Download Prince Sultan Military Medical City

Prince Sultan Military Medical City
Department of Paediatric Some Important Tips for JCI Survey
Standard
1.
International
Patient Safety
Goals (IPSG)
“Very Important
To know”
Common Questions & Explanation
Their achievement is critical to full compliance with the JCI standards. Any failing goals is
consider a failing in JCI ACCREDITATION.
• IPSG.1 Identify Patient’s Safety:
v What is the process of identifying patient? & when it must be used ?
- Patient is identified (Hospital ID band) before any treatment, collection of samples, blood
transfusion, drug administration, diagnostic test or procedure is conducted.
- Patient’s complete Name, Hospital ID Number, National ID card/Iqama
- Patient’s Full Name: Refers to the patient’s name to the Third Level.
- For infant/ child: Identification should be carried out by two hospital staff using
identification information available in the Medical Records.
-Important: In the event identification band is lost, it must be reported as ‘Incident Report’
to prevent using the lost band in infant/child abduction.
• IPSG.2 Improve Effective Communication:
v What is process for Telephone/Verbal Orders and when receiving Critical Values
Result?
-You must be familiar how to place any of the two (2) orders, and the relevant policy:
1-Verbal Order: limited to urgent situations where immediate written/ electronic
communication is not feasible.
2- Verbal/ Telephone Order: will not be accepted for:
Physical restraints, Starting Patient Controlled Analgesia (PCA),
Starting Narcotic/ Scheduled medications, Initiating TPN therapy
Category of care (Code status), Withdrawal of life support, Chemotherapy.
-Critical Test Reporting (Laboratory & Radiology):
i.e. ‘Write Down, Read-Back, Confirm/Verify’.
• For Telephone Orders, responsible physicians requires to sign order within (24 ) h.
• For Verbal Orders, physicians require signing order after situation is over Or before
physician leave the area.
- Handovers: See hospital wide Handover Form, used for communicating critical content
between health care providers during handovers of patient care.
• IPSG.3 Improve the Safety of High-Alert Medications (HAM):
v What is your process to ensure safe identification, storage, preparation and dispensing of
High Alert Medications (HAM)?
- The hospital has a list of all high-alert medications, including look-alike / sound- alike
medications that is developed from hospital-specific data. Look-alike and Sound-Alike
(LASA) medications are recommended to have Tall Man letters over the medication
storage. Examples:
hydrALAzine and hydrALAzine - EPINEPHrine and EPHEDrine VinBLASTIN” and “VinCRISTINE.
- All high alert medication shall be stored in a secured cabinets and clearly labelled.
- Concentrated electrolytes are stored ONLY in areas that requires it with appropriate
labelling.
- Storage bins for HAM based on its strengths shall be segregated.
- It is the responsibility of MRP to prescribe medications within the approved formulary
that includes orders and prescribing HAM.
- Verbal orders for HAM are only allowed during Emergency or Life threatening situation.
-HAM orders must be double checked during preparation & before administration.
1 Standard
International
Patient Safety
Goals (IPSG)
Cont......
International
Patient Safety
Goals (IPSG)
Cont......
Common Questions & Explanation
• IPSG.4 Ensure Correct-Site, Correct Procedure, Correct Patient Surgery:
v When does the Time-out conducted?
TEAM TIME OUT- applied to some procedures /first skin incision performed for
paediatric patients:
• All activities should be STOPPED and all members of the surgical/procedural team
must fully participate in the TIME-OUT:
a- Confirms all members are present and attentive.
b- Addresses the following standard information:
-Correct patient identity
-Correct type of procedure to be performed
-Correct procedure site has been marked (if applicable)
-Availability of correct equipment for the procedure.
c- Correct and appropriate documents and diagnostic images are available.
Any attending staff can identifies anticipated critical events.
• IPSG.5 Reduce the Risk of Health Care-Associated Infections:
v What is the process in your department to reduce HAI’s?
-You must be familiar with (MCWP 1-1-9415-02-003 Hand-Hygiene)
- You must be familiar with (5-Moments of Hand Hygiene)
1- Before touching a patient.
2- Before a procedure.
3- After a procedure or body fluids exposure risk.
4- After touching a patient.
