Download Survey_Readiness_Manual - Center for Education and

2015 Joint Commission
SMAR
& CMS Survey
Questions & Answers
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GENERAL INFORMATION
What is the purpose of the Joint Commission survey?
We participate in the survey process once every 18 months to 36 months. Surveyors take an in-depth look at our patient
care processes, policies, staff competence and leadership. They look at these things to see how we provide patient care in
a safe and effective environment. They also look at our performance improvement activities and the progress we have
made in these areas. Performance improvement activities are documented on a scorecard or dashboard. The information
collected during the survey determines whether or not we will be accredited for another three years.
Is the survey mandatory? If not, why do we participate?
The survey process is completely voluntary. We invite the surveyors to look at our organization so that we can get
objective feedback that will aid us in identifying areas where we can improve. The surveyors provide consultation about
best practices in providing patient care so that we can improve the safety, quality of care and services that we provide.
The Centers for Medicare/Medicaid Services accepts this survey as proof of compliance with the Conditions of
Participation for Medicare/Medicaid. Successfully completing a survey makes the hospital eligible to participate in the
Medicare and Medicaid programs.
When is the survey?
The surveys are unannounced. We are expecting a survey at University of Missouri Healthcare (MUHC) anytime between
now and May, 2016.
What kind of questions is the surveyor likely to ask?
Surveyors are likely to ask staff questions pertaining to the following subjects:
Fire Response/Evacuation procedures
Patient and general safety (including the National Patient Safety Goals)
Patient care processes
Patient rights
Infection control
Staff education, training and competency
Performance improvement activities
Medication management
Patient privacy
Staffing levels, and how you adjust to census/ acuity changes
Unit or department specific performance improvement activities
Emergency Management
What is the best way to prepare for the survey?
You are taking an important step by reading this handbook. Here are some other tips to help you prepare:
 Understand the policies/procedures for your job. If you have questions, be sure to ask.
 Review the National Patient Safety Goals in this packet.
 Know what performance improvement activities your department has been involved in for the past year.
What if a surveyor asks ME a question?
Number 1– Relax. The surveyor asks questions of staff to ensure they understand and follow processes for providing safe
and high quality care to the patients we serve. Think carefully before you answer the question.
 Do not become defensive if a surveyor asks probing questions after you have given a response.
 If you don’t understand the question, ask the surveyor to repeat or explain the question. Don’t guess if you don’t
know the answer.
 Tell the surveyor whom you would contact to get the answer or reference a specific manual.
 Simply answer the question asked. Provide only the information that you were asked for, you do not need to
elaborate unless asked to provide examples.
 Don’t give opinions.
 Avoid acknowledging violations.
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Do not self-report non-discovered incidents or areas of concern.
Simply say “let me find someone to assist you” as opposed to “”no one ever told me that”.
Understand your statements may be quoted in the surveyors final report, especially for a CMS survey.
Surveyors have the right to talk with staff. If you are interviewed by a surveyor, you do have the right to ask for
someone from leadership to sit in on the interview. Managers or administrators sitting in on the interview are
prohibited from coaching you or leading you in any manner during the interview.
Who do I contact if I have questions?
If the question relates to your department activities, you should contact your immediate supervisor. If you have questions
specific to the survey process, speak to your department manager regarding who to contact or call the Office of
Regulatory Affairs at 884-3521.
When will we find out the results of the survey?
We will no longer receive a score on the survey like we have in the past. We will receive a pass or a fail along with any
“recommendations for improvement”. The surveyors will meet with the organization’s leaders prior to departure and
provide a summary of findings for the survey. This information will be shared with staff as soon as possible. The final
report usually takes about 1-2 weeks.
LEADERSHIP
Who is the “governing body” for MUHC?
The President of the University of Missouri has been delegated governing responsibilities for University of Missouri
Health Care (MUHC) by the Board of Curators. University Hospitals and Clinics is part of MUHC.
What is our mission?
To advance the health of all people, especially Missourians, through exceptional clinical service, University of Missouri
Health Care supports the education and research missions of the University of Missouri.
What is our vision?
Through discovery and innovation, University of Missouri Health Care will be the health system that people choose for
exceptional service and exemplary health care.
What are our core values?
To pursue its vision within an environment that fosters integrity, respect, trust, openness, fairness, quality performance,
accountability and dedication to quality care for patients and their families.
How does the leadership plan the annual budget?
Hospital leaders develop and monitor an annual operating budget and a long-term capital budget plan. These budgets are
based on the overall MUHC strategic plan and the specific needs of individual departments. When preparing a budget
forecast, leaders use information gathered from employee feedback, assessment of community needs, survey information
and historical data.
How do Hospital leaders communicate important information to the staff?
Leaders use a variety of methods to communicate with staff. Staff forums are conducted on an as needed basis to update
staff on key matters related to Hospital operations. Publications such as Insight and Archives are also used to
communicate important information to staff. Management Team meetings are held monthly to provide hospital leaders
with information and tools to pass along to their staff.
What is the role of leadership with regard to patient safety?
Leadership appoints a Patient Safety Officer to serve as the primary contact person for issues and concerns related to
patient safety. Our Patient Safety Officer can be contacted through the Office of Clinical Effectiveness (573-884-2373). In
addition, the Clinical Coordinating Quality Council identifies trends in data related to patient safety. Leadership
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encourages all staff to monitor their respective areas to ensure patient safety. Our leaders are working to create a culture
that supports a proactive approach to patient safety that encourages reporting and investigation of medical errors. Patient
Safety is one of the organization’s top priorities and is everyone’s responsibility.
Who is responsible for creating and updating the Hospital’s policies and procedures?
MUHC leadership defines the organizational, facility and department specific policies and procedures. Laws and/or
regulatory and accrediting agencies may also require certain policies to be in place. The policies and procedures describe
our standards of administrative practice. Facility and/or organization-wide policies and procedures typically cross over or
impact several disciplines or departments.
Who approves the Hospital’s policies and procedures?
The Regulatory Standards and Policy Oversight Committee is charged with the identification, development, and on-going
review/revision of Hospital policies and procedures. This committee is directly responsible to the Chief Executive Officer.
