INFORMED CONSENT

Important Policies Tips !Important Policies Tips !Important Policies Tips !Important Policies Tips !(Leave Against Medical Advise)(Leave Against Medical Advise)

Department of Emergency Department of Emergency

48

Important Policies Tips !Important Policies Tips !Important Policies Tips !Important Policies Tips !(Leave Against Medical Advise)(Leave Against Medical Advise)

Other Departments :Other Departments :Investigate the reasonCommunicate with support servicesservices Place follow up clinic Appointmentwithin two (2) weeksD t i th M di l R dDocument in the Medical Record

49Ref: Patients Who discharge Against Medical Advice

Interdisciplinary Assessment &Interdisciplinary Assessment &Interdisciplinary Assessment & Interdisciplinary Assessment & ReassessmentReassessment

In what time frame should inpatient assessments be performed?In what time frame should inpatient assessments be performed?• within 24 hours. • Assessments performed by junior staff are reviewed, validated and co-p y j

signed within 24 hrs by the consultant.• Discharge planning: on admission, involving: physicians, nurses, health

educators, social workers, transportation and planners.

When are patients reassessed?When are patients reassessed?At least daily + when indicated by patient’s condition.The Attending Physician shall:

Review the patient’s progress dailyReview the patient s progress daily.Co-sign his/her juniors’ notes daily.Enter at least a weekly note.

How often are chronic patients reassessed?How often are chronic patients reassessed?weekly or more frequently if indicated.

Allergy status DocumentationAllergy status Documentation

All must be documented in ICIS.

Th h i i d th t i d d tl it• The physician and the nurse must independently assess it.

• When shall it be assessed?• On every single admission.On every single admission. • Every OPD visit/any new encounter.

• Assessment shall include substance, type and severity of reaction

• NKA may be entered if no know allergies found after proper allergy assessment.

52 Ref: MCO-MC-ADM-07-013 Assessment, Documentation, Review and Evaluation of Patient Allergies

D t tiD t tiDocumentationDocumentation

• All entries shall be dated (Gregorian date) (dd/mm/yy) and timed (24-hr clock).

• All documentation entries shall be legibly written in black or blue.

A th l l id tifi d b i t ID B d N b d/• Author clearly identified by signature, ID Badge Number and/or Pager number.

• The use of signature stamp is strongly encouraged.The use of signature stamp is strongly encouraged.

• Only hospital approved abbreviations shall be used.

53 Ref: Interdisciplinary Assessment/Reassessment And Documentation in the Medical Record MCO-MC-ADM-01-024

DocumentationDocumentationDocumentationDocumentation

Ambulatory Care: Patients presenting to a clinic for the first time shall have an initial full assessment performed specific to the particular clinicinitial full assessment performed specific to the particular clinic

Patient Consultation: • Inpatient Consultation: Consultation shall be attended to and documented on p

the consultation request form within:• 24 hours for non urgent• 6 hours for urgent consultation

R f I t di i li A t/R t A d D t ti i th M di l R d MCO MC ADM 01 024

54

Ref: Interdisciplinary Assessment/Reassessment And Documentation in the Medical Record MCO-MC-ADM-01-024

P d l S d tiP d l S d tiProcedural SedationProcedural Sedation

The assessment must be completed , and documented prior to

th ti t b ithe patient being scheduled for any procedure utilizing

procedural sedation.

Physical Examination ASA Score

55

Ref : Procedural Sedation Protocol (MCO-MC-)

Reports availabilityReports availability

– A transcribed discharge summary within one week from discharge

– A transcribed operative reports within 48 hours of the Operation

– Death summary within 48 hours

O t ti t t ithi th f th fi t t ti t li i i it– Outpatient report within a month of the first outpatient clinic visit

57

Ref: Interdisciplinary Assessment/Reassessment And Documentation in the Medical Record MCO-MC-ADM-01-024

Outpatient Summary will be launched soon in ICISOutpatient Summary will be launched soon in ICIS

58

MedicationsMedications

Medication Clarification:

• The physician must co-sign the order clarification in his inbox as telephone/verbal order within 24hrs.

• During downtime and for chemotherapy the Notice of Medication Clarification Form will be sent to the unit with the first dose of medication, and should be signed by the physician within 24 hrs.