5- After touching a patient surroundings
- You may be asked to demonstrate how to do: See attachments
1- Hand Rub Procedure.
2- Hand Wash and Hand Disinfection Procedure.
• IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls:
v When is fall risk assessment/reassessment conducted ?
• ASSESSMENT: Upon patient admission in the unit.
• REASSESSMENT:
ü Transfer of patient from one unit to another within the facility
ü Any changes in patients status/condition
ü Following a fall
-Patient initial fall risk nursing assessment performed Within (3) hours of admission using
the ‘Humpty Dumpty Fall Scale’ and re-assessment daily or with any changes.
- Score 6-11 is:
Low Risk - Activate low risk prevention protocol by nursing.
- Score 12 and above is: High Risk -­‐ Activate high risk prevention protocol by nursing.
- For Paediatric in-patients ages 3 months to 14 y/o, Identified as high risk of fall:
Will be fitted with yellow ID printed with “FALL RISK” and a Humpty Dumpty to be
placed outside the patient’s active medical file.
- For Neonates and/or Infants ages 0 to 3 months, Identified as high risk of fall:
Must have a Humpty Dumpty sticker to be placed outside the patient’s active medical file
and a Humpty Dumpty poster placed at the bedside.
- For Out-patient & ED: Nursing Screening for fall risk, and if parameters are positive will
receive a full risk assessment. Use of assistive device i.e. Gait unstable, Poor balance and
Focuses on apparent need. Patient Re-assessment at each visit.
After a Fall What is Physician’s Role?:
1- Assess level of injury and treat any resulting problem.
2- Initiate diagnostic& treatment interventions for contributing intrinsic & extrinsic causes
3- Document post-fall assessment and treatment.
4-Find out probable cause of fall, such as history, physical factors, medications, and
laboratory values.
5-Refer patient to appropriate services if needed.
- Important: All events of patients fall: An ‘Incident Report’ must be completed.
2 2.
3.
Standard
Patient Medical
Assessment.
Nutritional and
Pain
Assessment.
(AOP)
Medication
Management
and Use
(MMU)
Common Questions & Explanation
• Must be familiar with: 1.The contents of Initial paediatric/ Neonatal Medical Assessment
Form, that to be completed and verified by MRP within (24h) of patient admission.
• 2. Nutritional nursing screening & medical nutritional assessment, as in assessment form.
• It is Important You know the (6) steps for Perfect Pain Management:
1- Pain Screening by nursing.
2- Informing physician if patient suffering of pain.
3- Physician completes pain assessment. 4- Physician Pain Management.
5- Physician Re-assessment.
6- Patient Education.
v Do we have a Medication List (Drug Formulary)?
- Yes, we have PSMMC Formulary that can be found in PSMMC ego Portal.
- PSMMC Formulary is updated annually based on safety and efficacy information.
- Pharmacy and therapeutic committee (PTC) maintain and monitor medication
formulary.
v How do you manage medications that are brought-in by your patients?
- All medications brought-in by patients upon admission should be approved by the
Main Responsible Physician to outline those that can be used by the patient
during hospital stay.
4.
Patient and
Family Rights
v Do you have a process for reporting adverse drug effects? Yes we have a process.
Please refer to the relevant policy.
v What is the Elements of a Complete Medication Order:
1- Patient’s full name and MRN
2- Date (Gregorian, e.g. 26/01/14)
3- Generic Medication Name, (Combination Products can be ordered by brand name)
4- Dose or concentration (metric system, e.g. mg, grams, mls)
5- Frequency, route and special instructions.
6- LASA (if applicable) & PRN medications must include frequency & indication for use
as part of the order (e.g. “Morphine 4mg IV q4hr for 24hrs, PRN for Pain”).
7- No prohibited abbreviations are used. (See MSD Abbreviations Booklet)
8- Weight based orders are required for pediatric patients & updated wt. included in order.
9- Physician name (printed), code, bleep & signature.
• Renewal orders shall be complete orders. Orders such as “renew old meds”, Renewal
orders shall be complete orders. Orders such as “renew old meds”
• Documenting in the ‘Medication Reconciliation List’, home medications and comparing
the physician’s mediation orders on admission to the list of home medications
• You must be Familiar With:
Medication Error: is defined as any preventable event that may cause inappropriate
medication use or jeopardize patient safety.