The Chief Executive Officer and/or the Chief of Staff give final approval to all Hospital policies and procedures or send
them back to the Regulatory Standards and Hospital Policy Committee for revisions. The Chief Human Resources Officer
approves all MUHC HR polices.
Where can I find MUHC policies and procedures?
The MUHC Policy and Procedure Manual is available online through iPortal/Citrix Receiver/MyApps , which is available
via the Navex icon (pictured above) found on the iPortal/Citrix Receiver/MyApps page on each computer workstation.
ENVIRONMENT OF CARE/EMERGENCY MANAGEMENT/LIFE SAFETY
What are the areas covered by the Environment of Care?
There are management plans written annually for:
Safety
Security
Hazardous Materials and Waste
Fire Safety
Medical Equipment
Utilities
Who is on the Global Environment of Care Committee?
There are multidisciplinary representatives from clinical, administrative, and support services. There are subcommittees to
provide expertise on the various Environment of Care standards.
Where would you find our Safety policies?
Organizational Safety Policies are available on the intranet on the iPortal/Citrix Receiver/MyApps page under Navex .
See your supervisor regarding department specific policies.
How do you get your annual Safety training?
Employees are given their first safety training during new staff orientation. Annual safety update training is provided
online. Staff are expected to achieve a threshold score of 80% to pass. Safety training must be completed before annual
staff evaluations.
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What areas are security-sensitive and what steps are in place to prevent or limit access to those areas?
Pharmacy, Data Closets, Emergency Departments, Labor & Delivery, Post Partum, Nursery, Peds/Adolescents and all
ICUs are all secure areas. A combination of cameras, access control systems and panic control devices have been
installed.
What can you do if you see violence, the potential for violence, or just feel unsafe?
Security Officers can be called to assist in any situation where there is violence, the potential for violence or employees
just feel unsafe. Officers may be contacted at: 882-7147or 882-7979 at UH or MOI and WCH. Offsite clinics should call
911with a follow up call to 882-7979.
How do you respond if there is a fire alarm activation or real fire event?
Fire alarm system activations will be investigated to determine the cause of the alarm. Fire Alarm Activation DOES NOT
Automatically Inititate The Facility Alert – Fire Response Plan. MUHC Telecommunications will announce overhead:
‘ALARM ACTIVATION (and the location)’. Responders will determine if a threat is present. If staff see a smoke of fire
that should call their emergency number. A Facility Alert – Fire Response will be announced over the intercom system if
there is a real fire event called in by staff or determined by the response team. Staff should utilize the acronym RACE can
help you remember the immediate actions to take and how to respond during a fire.
Rescue – Rescue or remove all individuals from the area (discuss with unit manager where patients and families will be
moved)
Alarm – Use the pull box and call your emergency response number (882-7979 at UH or MOI and 875-9333 at WCH.
Off site clinics and support facilities (e.g. Quarterdeck) should call 911 with a follow up call to 882-7979.
Confine – confine the fire by shutting fire and smoke doors and windows.
Extinguish or Evacuate – Extinguish the fire if it is small and contained. Familiarize yourself on using the extinguisher
and use escape route if remains protected. Otherwise evacuate. Do not endanger yourself or others.
How do you use a fire extinguisher?
The acronym PASS can help you remember the steps in using a fire extinguisher.
Pull the pin – There is a pin in the carrying handle of every fire extinguisher that must be pulled before the fire
extinguisher will work.
Aim – Aim at the base of the fire.
Squeeze – Squeeze the discharge handle (the top handle).
Sweep – Sweep from side to side until the fire is out.
Where can you find the “Safety & Emergency Management Quick Guide?
The “Safety & Emergency Management policies and plans can be found as an electronic resource on Navex via the
iPortal/Citrix Receiver/MyApps. Emergency Management Quick Guides contain general overview information for all of
MUCH and department specific guidance. They are located in your work area and clicking on the “EM” icon.
What is the Emergency Operations Plan? The Emergency Operations Plan describes the overall plan for how MUHC
will manage a disaster and emergency response situation.
What is a SDS? Where would you find a SDS if you need one?
SDS Safety Data Sheet (formerly MSDS, for Material Safety Data Sheet). It contains information about: potentially
hazardous materials (including physical and chemical characteristics), how to protect someone working with the chemical,
signs and symptoms of overexposure (if any), what to do in case of a spill. The “Right to Know” act requires a SDS to be
available in the “end users” work environment. They can be accessed in Navex Policytech by going to the iPortal/Citrix
Receiver/MyApps public directory and clicking on the gold “SDS” icon.
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Instructions are there for accessing the documents.
What is the process for the cleaning of a hazardous material or chemical spill?
Secure the area, contain the spill, identify the chemical before cleaning up, and check SDS for precautionary measures.
See Emergency Management Plan: Focused event – Chemical Spill Response for detailed guidelines on an uncontrolled
chemical spill.
Who is authorized to shut off oxygen control valves?
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The clinical supervisor and/or their designee determine if O , medical air and vacuum zone valves should be turned off.
They contact Respiratory Therapy if a decision is made to turn off zone valves. If possible, turn zone valves off after
Respiratory Therapy arrives and when areas served by zones are notified.
If a piece of patient care equipment were to malfunction while you were using it on a patient, what should you do?
 Discontinue using the equipment without jeopardizing the patient’s care.
 Replace the equipment with properly functioning equipment.
 Notify the proper service department (Clinical Engineering).
 Complete a “Broken Equipment” tag and place it on the piece of equipment so nobody else will use it. Don’t write
on post-it notes since they can fall off.
 If the piece of equipment failed while being used for a patient’s care, complete a Patient Safety Network (PSN)
report.
Where are people allowed to smoke?
Smoking is prohibited within our facilities and on hospital grounds.
Where are your primary and secondary exits in an emergency?
You should know your escape routes in case of a fire. If you don’t know what your primary and secondary exits are
contact your supervisor. Know the location of the adjacent smoke zone. You should also know the location of your next
smoke compartment.
What are the other Life Safety elements in your work area?
Exit lights – Are they lit?
Sprinkler heads – Is all storage at least 18 inches below the sprinkler heads?
Fire Doors – Do they all shut to latch?
Fire extinguishers – Do you know where they are located?