59 Ref: Processing of Medication Clarification MCO-CS-PIP-07-038

MedicationsMedications

Medication Renewal FrequencyMedication Renewal Frequency

R l FM di ti ( )/ P d t( ) Renewal FrequencyMedication (s)/ Product(s)

AnticoagulantsIV paracetamol

DailyContinuous intravenous infusionsBlood derivatives [e.g. albumin]

3 DaysNarcoticsLiposomal Amphotericin B

7 daysAll other drugs

60 Ref: Medication Administration Schedule and Renewal Frequency (ASO) MCO-CS-PIP-07-040

M di tiM di tiMedicationsMedications

• Medication reconciliation process shall be applied upon:Medication reconciliation process shall be applied upon:

Admission, Discharge, and TransferP ti l d ill b d d b th tt diPre-operatively, orders will be suspended by the attending physician/ designee. Post-operatively, those medications are resumed or cancelled as necessary.

Ref: Medication Reconciliation Process MCO-MC-ADM-06-002

61

Effective CommunicationEffective CommunicationEffective Communication Effective Communication Medication Orders Medication Orders

When is aWhen is a telephone ordertelephone order used?used?•• When is a When is a telephone order telephone order used?used?

• When immediate intervention is required. The qphysician/team signs the order at the earliest possible time and no later than 24 hrs.


Wh iWh i b l db l d d?d?•• When is a When is a verbal order verbal order used?used?

In an emergency situation when the physician is present. g y p y pThe physician signs the order as soon as the emergency situation is resolved.


• What is the process for taking a T.O and/or a V.O?

• The prescriber shall: Confirm correct patient by stating the Patients full nameConfirm correct patient by stating the Patients full name and MRN.State the purpose of the medication (e.g. captopril for high

)blood pressure).State the order slowly and clearly.State the numbers using single digits (e g “one five” forState the numbers using single digits (e.g. one-five for fifteen, “five-zero” for fifty).

Effective CommunicationEffective CommunicationEffective Communication Effective Communication Medication OrdersMedication Orders

• The receiver shall document the following on the appropriate g pp pform:That the order is a T.O or V.O. The prescriber’s surname and pager number (e.g. Dr. M. p p g ( gGhamdi, pager 8881). Name, title and identification of receiving staff (e.g. K. James, SNI, ID 71265). “Read“Read--back” back” the documented order to the prescriber for confirmation.

Effective CommunicationEffective CommunicationEffective CommunicationEffective CommunicationCritical Lab Results Critical Lab Results

How is a How is a critical lab result critical lab result reported?reported?

Laboratory staff document the results in ICIS in the comments field next to the critical result. Laboratory staff document the 2 2 patient identifiers (Patient’s full name and MRN ) and the ID # of the staff receiving the result.

Effective CommunicationEffective Communication --Effective Communication Effective Communication Critical Lab ResultsCritical Lab Results

Th i f th lt d t• The receiver of the result documents: • ID # of the laboratory staff reporting the result. • The critical laboratory result.• ID # of the staff receiving the result.

• The receiver “reads back” “reads back” to the laboratory staff the patient’s full name, MRN, laboratory test and result. p , , y

Effective CommunicationEffective Communication --Effective Communication Effective Communication Critical Lab Results Critical Lab Results

Once the critical lab results are documented in the Once the critical lab results are documented in the patient’s chart, what happens? patient’s chart, what happens?

• The authorized attending individual or designee documents a plan of care in reference to the critical laboratory result in the chart.

Patient RestraintsPatient Restraints

When do you use restraints?When do you use restraints?Only when other methods of restraint have failed to prevent injury toOnly when other methods of restraint have failed to prevent injury to patients, staff and others.

Do you need a physician order to apply a restraint?Do you need a physician order to apply a restraint?Do you need a physician order to apply a restraint?Do you need a physician order to apply a restraint?Yes, the order must include the reason for the restraint, and the length of time it should be applied for.It must be renewedrenewed everyevery 2424 hrshrs and only after a physicalIt must be renewed renewed every every 24 24 hrs hrs and only after a physical evaluation by the physician.In emergency situations, where the nurse has initiated the restraint, the physician must be notified within one hour to obtain the p yrestraint order.