Near miss: A potential Medication error that occurred but did not reach the patient yet and
is caught prior to being administered to the patient.
• Time frame for reporting medication error & near misses: (See attachment).
Levels A to F must be reported within (one week).
Levels G, H and I must be reported within (24) h of identifying and documenting error.
• Time frame for reporting adverse drug effects is (24) hours.
v When do patient and family rights information provided to the patient?
- Information about patient rights and responsibilities is provided as early as possible
during the course of treatment.
- Information is provided in writing to each patient.
-The statement of patient rights and responsibilities is posted in all clinical areas and
available from nurses’ stations at all times in a form of pamphlets.
- The hospital has a process to inform patients of their rights and responsibilities when
written communication is not effective or appropriate (patient/family illiterate);
ü INPATIENT: Health educator should explain upon patient admission
ü OUTPATIENT: Appointment are set for patient/family to attend a session for
their rights and responsibilities.
v How do you Reduce Language barriers to patients and/or patient’s family?
- Patients receiving healthcare services in the organization, and their families should be
informed, in a manner and language they can understand, of their rights and
responsibilities using verbal instructions, displayed posters and patient information
booklets.
3 Standard
Patient and
Family Rights.
Cont......
5.
Care Of Patient
(COP)
6.
Prevention and
Control of
Infections
(PCI)
Common Questions & Explanation
v If a patient refuses for any treatment, what should be done thereafter?
- The hospital informs patients and families about their rights to refuse or to discontinue
treatment and the hospital’s responsibilities related to such decisions.
- The hospital informs patients about the consequences of their decisions, their
responsibilities related to such decisions and available care and treatment alternatives. v How is the patient complaints handled in your unit/department?
- Patients are informed about the process for voicing complaints, conflicts, and differences
of opinion.
- Complaint of the patient will be forwarded to the Complaint Unit and categorized/routed
as Clinical and Non-Clinical Complaint Tickets.
- Complaints, conflicts, and differences of opinion are investigated by the responsible
personnel of the hospital.
• FEEDBACK:
ü An SMS will be received by the complainant that the complaint is received and
logged by the responsible authority (Complaint Unit)
ü Result/outcome of the investigation will be disclosed to the patient by the hospital
administration.
• You must be knowledgeable about patient rights and can explain your responsibilities in
protecting patient rights. P&P Patient and Family Rights & Responsibilities (1-1-8062-01-019)
• Be aware of the content of ‘Patient’s Bill of Rights Posters’, available in hospital areas
Ensure the respect of the patient’s values and beliefs, privacy and confidentiality of care
and information, and the protection of patients from physical assault.
• The Medical Care Plan for in-patients:
- Must be documented within (24 ) hours of admission.
- The planned care must be documented in the patient’s record in the form of objective,
measurable goals. “Simple doctor orders are NOT care plans”.
- The goals in the care plan shall be updated or revised, as appropriate, based on the
re-assessment of the patient by the health care practitioners.
- The patient and family must be involved in the planning process.
• The Medical Care Order:
- To be documented in uniform location (the order sheet), you write orders according to
your granted clinical privileges.
- Diagnostic imaging and clinical laboratory test orders must include a clinical indication
& rationale when required for interpretation. (Avoid writing in complete forms)
• The Medical Care Plan for out-patients: Must be documented, in the patient’s record
(out-patient medical assessment form) before seeing the Next Patient.
- You must know types of high-risk patients and services identified by Hospital
leadership.
- You must know the location of CPR trollies in your area. You will may asked, if you
can demonstrate appropriate competence in Resuscitative Techniques.
• Restrain: You must know types of Restrain:
- Physical
-Chemical
-Mechanical
-Environmental.
- Restraint must never be used for punishment, lack of adequate staffing and Perform a
test or procedure that the patient/family has refused.
- A restrain order must be documented in the restrain form by privileged physician
before conduction restraint, and explained reasons/procedure to the patient/family.
• The PSMMC infection prevention and control program is based on the World Health
Organization (WHO) Per MSD directives.
• What is the way of proper Hand Hygiene?
- Do you know the 5 Moments or opportunities for hand hygiene?