Fire alarm systems – Do you know where pull stations are located? Where detectors are?
Unobstructed corridors – Are items that support patient care removed from the corridors?
Do you know your emergency phone numbers?
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What is the frequency of emergency exercises and what is your role?
Joint Commission requires two exercises per year. MUHC conducts multiple exercises each year. Some are community
wide exercises while others are table top exercise conducted internally to test the MUHC system. Everyone’s role is
unique but the majority of employees continue their normal duties until they receive further direction from their
supervisor or charge nurse. (For obvious emergencies such as fire or tornadoes, employees will respond immediately as
they have been trained.) .
What is a Hazard Vulnerability Analysis (HVA)?
A hazard vulnerability analysis is conducted by the health system to evaluate emergencies that could impact
our facilities. Separate HVA's have been completed for University Hospital, Women’s and Children’s Hospital, Missouri
Orthopedic Institute and Quarterdeck. Impact of event and likelihood of occurrence are factors that are reviewed to rate
emergencies.
Where does the hospital set up the command center and what is the phone number?
A command center’s location is dependent on the incident. MUHC utilized mobile command carts that can be brought to
any location to establish command. The location and number to call will be disseminated once command is in place.
MUHC utilizes eICS for electronic command allowing some personnel to monitor and assistance offsite.
What is an evacuation?
Evacuation is moving from an area of harm to an area of non-harm, this may be an adjacent space, another floor, or
exiting a facility.
Horizontal Evacuation – Relocation of patients and staff to the adjacent smoke compartment. Horizontal Evacuation is
completed first in an event and subsequent types acted upon, if needed.
Vertical Evacuation – Relocation of patients and staff to another floor of the building. Begin with those in immediate
danger and requiring the least resources to move. Use the nearest stair outside of the fire area. Use only those elevators
approved by the Fire Department, AOD, House Manager, or Safety & Emergency Management Personnel.
Total evacuation of a facility may only be authorized through the Incident Command Center, by AOD, House Manager,
Fire/Safety Personnel.
What are the red electrical outlets?
The red outlets are connected to an emergency generator. They should be used for critical equipment in the event of a
power failure.
What should you do if you see someone in an area but they are not authorized to be there?
Ask them to leave the area
Monitor their departure
Call Security if the person is not cooperative
How do you know that patient care equipment is safe to use?
When equipment is in Clinical Engineering, corrective or preventive maintenance is being performed and equipment is
not available for use. When Clinical Engineering returns equipment to the department it is ready for use.
Whom should you contact if you have an electrical power failure?
Call your emergency response number for your location of any failure of power fixtures or outlets or other utilities
(Water, med gas, steam, etc…).
What is the means of communication in the event of a telephone failure?
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At University Hospital & Clinics and Missouri Orthopedic Institute use the ASCOM, two way radios or the Emergency
Intercom system, AIPHONE, (back-up phone system) as needed, and only as needed, to maintain patient care needs. At
Women’s and Children’s Hospital use the two-way radios.
Has your area ever been under construction and had Interim Life Safety Measures (ILSM) implemented? If so, do
you remember how it affected you?
Yes. Increased rounds by Engineering and Security staff.
Has your area ever been under a fire watch?
This is when the fire alarm or fire sprinkler system is out of service for more than 4 hours.
How do you know? Through e-mail notification.
What do you do? Be extra alert and if there is smoke or a fire report it at: 882-7979 at University Hospital & Clinics and
the Missouri Orthopedic Institute or 875-9333 at Women’s and Children’s Hospital.
What has the hospital done to limit the amount of “E-tanks” of oxygen on your unit?
Provided locked storage cabinets with a 1 hr. fire rating.
How should E-tanks be stored?
Always upright in the approved storage. A cylinder should never be stored on its side on the floor or outside the rack.
Empty cylinders are to be placed in the storage area and picked up by Patient Support Services personnel.
Where can you find patient care equipment histories?
Patient care equipment inventory and histories are located at: http://MUHC-ce01/Public/medequipinfo.aspx. Contact
Clinical Engineering if you see any discrepancies or changes that need to be made (e.g., equipment that needs to be sent to
Surplus, transferred, etc.)
HUMAN RESOURCES
Who keeps current licensure, certification and/or registration up-to- date in the staff member’s department file?
The Human Resources office primary source verifies all required credentials/registrations/certifications/licensure prior to
employees assuming the position for which it is required. The primary source verification will be placed into the staff
member’s file. It is Human Resources responsibility to ensure that all staff are currently licensed, registered, or certified
for any position that requires a credential. Human Resources will be responsible to ensure that staff credentials are kept
in good standing.
Where can I find the University of Missouri Health Care and University of Missouri System Human Resources
Policies?
All Human Resources policies can be obtained from the Human Resources Intranet site (http://jobs.muhealth.org/hri and
then clicking on “Policies”.
Who is responsible for completing a criminal background check on employees?
HR completes checks on criminal backgrounds, Employee Disqualification List (EDL), Office of Inspector General
(OIG), Department of Mental Health (DMH), and a drug screening on new hires, volunteers, and authorized members of
the organization. A check is also completed when a current employee transfers to another position outside of their current
department/management area. For agency, contract staff, and students, the background checks are completed by the
contracting agency or school and provided to HR prior to starting.
When can I expect to receive an evaluation of performance at University of Missouri Health Care?
MUHC has a “common review cycle” for completing all performance evaluations. The evaluation is delivered mid-year of
each calendar year.
How do I know which mandatory web-based training needs to be completed annually?
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The CED Web site, http://ced.muhealth.org/, outlines the mandatory requirement for all employees, nursing staff, and
includes other modules that are manager assigned. The mandatory requirements for all staff are automatically applied to
Learning Plans for easy access. Many departments also have their department specific requirements assigned on the
Learning Plans. The CED Web site can be accessed at http://ced.muhealth.org, or by clicking on the CED icon in
iPortal/Citrix Receiver/MyApps
How are staff members’ competencies assessed?
During the orientation process, reviewers/preceptors validate and document a direct patient care staff member’s initial
competence with core position responsibilities using a competency summary checklist specific to that position.