Pain AssessmentPain AssessmentThe physician shall incorporate a comprehensive pain assessment into the history and physical for patients with a pain score greater than 0:

Severity (utilizing KFSH&RC approved pain scales)Location(s) Character Onset, frequency, variation, and patterns Alleviating and aggravating factorsAlleviating and aggravating factorsPresent pain management regimen and effectivenessPhysical exam/observation of the pain sitePain management historyPain management historyEffects of pain – chronic pain only, including impact on daily lifePatient Comfort Goal establishedReferral/Consultation, to Pain Service or Palliative Care, for patients , , pwho may require a more comprehensive assessment

71 Ref: Interdisciplinary Assessment/Reassessment And Documentation in the Medical Record MCO-MC-ADM-01-024

P i M tP i M tPain ManagementPain Management

What kind of scales are used What kind of scales are used when assessing patient’s forwhen assessing patient’s for

pain?pain?

KFSH & RC approved pain KFSH & RC approved pain scales scales

ffAge and cognitive specific. Age and cognitive specific. Severity scale Severity scale 0 0 –– 1010..

Pain ManagementPain Management

•• How often are patients reassessed for pain?How often are patients reassessed for pain?

It depends on the condition of the patient and on administration of analgesia.

For example, nurses reassess patients: • 60 minutes following administration of oral medications. • 30 minutes following administration of IV/IM medications.

When do you wash your handsWhen do you wash your hands??

A. Before and after direct patient contactp

B. When your hands are visibly soiled

C. After removing gloves

D. After using the bathroom

E. All of the above

Hand HygieneHand HygieneHand HygieneHand Hygiene

Do you have hand hygiene guidelines?Do you have hand hygiene guidelines?Yes we follow the Center for Disease Control (CDC) guidelinesYes, we follow the Center for Disease Control (CDC) guidelines.We are required to perform hand hygiene with an approved product.

••AlcoholAlcohol‐‐based hand rub:based hand rub: rub hands together, covering all surfaces and fingersAlcoholAlcohol based hand rub:based hand rub: rub hands together, covering all surfaces and fingers until your hands are dry.

• Soap and water:Soap and water: wet hands, apply product & rub hands together vigorously pp pp y p g g ybetween 15‐30 seconds, covering all surfaces and fingers. Rinse hands with water and dry thoroughly.

Reference IPP MCO- MC-INF-04-027 Hand Hygiene Procedures

Hand Hygiene Procedures Hand Hygiene Procedures

•• When do you perform hand hygiene?When do you perform hand hygiene?

When hands are visible dirty. Before and after direct patient contactBefore and after direct patient contact. After contact with medical equipment in the immediate vicinity of the patient. Af i lAfter removing gloves.

H d H iH d H iHand HygieneHand Hygiene

When do you perform hand hygiene?When do you perform hand hygiene?

Before and after direct patient contact. After contact with medical equipment in the immediate vicinity of the patient.

When do you wash hands with soap and water, not with hand rub?When do you wash hands with soap and water, not with hand rub?

Hands are visibly dirty or contaminated with• Hands are visibly dirty or contaminated with proteinaceous material or with blood or other body fluids

• Before eating• After using the restroomAfter using the restroom• After caring for patients colonized with Clostridium difficile

Hand Hygiene ProceduresHand Hygiene ProceduresHand Hygiene ProceduresHand Hygiene Procedures

• Are you aware of any P.I. projects in relation to hand hygiene?yg

• Yes there is a hospital wide project• Yes, there is a hospital wide project. Our compliance rate is 80 %.

What PI methodologies are used atWhat PI methodologies are used atWhat PI methodologies are used at What PI methodologies are used at KFSH&RC?KFSH&RC?

A. FOCUS-PDCA/LEAN

B. SCREAM

C. HELP

D. FOCUS

Performance ImprovementPerformance Improvement

•• What is the process (methodology) used in KFSH&RC What is the process (methodology) used in KFSH&RC forforPerformance Improvement (P.I.) projects?Performance Improvement (P.I.) projects?

• The process we use is: FOCUS-PDCA• FOCUS:

Find a process that needs improvementFind a process that needs improvement. Organize a team who is knowledgeable in the process. Clarify the current knowledge of the process. Understand the causes of variation. Select the potential process improvement.

