2011 JC Survey Readiness for Clinic -- BYOJeopardy

Environment of Care	Patient's Rights	Performance Improvement	Patient Safety	HR related	Miscellaneous
100 Who is our safety officer? Debra Fox Environment of Care 100	100 Posted in every exam room and in common areas (waiting rooms) and handed out to every new patient upon registration. How are patients informed of their rights? Patient's Rights 100	100 Artificial finger nail policy Critical test result stickers 'time-out' process before an invasive procedure What changes have been made to improve patient safety in our organization. Performance Improvement 100	100 What we do when a patient verbally expresses the intent to hurt, punish, harm or kill him/herself Use our code words (I need a drink of water) to secure help without leaving patient. Seek MHC, physician or manager. Refer to PIP (Psychiatric Intervention Program) DO NOT LEAVE PATIENT UNATTENDED WHILE PLAN IS IN PROGRESS. Patient Safety 100	100 Your ID Badge is part of the dress code and must be worn above the waist at all times. you can be sent home if you arrive to work without it. HR related 100	100 HIPPA guidelines. confidentiality statement signed at hire. Passwords for electronic patient information (don't share passwords). info shared on need to know basis only. No patient information in view of other patients or visitors. We have a HIPPA officer to consult when in doubt. How patient-specific information is protected Miscellaneous 100
200 How do you know if a piece of equipment has been cleared for patient use? A bright green inspection sticker should be visable with the date of the next inspection due. If expired, call biomed. Environment of Care 200	200 When any member of the clinical team becomes aware of an ethical issue concerning a patient When can you reach out to a member of the ethics consultation team via intratnet or operator? (ARMC has an interdisciplanary medical ethics committee) Patient's Rights 200	200 Online occurrence form on the intranet. Also hotline for anonymous report. How do you report an occurrence (incident)? Performance Improvement 200	200 2 step process: put gloves on first. -clean visibly soiled surface first, -then again well enough to get surface visibly wet for 3 minutes. Air dry. Wash hands. Do not ever re-use wipes. Multiple items to be cleaned each require their own wipe. How we use our Cavi and Clorox wipes Patient Safety 200	200 Policy 409- Harrassment Free Workplace Policy 375-Code of Conduct It is the policy of AtlantiCare to provide an environment where we treat each other with respect, courtesy, and professionalism How employees are protected from a disruptive workplace HR related 200	200 Signature with date and time of entry All entries into medical record must be accompanied by these Miscellaneous 200
300 What is MSDS? or Material Data Safety Sheet It is found on our intranet. It outlines steps to take in the case of accidental exposure. Environment of Care 300	300 Closing exam room door, refraining from clinical discussions where others can hear, keeping voices low on telephone How patients rights to personal privacy are ensured Patient's Rights 300	300 The definition of a sentinel event An event that results in unanticpiated death or permanent loss of funtion to a patient. Performance Improvement 300	300 Before and after all patient contact or contact with the patient's environment. When you can use an alcohol based hand gel. Patient Safety 300	300 Competency is assessed thru direct observation, written tests. Competency selection is guided by high risk, high volume, or problem prone duties. Competency is assessed at orientation and is ongoing to ensure that an employee is able to properly, safely perform a task or activity necessary to do his/her job. How is it that you are deemed compentent to do your job? HR related 300	300 Should not be found anywhere! Is a patient safety factor, infection control factor. This includes nurse's stations, hallways, and offices. Where is it ok to have some clutter? Miscellaneous 300
400 What is the group that oversees the safety program in our organization? the enviornment of care committee that meets monthly to review results of measurement, incident reports and complaints. They keep the plans up to date and develop new policies as needed. Environment of Care 400	400 Statements that provide direction for caregivers regarding patient's preferences for care & treatement in case the patient cannot speak for him/herself What is an advance directive? Patient's Rights 400	400 Our current PDCA's Posted on bulletin board, discussed in staff mtgs. Advance Directives Pain Assessment Customer Service (and Pap Smears in ID clinic) Performance Improvement 400	400 When hands are visibly soiled, after rest-room, when patient has dirrhea or vomiting. When you wash with soap and water, and for how long. Patient Safety 400	400 Assessing all data such as patient complaints, patient satisfaction scores, incident reports, infection rates, etc. How the organization determines if there are competency issues that must be addressed. HR related 400	400 By assessing hx. of falls, mental status, unsteady gait, assistive devices, medication use such as (but not exclusively) sedatives, narcotics, anti-hypertensives, diuretics. LEAF ON CHART, LEAF ON DOOR. How would we know who\'s at risk for falls? Miscellaneous 400
500 Safety - Fire Safety - Hazardous communication - Medical equipment - Utility - Security - Emergency management What are the seven environment of care plans? Environment of Care 500	500 An informed consent and a time out. Needed for any invasive procedures done at clinic. Patient's Rights 500	500 Plan Do Check Act our performance improvement model. What is PDCA Performance Improvement 500	500 1. Patient ID (name, DOB) 2. Communication (critical value timeliness) 3. Medication Safety (labeling, anticoag safety) 7. Prevent infections (hand hygiene) 8. Medication Reconciliation 15. Suicide Prevention NATIONAL PATIENT SAFETY GOALS! Patient Safety 500	500 How staff is trained in infectional control, fire safety, emergency management, and other core competencies. Mandatory ANNUAL corporate education, new employee education HR related 500	500 Outpatient, Visitor, Employee emergencies. At healthplex, dial 1-2997 (found affixed to every phone) team responds, 911 for further treatment. What is a CODE 10? Miscellaneous 500
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