Competency is measured using a variety of techniques including direct observation of daily work and simulated/mock
events. At a minimum of every three years, direct patient care staff should have their ongoing competency validated on
identified competencies that reflect the changing nature of their job. This could include new equipment and processes,
high risk and time sensitive job duties, process improvement initiatives and problematic aspects of the job. If you are a
clinician and you are supervised by a non-clinician or someone from another discipline, arrangements should be made to
have a qualified person validate your competency.
How are new staff members oriented?
All new staff are required to attend general new staff orientation on the first day of their employment. Staff then receive
training specific to their job as they go through the rest of house-wide and departmental orientation. Checklists are used to
maintain consistency in department orientations. Contractual personnel who are working on site for over 30 days must
also attend new staff orientation. Volunteers either attend new staff orientation or an equivalent orientation in Volunteer
Services.
What are the rules about wearing name badges?
Your badge is to be worn on the front of outer clothing at or near shoulder level so that it is easily visible to others.
Badges on necklace loops are acceptable as long as visibility is maintained. Name, credentials and licensure must be
visible. Lab coats, smocks, sweaters, etc., should not cover badges. No other items are to be affixed to or attached to the
I.D. badge, either temporarily or permanently. No stickers, tape, lettering, drawing, or wording other than what was issued
on the I.D. badge is permitted.
Can students do clinical experiences at a MUHC facility without a contract?
No. All student clinical experiences should be arranged after ensuring that a signed agreement or contract is in place with
either the school they are attending, or, in rare instances, with the hospital where the student is employed, or the student
themselves. Contracts are arranged using a template developed by Managed Care Contracting in conjunction with the
Center for Education and Development and follow an agreed approval process. All students must be vetted, which
includes background checks, health and immunization requirements, and drug screening. For more information on
Student Clinical Experiences at MUHC go to http://ced.muhealth.org/Resources/studentorientation.htm.
How are staff oriented to cultural diversity and sensitivity?
Cultural diversity and sensitivity training are included in New Staff Orientation, and during Service Excellence and
Patient and Family Centered Care training. Staff are given information about tools and resources available to assist our
diverse population.
How do you obtain the services of an interpreter for a Limited English Proficient (LEP) or Deaf/Hard-of-Hearing
(DHH) patient/family, or access a telephone interpreter?
University of Missouri Health Care provides free interpreter service for LEP and HDD patients in order to ensure
“meaningful access” to health care services. To arrange for an interpreter for an LEP patient/family 24/7, page 2568320. For sign language interpreter services call Access Interpreting at 445-5890 or pager 499-8404. For phone
interpreting services use the blue Clearlink phone assigned to your unit/office/department or call Language Services for
instructions on 3-way calling on any phone. Video Remote Interpreting is available through mobile devices at WCH and
UH Emergency Departments for American Sign Language and several other spoken languages, when on-site interpreters
are not available. Page Language Services at 256-8320 for questions regarding use of the devices. Translation of written
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materials is available by contacting the Language Services Coordinator at [email protected]. More
information can be obtained by reviewing the following policies: Provision of Meaningful Communication for Persons
with Limited English Proficiency and Provision for Meaningful Communication for Deaf/Hard-of-Hearing (DHH)
Persons.
INFECTION CONTROL
Am I allowed to have food or drink in patient care areas?
No. Food and drink are not allowed at nursing stations, control rooms, gym or medication areas. Food and drink should be
kept in non-public areas, such as break rooms or office areas. These rules are a requirement of the Center for Disease
Control (CDC) and are intended to protect staff from infectious diseases.
Is there a plan in place to decrease the risk of spreading infection between patients and staff?
Yes. We use body substance precautions in our organization. Body substance precautions are the consistent use of barriers
or personal protective equipment (PPE) to prevent the spread of infection. Body substance precautions states all moist
body fluids are potentially infectious and appropriate barriers need to be used to prevent coming into contact with body
fluids.
What is enhanced body substance precautions?
Enhanced body substance precautions is a form of isolation used for anyone with uncontained secretions, excretions or
wound drainage. This includes patients with a severe cough or diarrhea such as a person with influenza or symptomatic
Clostridium difficile.
Does the hospital have any other systems in place to protect patients and staff?
Yes. The hospital uses needle safe devices to prevent accidental exposures. The flu shot program is to help prevent staff
from getting the flu and passing it to other staff or patients. The Hepatitis B immunization is offered to patient care staff as
well as MMR, tetanus, and varicella (chickenpox), if needed.
What do I need to know if CIDEX or CIDEX OPA is used in my area?
Ensure that the quality controls are performed and documented daily on a log or before each use, if not used daily.
Controls have to be dated when opened and expire within 90 days. Be sure to run quality control on the strips when a new
bottle is opened. Use in a well-ventilated area. Wear appropriate personal protective equipment (PPE).
What would you do if a patient came in with active pulmonary TB or rule out TB?
Clinic: If the patient were being seen in clinic then he or she would be given a surgical mask and instructed to wear it the
entire time they are in the hospital or clinic building.
Hospital:
If the patient is being admitted to the hospital he or she would be placed in “Stop sign alert”.
The patient would be placed in a negative pressure room with the door closed at all times.
A “stop sign” would be placed on the door. The patient would be instructed not to leave the room except for necessary
medical tests. If necessary tests such as X-rays need to be done, then the patient should be transported to the appropriate
department wearing a mask. The department should be notified of the patient’s airborne disease prior to transport.
Does this hospital have an infection control surveillance plan?
Yes. The surveillance plan is based on the kind of patients we care for at UHC. The surveillance plan includes:
Ventilator-associated pneumonia
Central line-associated bacteremias
Surgical site infections
IV site infections
Reportable diseases as required by law
Deaths of patients who meet the definition of nosocomial infection
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MRSA, VRE, Acinetobacter and C. diff.
Hand hygiene monitoring
If there were any outbreaks or clusters of infections these would be investigated as well.
Does the hospital track antibiotic- resistant organisms?
Yes. The Infection Control Department tracks Methicillin Resistant Staphlococcus Aureus (MRSA) and Vancomycin
Resistant Enterococci (VRE).
What about those diseases that need to be reported to the state?