• PDCA (Plan-Do-Check-Act) .

• Lean.

Performance ImprovementPerformance Improvement

•• Do you have any P.I. projects in your area?Do you have any P.I. projects in your area?

• Hospital wide Hand Hygiene project (eg. We have improved our hand hygiene compliance by 40% ).

• Unit/ area specific PI project (if applicable).p p j ( pp )

•• What kind of P.I. education is available?What kind of P.I. education is available?

Online PI. Educational module.QRM provide P.I. (basic and advanced) and Lean workshops.

• Requirement: once during employment.

Reduce the risk of patient harmReduce the risk of patient harmReduce the risk of patient harm Reduce the risk of patient harm resulting from fallsresulting from falls

1 N i t ll d i i (l d t hi h i k)1. Nursing assessments on all admissions (low, moderate, high risk).2. Weekly reassessments & when the patient condition changes.3. Managed according to the risk (defined protocols).4 Ed ti i d & di i d i d4. Education, signs on doors & discussion during rounds.5. If a fall occurs, MD assessment immediately.6. Reported in the AORS.

Orientation to Hospital & DepartmentOrientation to Hospital & Department

• How were you oriented to the hospital & your department?• How were you oriented to the hospital & your department?• Hospital orientation and department specific orientation. • How was your role responsibility defined?• In my job description• In my job description. • Are there any specific competencies or qualifications required for

you to work in this area?• Please be aware of these and ensure that they are up to date• Please be aware of these and ensure that they are up to date.

Where would you find your jobWhere would you find your jobWhere would you find your job Where would you find your job responsibilities?responsibilities?

A. In your contract

B. In your job description

C. In the human resources

Staff Orientation toStaff Orientation toStaff Orientation to Staff Orientation to the hospital & the Department the hospital & the Department

• All new staff should have hospital and department specific• All new staff should have hospital and department specific orientation.

Your responsibilities are defined in your job description• Your responsibilities are defined in your job description.

• Please be aware of specific competencies & qualifications that i d f k i & l hare required for you to work in your area & please ensure that

they are up to date.

What is the first thing you do in case of What is the first thing you do in case of g yg ya FIRE?a FIRE?

A. Panicking

B. Running the other way screaming

C. Activating the Alarm

D. Rescuing the person in immediate danger

E. Hiding

Fire SafetyFire Safety


• Question: How do you use a fire extinguisher?• PASS:


All ff d k h l i fAll staff are expected to know the location of:

• Emergency exits for your area. Emergency exits for your area.• Evacuation routes and assembly points.• Nearest fire alarm and how it works.• Nearest fire hose reel/ extinguisher.

Who is responsible to maintaining aWho is responsible to maintaining aWho is responsible to maintaining a Who is responsible to maintaining a safe environment?safe environment?

A. Quality Management

B. My department head

C. Everyone at KFSH&RC except ME!

D. Facility Management

E. Everyone at KFSH&RC

What color bag do you place bloodWhat color bag do you place bloodWhat color bag do you place blood What color bag do you place blood soaked dressings in?soaked dressings in?

A The first bag I see first no matter what color it isA. The first bag I see first no matter what color it is

B.B. BlueBlue bag, or the orange bag if it is fullB.B. BlueBlue bag, or the orange bag if it is full

C.C. RedRed bag

D.D. PinkPink bag

Hazardous Waste DisposalHazardous Waste Disposal

Do you know the correct bag /container for disposal of hazardous Do you know the correct bag /container for disposal of hazardous waste in your work area?waste in your work area?

•• Red Bags:Red Bags: Blood / blood tubing and bags, drainage collection devices, hemodialysis tubing & dialyzer, isolation waste, suction

i t li ti / d d l/ t t t bcanister liners, nasogastic/ duodenal/ gastrostomy tubes,suction canister liners, waste from OR’s and delivery rooms, gauze and dressings saturated to the point of dripping.

•• Orange Bags:Orange Bags: Chemotherapy waste including all personal protective equipment (PPE) used while preparing or dispensing

d it t i t d (f 48 h ft l ti fand items contaminated (for 48 hrs after completion of chemotherapy).


