KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTER P.O. … · KING FAISAL SPECIALIST HOSPITAL &...

Date: 9-Mar-14

JCIA Surveyors: Angela Norton

Escort: Akram Bashaireh Time: 13:00 - 14:30

Scribe: Akram Bashaireh

Session Staff Location

Individual Laila, ID 30039 OB-Gyne Clinic

Tracer

unnecessarily.

Transcriber:

risk and those who are self payer, the answer was it is only for high risk

protocol (VIP) patients, she was advised later not to elaborate

patient in the clinic from the registration until discharge, she did well.

2 minutes after we called the charge nurse. The health educator gave

educator answered that they only see the high risk pregnancy patients.

that they are seen Family Medicine.

overview about the clinic quickly.

• Asked about the type of patient seen in the clinic, and the

• Asked about the non-high risk pregnancy, the charge nurse answered

• She asked about the regular patient who is normal delivery not high

and the rest will be directed to other hospital.

• The educator elaborated more in the type of patient and include the

• The surveyor asked the educator to go through the process of seeing

KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTER

P.O. Box 3354, Riyadh, Saudi Arabia

JCIA Survey 2014

SCRIBE NOTES

Question/Issue

The surveyor observed the whole clinic quickly. Health educator arrived in

Date: 9-Mar-14





Individual

Tracer

Thaliba 95176

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• During the explaining of the process, the surveyor asked about the

patient interviewing room, and how to identify the patient who are

unstable in the waiting area who needs to be seen immediately, the

educator answered that there is a nurse who visit the patient while

awaiting to be seen, the surveyor asked about the frequency and the

educator answered.

• The surveyour asked about the Qmatic system and how long the

Qmatic has been in use, the educator answered.

• The surveyor interviewed one of the very new trainee in the clinic and

asked her about the courses that she received in order to work in the

hospital and in the clinic, she answered with the help of the educator and

another nurse.

• What kind of training for new employee, and the about the different

type of orientation, the educator answered that there is GHO, and unit

specific orientation.

• Asked about fire course, infection control class room. The charge

answered.

Date: 9-Mar-14





Individual

Tracer

Rubina 1503766

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• The surveyor asked the Educator about the orientation that the staff

received prior to work in the clinic, and the educator answered that we

have GHO, GNO, and Departmental specific for 3 weeks.

Question: Asked the trainee what she will do with file of the patient and

where to document her finding, the trainee answered with the

assistance of another staff nurse.

Question: How long you have ICIS, the nurse answered that it is more

than 10 years.

Question: Asked about summary sheet on ICIS, there was no

comprehensive summary of the previous patient visit, the nurse explained

the finding from the previous visit.

Question: The health educator explained to the surveyor about using the

waiting time of the patient in health education and she was impressed

about the utilization of the patient time while waiting to be seen.

Asked about the topics of teaching and the educator answered the

following: safety program, stage labor, and breast feeding.

Asked whether the educator ask patients to do the position for labor and

the answer was no.

Date: 9-Mar-14





Individual

Tracer

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

The educator elaborated on the borrowed bed from the Gynecology

clinic to the liver clinic, the surveyor asked whether the Ob/Gyn nurses

working with those borrowed bed and the answer was no.

The surveyor interviewed one of the patients who is a a hospital employee.

Asked her whether she likes the place and her experience during the

pregnancy follow up. The patient showed full satisifaction about the

service, and she would recommend to any one. She likes the experience

in KFSH.

• Health educator continued the patient journey through the clinic.

• Surveyor asked where to document education of patient and family.

The health educator opened her ICIS and showed the surveyor.

• Surveyor asked about the initial assessment of the education need on

ICIS, the educator showed her the assessment.

• Asked if the educator is the only one doing the education, the answer

was no. Every one in the clinic provides the education according to his

position.

Date: 9-Mar-14





Individual

Tracer

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• Education talked about fetal monitoring clinic and fetal monitoring

course. The answer was the course will be done once during the

employment, then the surveyor asked how to maintain the knowledge

about the fetal monitoring and the answer was through the journal club

meeting and the online module.

• Through the discussion of the fetal monitoring course, the issue of the

SNs were discussed and the educator was asked what is the difference

between the SN 1, SN 2, SN 3 according to the qualification and type of

work. Her answer was not clear and direct.

SN 1 BSN - Degree, SN 2 Diploma - Diploma

• The surveyor asked one of the nurses how often you check the crash

cart, and the answer was every day, and full inspection of the content

every month.

• The surveyopr asked the nurse to do full daily check in the crash cart

according to the checklist, and it was demonstrated perfectly.

• The surveyor asked whether they use specular in the clinic and the

answer was yes. Then she asked to see where they keep the utilized ones,

she was taken to the dirty utility room and shown the area where those

instruments are kept.

Date: 9-Mar-14





Individual

Tracer

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• The surveyor asked the nurse whether anyone other than the anesthesia

gives sedation in clinic, the nurses was not sure, and she will clarify the

issue with the charge nurse.

• Finally the surveyor asked to be directed to the DEM to see the process

of triaging the pregnant patients on arrival.

KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTER P.O. … · KING FAISAL SPECIALIST HOSPITAL &...

Documents

Transcript of KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTER P.O. … · KING FAISAL SPECIALIST HOSPITAL &...