The Missouri Department of Health has a list of diseases and conditions that need to be reported to the state. The list is
available from the Infection Control department. If you have a patient with a disease that you think might need to be
reported, call or fax the patient’s name, medical record number and what the disease is to the Infection Control department
and they will take care of reporting the disease to the state of Missouri. What if the patient is from another state? The
information will be reported to the state of Missouri Department of Health who will then forward the information to the
appropriate state.
How would I contact the Infection Control department if I had a question or needed to report something?
Concerns may be put in the Patient Safety Net and directed to the Infection Control department. If you have a question or
need a quicker response, then you may call 882-2264 or page beeper number 441-4412.
How do I know when a patient care supply is expired?
Most patient care supplies have an expiration date on them designated by an hour glass icon.
If the patient care supply does not have an expiration date listed on the package, the supply is considered to be sterile as
long as the package remains intact and is not discolored.
The exception to this policy is gloves. Sterile gloves are good for 3 years from the manufacturer’s date listed on the box
by a factory icon. Non-sterile exam gloves are good for 5 years from the manufacturers date on the box. The
manufacturers date appears as a factory icon.
RECORD OF CARE, TREATMENT AND SERVICES
What is the survey process regarding management of information?
The use of Tracer Methodology will entail a detailed review of a sample of patients using the open medical record as a
framework. If issues are identified in those records the surveyors may ask for a sample of closed records to determine
whether there is an issue with our documentation. Also we must be able to show we have successfully integrated both
paper and electronic information in the patient chart.
What will the surveyors be looking for?
Surveyors will be looking to see that we:
 Consistently identify information needs of all types
 Adequately design our information management system to be accurate, complete, timely, secure and accessible
 Have effective processes for documenting, storing, organizing, using, collecting and analyzing data and
information
 Provide data and information to users for decision making through reports, displays or electronic transmittal
 Protect the confidentiality and integrity of data and information
 Improve patient outcomes, safety and documentation
 Documentation has been completed in a timely manner – History & Physical within 24 hours or prior to a
procedure; Operative Notes immediately following surgery (through SurgiNet) with a transcribed note or
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PowerNote available in the electronic record within 24 hours; all verbal order authenticated within 48 hours, and
the Discharge Summary completed within 72 hours of discharge.
How do we ensure timely medical record completion?
All patient records should be complete and accurate according to Health System Policy ROC-09. All orders should be
promptly signed. According to our Medical Staff Bylaws medical records must be completed (e.g., all entries made and
authenticated or signed) within 21 days after a patient is discharged. If the record is not completed within 21 days it is
considered incomplete. Joint Commission requires that we monitor our delinquency rate and take appropriate action to
minimize delays in record completion. The Bylaws now require suspension for providers who fail to meet this
requirement.
INFORMATION MANAGEMENT
How can I get ITS to assist if there is a need to obtain patient, financial or administrative information for my job?
Complete a project intake form to explain and justify the request and to help determine the number of resources needed.
Information needs are evaluated by the ITS Steering Committee, the Medical Records Committee and the Management of
Information Committee to determine if the request can be completed.
What are we doing to protect our automated information from being accessed illegitimately or destroyed?
ITS has an active program to stop illegitimate access to our systems. Our Corporate Security policy and University
System Fair Use policy guide users in the appropriate use of information resources. Users are also advised of their
responsibilities on a screen disclaimer at each network log in. Audits on the use of Hospital information are performed to
monitor security and privacy compliance. Access to protected health information (PHI) is permitted only to appropriate
staff to perform their assigned duties.
How will we know when our policies are modified or a new policy has been adopted?
Executive leadership and Managers receive an electronic notification of all policy modifications or the posting of new
policies. It is the responsibility of the managers to communicate any new policies or changes to policies to the staff.
What are the privacy requirements under HIPAA and HITECH? Are we compliant?
The HIPAA Privacy Rule and HITECH establish standards to protect our patients’ health information including
appropriate access, use, disclosure and disposal of this information, known as protected health information (PHI). We
have policies that address our responsibilities for proper handling of PHI. We give our patients a copy of our Notice of
Privacy Practices that explains our responsibilities and commitment to protect their confidential information, how we can
and cannot use their information, and how they can access their information. We audit use of patient information to
confirm that it is used appropriately. We also manage the disposal of patient information to ensure proper handling. Our
internal auditor, PricewaterhouseCoopers, audits us to ensure that we meet all of the HIPAA/HITECH requirements.
Do we have a disaster recovery plan for our automated information systems in case of an emergency?
ITS developed a disaster plan in the event of a catastrophic loss of our automated systems.
In addition, each department has downtime procedures to maintain services when automated systems are unavailable for
use.
MEDICATION MANAGEMENT
What are some of the ways we make sure medications are stored safely and securely throughout the hospital and
clinics?
“Look-alike” and “sound-alike” medications are segregated in the medication storage areas
Concentrations of intravenous medications are limited and standardized throughout the hospital (e.g. heparin).
Regular inspections are performed in all medication storage areas to remove expired and unused products.
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All medications, including refrigerated items, must be secured at all times. The goal is to prohibit access at all times by
any unauthorized personnel.
Why is it necessary for prescribers to use only “approved abbreviations” when writing an order? I’ve seen the
“prohibited abbreviations” list and it’s hard to remember NOT to use them.
The goal is to have agreement among all the health care professionals about the meaning and interpretation of
abbreviations used in the hospital. Abbreviations that appear on the “prohibited” list are those that are most easily
misinterpreted and mistaken, especially in hand-written communications between health care professionals. Instances of
prohibited abbreviations are frequently found in orders and medication-related documents. This places the importance on
individual prescriber’s to keep our patients safe. *As a reminder, this also refers to nurses transcribing verbal or telephone
orders! Their use is frequently cited when medication errors occur. Unclear and poorly written orders will continue to
require clarification, but eliminating the use of confusing or unclear abbreviations will help make our patients safer.
The official list of Prohibited Abbreviations can be found on the next page or on the iPortal/Citrix Receiver/MyApps page
on UHC computer workstations at: http://www.muhealth.org/~abbreviations/
I don’t work with medications in the hospital. What should I do if I hear or know about an employee that might be
stealing medications?