- You may be asked to demonstrate how to do:
1. Hand Rub Procedure.
2. Hand Wash and Hand Disinfection Procedure.
• Are you aware of the policy & procedure on isolation practices? i.e. Contact, Droplet,
Airborne. (You may be asked to demonstrate how to access them from hospital internet)
4 Standard
Prevention and
Control of
Infections
(PCI)
Cont......
Common Questions & Explanation
• What Personal Portative Equipment (PPEs) should you wear before entering a Contact a
Isolation Room? - You may be asked to demonstrate the followings:
- Do you know how to put on PPEs? Put on in this order:
§ Perform Hand hygiene
§ Gown: Select appropriate type and size, opening is in the back, secure at neck and
waist
§ Mask: Place over nose, mouth and chin, fit flexible nose piece over nose bridge,
secure on head with ties or elastic, adjust to fit
§ Eye and Face Protection: Position goggles over eyes and secure to the head using the
ear pieces or headband, position face shield over face and secure on brow with
headband and adjust to fit comfortably
§ Gloves: Put on gloves last, select correct type and size, insert hands into gloves,
extend gloves over gown cuffs.
- Do you know the order of Remove PPEs? Remove in this order:
§ Gloves
§ Hand hygiene
§ Googles or Face Shield
§ Gown
§ Mask or Respirator
§ Wash Hands/use an alcohol-based hand sanitizer immediately after removing all
PPE
• Do you know to whom and how to report Commendable Diseases to Ministry of Health.
• Do you know the name and pager number of the Infection Control - IC Link Practitioner
(Physician / Nurse covering your area?
• Do you know the Infection Rate in your ward/department? Or the Hospital?
• Your White Coat/ Uniform must be clean all the time: you will be asked how frequently
you change them?, and if you wash them in the hospital laundry or at your home?
(they are source of infection).
• Have you attend Infection Control (IC) Education ? (lectures, workshops, campaigns,
orientations, discussions on your ward.
• Did you attend any of the Hospital wide IC education sessions? e.g. TB Day activities,
JCI Accreditation Education -PCI Standards, etc.
• Do you know how your hospital reduces the risk of infections through proper disposal of
waste? It is as Follows:
• Sharp Containers:
- Used for needles, scalpels, pipettes, syringes, glass items.
- Do you know how can you prevent a sharp injury?
§ Wear gloves when using sharps and needles.
§ Do not recap / manipulate / disassemble- use one-handed method or mechanical
device if recap is necessary.
§ Discard sharps at point of use - You use it, You dispose it.
§ Dispose it in the designated container.
- Important: All sharp injures must be reported via incident reports.
• What kind of waste is disposed in a yellow bag?
- Infectious Waste
- Container with blood/body fluids that cannot be emptied
- All specimens: Blood, body fluid, swabs, etc.
- Items moderately or heavily soaked in blood or body fluids.
- Chemotherapy Waste.
• What kind of waste is disposed in a Red Bag?
- Body parts, organs, fetuses
• What kind of waste is disposed in a Black Bags?
- General waste
- Items NOT moderately or heavily soiled in blood/body fluids
Note: All bags must to be labelled with the corresponded Hazards labels.
5 Standard
7.
Management Of
Information.
(MOI)
8.
Facility
Management and
Safety (FMS)
a. Major Disaster
b. Fire Events
Common Questions & Explanation
• The Medical Record will be arranged in a reverse Chronological Order (i.e. the most
resent admission/ outpatient visit will be first).
• Inpatient Diagnoses & Outpatient Procedures will be coded using the ICD-10-AM. They
are used to help the organization to identify the top Diagnoses and Procedures
performed, facilitate Clinical Research and participate in outside databases/ registries.
• Be aware of validity of documentation in the patient medical records i.e. eligibility, etc.
• Any Errors: must be crossed out with a single horizontal line, and initialled. “Error” must
be written next to it. No Erasers, correction pens to be used.
• Late Entry: When a pertinent entry was missed or not written in a timely manner.
- Identify the new entry as a “Late Entry”. Enter the current date and time. ” Do Not”
attempt to give the appearance that the entry was made on a previous date or an earlier
time. The entry must be signed.