•• Blue BagsBlue Bags: : Chux pads, diapers, disposable bedpans, urinals, i b i b th b i f l C th t /t bi d bemesis basins, bath basins, foley Catheters/tubings and bags

(empty), gauze and dressings (not saturated to the point of dripping), IV arterial catheter (non-metal), IV tubing and bag (empty) ventilator circuits peripads tissues and paper towels(empty), ventilator circuits, peripads, tissues and paper towels, suction catheters and endotracheal tubes.

Sh BSh B N dl ( d & d if d) l t•• Sharps BoxesSharps Boxes: : Needles (used &unused if opened), lancets, scalpels, scissors, needles, syringes containing blood or body fluids, used or expired vials.


Correct bag /container for disposal of hazardous waste:

• Red Bags: Infectious wastes

• Orange Bags: Chemotherapy waste

• Blue Bags: General waste• Blue Bags: General waste

• Sharps Boxes: Needles & other sharp objects.

Ref: IPP(MCO-MC-INF-04-02)

JCIA Surveyors visitJCIA Surveyors visityyGeneral Knowledge Tips ! General Knowledge Tips !

• Practice Hand Hygiene & wear appropriate Personal Protective Equipment (PPE) to prevent spread ofProtective Equipment (PPE) to prevent spread of infection

• Dress Appropriately and professionally ((Professional, clean & well groomed uniforms) Professional, clean & well groomed uniforms) Ref: APPRef: APP 14261426--0404Ref: APP Ref: APP 14261426 0404

• Follow the hospital “ No Smoking” PolicyRef: APPRef: APP 14261426 0404Ref: APP Ref: APP 14261426--0404

Personal Protective Personal Protective Equipment (PPE)Equipment (PPE)

What would you do if you had a hazardous spill?What would you do if you had a hazardous spill?Contain the spill using the items in the spill kit and p g pcall the Safety Officer.

Can you show me your spill kit?Can you show me your spill kit?Please be aware of the location and contents of the spill kit.

D h M t i l S f t D t Sh t (MSDS)D h M t i l S f t D t Sh t (MSDS)Do you have Material Safety Data Sheets (MSDS) Do you have Material Safety Data Sheets (MSDS) in this area?in this area?Yes (know the exact location of the MSDS folder).

What is the name of the ExternalWhat is the name of the ExternalWhat is the name of the External What is the name of the External Disaster Plan?Disaster Plan?

A. Code Blue

B. Code Purple

C. Evacuation Plan

D. Code yellow

E. Code Amber

External Disaster Response PlanExternal Disaster Response PlanExternal Disaster Response Plan External Disaster Response Plan (Code Amber)(Code Amber)

D h t l di t l ?D h t l di t l ?•• Do you have an external disaster plan?Do you have an external disaster plan?

• Yes, it’s called Code Amber Code Amber and is activated in response to anpemergency situation that has occurred outside KFSH&RC.


104Ref: Code Amber Plan


• The hospitals response to an emergency situation that occurred OUTSIDE the hospital.

• Carry hospital ID all times

• If you are on duty remain in your clinical area unless instructor otherwise

• If you are called in report directly to your dept or appropriate manpower pool location

105• Follow your dept Code Amber Plan

Ref: Code Amber Plan

Facility Management & SafetyFacility Management & Safety

Internal Disaster Plan: Internal Disaster Plan:

• Hospital’s response to a major emergency situation WITHIN the hospital

• Any staff can report this by calling 22222222• Any staff can report this by calling 22222222


•• What is your responsibility in the event of an external disaster?What is your responsibility in the event of an external disaster?

• Each department has a sub-plan which is implemented during the code.your role is to:Review the department sub-plan.Ensure that my telephone and mobile numbers are correct on theEnsure that my telephone and mobile numbers are correct on the departmental recall list.Know how to use the recall list.Carry Hospital Identification badge at all times.If you are on duty you are expected to remain in your clinical area unless otherwise instructed.If you are called in, then you report directly to the manpower pool and sign in.Manpower Pool Location: PGC.p

Thank youThank youThank youThank you

JCIA Survey Expectations 2003 - KFSH&RC · JCIA Survey Expectations Quality Management Director...

Documents

Transcript of JCIA Survey Expectations 2003 - KFSH&RC · JCIA Survey Expectations Quality Management Director...