It is the responsibility of EVERY hospital employee to report actual or suspected diversion (theft) of medications or
property to his/her supervisor or manager. While ALL theft is wrong and may result in criminal prosecution, diversion of
controlled substances is especially serious because of state and federal regulations. The Pharmacy MUST be notified of all
discrepancies regarding controlled substances.
What is going on at MUHC to ensure that all medication orders are reviewed by a pharmacist prior to
administration?
Medications stored in the Pyxis Medstations are NOT available to nursing staff until the order has been entered into the
pharmacy computer system and first verified by a pharmacist. This includes medications administered by Respiratory
Therapists. Exceptions are made for urgent and stat medications and situations where care is under the direct supervision
of a physician or designee such as the Emergency Departments. As an additional patient safety initiative, we are
implementing a process for pharmacist review of medications that have already been administered.
Accurately and completely reconcile medications across the continuum of care by: developing a home med list,
reconciling hospital list with home medication list and informing caregivers at the next level of care.
MEDICAL STAFF
How do you know if a physician has privileges to see and treat patients?
All physicians must submit a complete application for credentialing and privileging from the Medical Staff Office.
Applications must be recommended by the Credentials Committee, approved by the Executive Committee of the Medical
staff and then granted by the Vice Chancellor for Health Affairs, as delegated by the President of the University of
Missouri prior to seeing patients at University of Missouri Health Care (MUHC). Privileges granted to Medical Staff
members are available on Navex via: https://muhealth.policytech.com
After logging into the system find the “Search” field on the upper right of the page and type “Privileges Granted” or
“Approved Agreements” , then select the proper document from the returned results.
If you have any questions about whether a physician has been credentialed or about their approved privileges, please
contact the Medical Staff Office at UH (882-4913).
Are Advanced Practice Professionals required to be credentialed?
Yes, all advanced practice professionals must be credentialed and privileged through the Medical Staff process. Advanced
Practice Professionals include: Certified Registered Nurse Anesthetists, Certified Nurse Practitioners, Certified Nurse
Midwives, Clinical Nurse Specialists, Physician Assistants and other professionals as determined by the Executive
Committee of the Medical Staff.
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What is our policy for dealing with disruptive behavior from medical staff?
The Disruptive Behavior Policy for UHC (MS-04) outlines the process for reporting and investigating complaints about
disruptive behavior by members of the medical staff. This document can be found on Navex via:
https://muhealth.policytech.com
After logging into the system find the “Search” field on the upper right of the page and type “Disruptive Behavior” , then
select the proper document from the returned results.
Who is the Chief of our medical staff?
The current Chief of Staff is Dr. Bert Bachrach and the current Vice Chief of Staff is Dr. Kirt Nichols. The past Chief of
Staff is Stevan Whitt who is also the Chief Medical Officer for MUHC.
Who is responsible for assuring the competence of members of our medical staff?
The Clinical Department Chairs are ultimately responsible for the continuous review of the professional performance of
all practitioners who hold clinical privileges in their department and reporting regularly thereon to the Executive
Committee of the Medical Staff. During appointment and reappointment of Medical Staff members, the Executive
Committee is ultimately responsible for coordinating with the Department Chairs to gain information that would
determine the competence of individual practitioners.
NATIONAL PATIENT SAFETY GOALS 2012
All employees should be familiar with the National Patient Safety Goals and understand their own department’s
contribution to helping promote a safe environment for our patients. Employees should be able to describe these roles as
well as the goal that is impacted.
Patients and their family members should be included as patient safety partners to help eliminate patient harm.
Patients/families should be educated on our patient safety efforts listed below during the hospital stay.
Improve the Accuracy of Patient Identification
What are the two patient identifiers used to improve the accuracy of patient identification?
The name and date of birth are the two identifiers that should be used with interactions with patients. If the patient is
unable to verbally give their name and date of birth, the arm band should be used for patient identification. Room
numbers or medical record numbers are NOT used to identify patients.
What process is used to check blood before administration?
A two person verification process is done by two RN’s or an RN and a physician before blood administration.
Improve the Effectiveness of Communication Among Caregivers
What is the process used to report critical test results in a timely manner?
The RN or LPN who is notified of a critical test result will notify the provider of the test expeditiously and document time
of notification to that provider.
Where should you label specimens and containers?
Specimens and containers should always be labeled at the bedside while in the presence of the patient.
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Improve the Safety of Using Medications
How does the hospital ensure that medications are safely labeled?
Medicine and solutions should be labeled with name, strength, quantity, diluents, volume and expiration dates.
Remember that if the medication leaves you hand before it reaches the patient, it must be labeled. “If on the table, it must
have a label.”
Multi-dose vials should be labeled with expiration dates (28 days after opening).
Improve Safety of Clinical Alarms
What has MUHC done to improve clinical alarm fatigue?
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MUHC has identified clinical alarm safety as a priority for keeping patients safe.
Alarm fatigue is a major safety concern. Clinical units are continually working on ways to minimize alarm events
and address alarm fatigue.
MUHC has formed a special multi- disciplinary team to identify system wide efforts to address clinical alarm
safety.
How can we take extra safety measures when working with anticoagulation drugs?
When heparin is administered continuously it should be given via the Alaris programmable pump through the guardrails
system. Before starting a patient on coumadin or warfarin always assess the patient’s baseline coagulation status by
checking the correct blood work. Reduce the likelihood of patient harm from anticoagulation therapy by using oral unit
dose, prefilled syringes, and premixed infusion bags.
Reduce the Risk of Health Care-Associated Infections
What is the best way to prevent the spread of infections?
HAND HYGIENE!!
When should I use hand hygiene?
Use hand hygiene:
Before and after patient contact
When you take off gloves
Whenever they become visibly soiled
When going from a dirty area of the patient to a clean area
When handling patient care equipment or other items in the patient’s room
You may use alcohol-based hand sanitizer instead of hand washing if hands are not visibly soiled or you have not come
into contact with fecal material.
What are the steps for appropriate hand hygiene?
Hand washing:
Wet hands with water.
Apply soap.
Rub hands together for at least 15 seconds.
Be sure to wash between your fingers and up to 2 inches above wrist.
Rinse and dry with disposable paper towel.
Use paper towel to turn off faucet.
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Alcohol-based hand gel:
Apply a small amount to palm.
Rub hands together covering all surfaces until dry.
Do not use alcohol-based hand gel when hands are visibly dirty, contaminated or soiled with any organic or fecal matter.
Accurately and Completely Reconcile Medications Across the Continuum of Care
How do we use medication reconciliation to ensure safety for our patients?
Obtaining an accurate medication list (including all OTC and herbal meds) at the time of admission is the first step in the
process. While in the hospital, the doctor orders medications and reconciles those medications with the patient’s home
medication list. Medications may be continued, discontinued, or substituted depending on the patient’s condition and drug
availability. Accurate reconciliation must occur with every patient hand off. In the end, the goal is for the next provider(s)
to have a clear and concise list of the medications to ensure patient safety. Medication reconciliation needs to occur at the
time of admission, in-house transfers, and upon discharge. Reconciliation is accomplished through a collaborative effort
among the patient, family members, nursing, physicians and pharmacy staff. The electronic medical record “Med Profile”
tab should be kept up-to-date and used to reconcile medications for those using Powerchart. Patients should clearly
understand what medications they are to continue taking at home
The Organization Identifies Safety Risks Inherent in its Patient Population
How are patients assessed for suicidal risk?
Patients are screened on admission for signs of risk of suicide in the baseline assessment. All patients who are at risk of
suicide should be given the suicide hotline number to call upon discharge. Precautions should be taken to keep the patient
safe while in our care.
Preventing Catheter-Associated UTI’s
What can we do to prevent catheter related UTIs?
Catheter related UTIs can be prevented if we limit the use of catheters for only patients that have to have one. Limiting
the duration of the catheter will also help decrease the chance of infection. Removing urinary catheters within 48 hours
after insertion will also help decrease the change of infection.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery
What are the requirements that must occur during a time-out?
The timeout should minimally consist of patient name, DOB, planned procedure, expected procedural contingencies (such
as specimen collection, the highest-risk procedure phase, etc.), and a safety statement delivered by the team’s senior
clinician, such as, “I expect each of you to speak up if you see or know of anything that appears unsafe”.
What procedures performed need to have a time-out done prior to performing?
Besides the typical OR scenario, timeouts are expected just prior to invasive procedures often done in ED, GI Lab, Cath
Lab, Radiology, Surgery Clinic, ICU, procedure rooms, etc. (Time outs are not required for only a limited number of
procedures, such as ng tube insertions, foley catheters, peripheral IV insertion, and venipuncture.)
PERFORMANCE IMPROVEMENT
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How do I submit a patient safety report?
Patient Safety Net (PSN) reports are completed online through the patient safety network portal on the “my applications”
page. There is also a PSN hotline (884-1PSN) that can be used to report a patient safety concern.
What is reported in the patient safety network?
Patient Safety Reports are used to help improve system issues. There are three options to report. The first option is when
an incident that reaches a patient. When you enter an incident, you will be asked to rate the harm score that has occurred
to the patient. The harm scores range from 0-5. Near misses are also entered so that system issues can be evaluated. Drug
variances are the third report option available. Complaints and compliments are available through a separate portal in the
patient safety network under Patient Comments.
What is “Root Cause Analysis”?
A Root Cause Analysis (RCA) is an investigation of a specific incident or close call/near-miss event. A team of
individuals involved in the incident or near miss and facilitators from the Office of Clinical Effectiveness are delegated to
perform the RCA. The RCA team’s purpose is to study the sequence of events surrounding the incident and then identify
basic or causal system factor(s) that contributed to the incident. Based upon the findings, the team develops an action plan
for administrative approval that is designed to improve the robustness of the processes, thus resulting in a safer system of
care.
What Performance Improvement Model do we use?
We use the Plan-Do-Study-Act (PDSA) Model for performance improvement.
PROVISION OF CARE/NURSING/TRANSPLANT SAFETY/WAIVED TESTING
What is your role in providing patient care?
Ask your supervisor for a good description of your role. For example, a pharmacy technician could say their role was to
see that medications are properly stocked.
How do you know you have the correct patient when you administer blood or medications?
We must use two identifiers to identify the patient. We use the date of birth and the patient name. We ask the patient for
the two identifiers as confirmation. If the patient is unresponsive, we use the ID band and compare it to the CMAR.
What do I need to do with the defibrillator during crash cart checks?
Zoll R Series defibrillators perform a daily self check at midnight. The defibrillator documents this check on an internal
log. Verify a green check mark on front of defibrillator to indicate unit is properly functioning.
Zoll M Series defibrillators must be manually test-fired at 30 joules to verify proper functioning.
What can I do to reduce the risk of patient falls?
At MUHC, we utilize the fall-management protocol to evaluate for fall risk assessment, which includes monitoring
criteria, including medications. We participate in NDNQI benchmarking to compare our falls against national rates.
Any patient fall is a reportable event that should be captured in the PSN under the event type “Fall”. Specific questions
are asked in the PSN to help the system-wide Fall Team propose and try different solutions to prevent harm from falls.
Patients who are identified to be at a risk for falls have a standard yellow fall risk band placed on the wrist.
What is the process for taking verbal or telephone orders? Verbal orders are discouraged. If the physician wants to
give a verbal order, provide them with an order sheet and have them write the order themselves. If the need arises in
urgent situations, a telephone order can be taken. After the order is written, a read back and verify is done. This means
you read the order back to the person you are taking it from and verify its content. This is the time to clarify any orders
you are unsure of.
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Do you know how to identify and report suspected abuse?
We have an abuse management protocol for your use. These are quick and easy tools to use that are on your units. Once
you identify the abuse, report it to the social work department and the physician or the abuse hotline. If they do not feel it
is reportable and you do, it is your responsibility to call the hot line.
What are barriers to learning that patients may have?
Barriers are circumstances that have an impact on a person’s ability to learn such as culture, language, emotional state or
physical disabilities.
What is MUHC’s policy on restraint?
We only use restraints after trying other alternatives and this must be documented. The least restrictive, safe, and effective
restraint should be used first.
What are some examples of restraints used at MUHC?
Soft wrist restraints
4-point nylon restraints
Is it OK to write a “PRN” order for restraints?
NO!
Where do you chart your plan to remove restraints?
Document in great detail your plan for and results of removing patients from restraints in the IVIEW section of power
chart.
Who performs nutritional screenings?
Diet technicians do the nutritional screening within one day of admission. RNs assess upon admission and refer to the
dietitian as needed. The dietitian will see the patient if they are found to be at risk by the dietitian tech or the RN.
How do you assess your patients for pain?
We have population specific pain assessment tools. We assess pain with each set of vital signs, on a schedule consistent
with patient condition/physician’s orders, or with any sudden onset, new, or increase in pain. We also assess pain prior to
and after each pain medication or any intervention administered (approximately 30-60 minutes after parenteral or 60
minutes after oral). If the patient’s pain level is at 4 or above and/or they are not satisfied with their pain management, the
nurse should call the physician and discuss more options.
How do you care for patients at their end of life?
We have two “Comfort Care” Management Protocols, one for ICU and one for medical/surgical patients. We educate and
support the patient and family in the process. We provide medication to provide patient comfort. We assist the family with
referrals to hospice care or home care. We also have a palliative care team that can be contacted through the hospital
operator.
How do you call a Code Blue?
Call your emergency response number (UH or MOI, call 2-7979. Off-site, call 911. At WCH, call 875-9333). We have an
adult team (Code Blue) and a pediatric team (Code Blue – Pediatric). Be ready to describe how you check your crash cart
on your unit.
How do I call Tiger Team or the rapid response team?
Call your emergency response number (UH or MOI, call 2-7979. Off-site, call 911. At WCH, call 875-9333). Once the
Tiger Team or Rapid response team has been activated the patient’s physician has to be notified. This does not replace a
code blue or Code Blue – Pediatric.
RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
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How are patients advised of their rights?
The Patient’s Bill of Rights is posted in patient care areas.
Information on patient rights and responsibilities is provided to every patient upon registration. Patients are offered their
own copy during the registration process.
Does a patient have a right to know the name(s) of his or her care providers?
Yes. Staff identification badges should be worn at all times. Staff members should introduce themselves by telling the
patient who they are and what service they will be providing.
Who should tell the patient about an unexpected outcome?
The physician involved with the patient’s care should tell the patient about the unexpected outcome as soon as possible.
Does a patient have the right to refuse care even if the physician believes the care should be provided?
Yes.
Does a patient have the right to leave the hospital even if the physician feels the patient should stay?
Yes.
If a patient or family has a complaint about care, who should they be directed to see or call?
Staff should make every effort to resolve the complaint immediately if they are able to do so. If staff are unable to resolve
a complaint, then he/she should report the complaint to their supervisor. The staff member should also document the
complaint in the PSN. The supervisor should refer to policy LD-6 (Patient Safety Event Reporting and Resolution). Guest
Relations Department reviews all complaints submitted through the Patient Safety Net (PSN) comments.
How do we meet the cultural and spiritual needs of our patients?
Staff members should ask if the patient has special needs. If the patient has special needs, staff members should respect
their needs and provide assistance whenever possible to meet them. Chaplains are available to provide spiritual support
for patients and their families through the Pastoral Care Department at 882-2236.
Is the organization watching out for the rights of research patients? What area is involved?
Yes. The Institutional Review Board (IRB) has responsibility for this activity.
Are staff members allowed to accept expensive gifts (e.g., trips) or money from a patient or their family?
No. However, a staff member may direct the patient or family to the Development Office where a gift may be accepted for
the organization. ( Conflict of Interest)
Are staff allowed to share patient information with their family and friends?
No. Patient information is confidential and should not be shared unless it is necessary for the care of the patient. (RI-8
Patient’s Rights and Responsibilities)
What happens to a DNAR order if a patient transfers to another patient care unit?
DNAR orders are not discontinued when a patient transfers to another patient care unit. The order stays in effect until the
accepting physician co-signs, changes or discontinues the order. (See policies: Do Not Attempt Resuscitation - DNAR and
Limitations of Treatment)
Who approaches the family member about possible organ donation upon the death of a patient?
Procurement coordinators from the Midwest Transplant Network or the Missouri Lions Eye Bank will speak with the
family. (See policy: Organ, Tissue & Eye Donation AND Organ Donation After Cardiac Death)
How are Advance Directives handled at UHC?
When patients are admitted, they are asked whether they have an Advance Directive. If the patient has an Advance
Directive a copy will be scanned into the medical record and the attending physician will be notified. If the patient does
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not have an Advance Directive an informational pamphlet will be provided if one was not provided in the Registration
area. If the patient wants additional information or wants to complete an Advance Directive, the patient may seek
assistance from the nurse, physician, social worker, chaplain or Guest Relations. (See policies: Do Not Attempt
Resuscitation - DNAR and Limitations of Treatment)
DAILY CHECKLIST FOR COMPLIANCE AND GOOD PRACTICE
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Halls are free from clutter
Unit and departments are clean and tidy
Nothing is stored on floors or within 18 inches from the ceiling
Only clean items in clean utility rooms; no clean items in soiled utility rooms
Medication refrigerators are clean and temperatures are recorded
Drugs within expiration dates
No drugs stashed around units
Multi-dose vials labeled with the 28 day expiration date
No open single dose vials
Insulin pens are single-patient use only
Med carts are locked
Prescription pads are secured
Lab specimens are in bags and labeled properly at the bedside
Food in patient nutrition refrigerators are labeled and not expired
Open food containers are labeled with patients name
Doors to clean and soiled utility rooms are kept closed
Lab specimen tubes are not expired
All IV tubing and dressings on patients are labeled with date and initials
Sharps are disposed of properly
Sharps containers no more than ¾ full
Nothing stored on top of sharps containers
Only approved cleaning solutions are kept under sinks. NO patient care items
Fluid warmer log is complete. Fluids are marked with 72 hour expiration date
No staff member food, drink or cosmetics in patient care area or where specimens are located
Clean linen is kept covered in clean supply room
Needles and syringes are kept secured
Oxygen cylinders are secured and no more than 12 full cylinders are kept in the same area
Pill splitters and crushers are clean
Explain body substance, enhanced precautions, and stop sign alert for infection control
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