- Identify or refer to the date and circumstance for which the late entry is written.
• An Addendum: is another type of late entry that is used to provide additional information
in conjunction with a previous entry. (Follow the same procedure of late entry)
• Any Patient: who remains in the hospital for more than Forty-Eight (48) hours including
patients held in the Emergency Department (ED) will require a dictated Discharge
Summary.
• A Discharge Summary must be completed within fourteen (14) Days after discharge.
• Death Summary must be completed within fourteen (14) Days after patient death.
• Monitoring of MR Content & Completeness: Regular open patient MR review must be
conducted by every MRP, as Two (2) files review per month.
Please note that: We needs evidence of four (4) month MR reviews before the date of
JCI Accreditation - April 2015. (This 4 month rule applies for any task requires
evidences of documentation and implementation).
• You must know the Major Disasters Codes:
Code Yellow: Stand-By - Code Red: Full Alert - Code Green: Stand Down.
• Our hospital is involved in Major Disaster Category (A): For aeroplanes crashes,
terrorism attaches and also covers North Riyadh Area. Participates in the Major Disaster
Category (B) with Ministry of Health such as water floods, sand storms & other Riyadh
areas.
• Agreed by Hospital Administration, receiving (25) patients/causalities at a time is
considered a Major Disasters.
• During Major Disaster: Staff to ask for and ensures availability of the following
Elements: Required medications, Bloods/Products, Infection Control, Utilities.
• Do not talk to any Media (Radio, TV, and Journalist), it is the responsibility of the
Hospital Administration.
• You must know Fire Code: Code F and The ext. (555) to activate Code F
• In event of fire: Your answer will be I use, Standard Fire Orders: R.A.C.E.
(You must be familiar with). Do not explain what is R.A.C.E. unless you are asked. (See attachment).
• Patients’ evacuation from fire area is Horizontal, if no fire exit in the receiving area
patients’ evacuation will be Vertical. During evacuation do not forget to look for
patients/staff in toilets (may not heard F Code). You have to ensure your safety as well.
• Must know the fire alarm sites in your area and how to use them.
• Must know the fire free zones area and collection zone in your area.
• Must know the location of fire extinguisher in your area, and if it is stabile to be
used for all types of fires.
• In case no fire extinguisher available, you can use any Powders for miner fires.
• You may be asked to demonstrate how to use the fire extinguisher: you must be familiar
with (P.A.S.S.) procedure. (See attachment).
• You must know the location of ‘Medical Gas Valve’ in your area, and you know how
and when to close it. In case you are required to do so (It is Charge nurse responsibility).
your answer will be: Must ensure that patients requiring oxygen are placed on portable
oxygen before closing the valve, to ensure patients safety.
• Must know the fire hose location in your area and if you can use it. If it is a low water
6 Standard
Cont......
9.
Child Abduction
10
Quality
Improvement
& Patient Safety
(QPS)
Common Questions & Explanation
pressure you can use, but if it is a high water pressure to be used only by hospital
foremen. This is to avoid harming yourself and the others.
Code Pink (pending): you will receive training on how to activate code pink, and each staff
responsibilities, once the infant/ child abduction policy and procedure is approved.
• You must be acquainted with the content of Hospital Mission and Vision.
• Must know Paediatric department Scope of Services and the department Objectives.
• Clinical guidelines/ Clinical Pathways:
- Aim to standardize patient care of certain diagnoses and reduces variation, ensure
patient safety, reduce length of patient stay.
- Criteria for Selecting:
High volume diagnosis or procedures
High risk diagnosis or procedures
High cost diagnosis or procedures
Problem prone diagnosis or procedures
Cause impact on the facility
• key Performance Indictors (KPI)
- Developed to reduce variation, improve the safety of high-risk procedures/treatments,
improve patient satisfaction, or improve efficiency.
- Criteria for KPI selecting is the same for selection Clinical guidelines/ Clinical
Pathways.
- KPI can be selected from JCI International library of measures. Our department is
collecting data for indicator :Systemic Corticosteroids for Inpatient Asthma, to prove its
superior efficacy to gain control of acute asthma exacerbation.
• Sentinel Events:
Unanticipated occurrence involving death or serious physical or psychological injury.
Serious physical injury specifically includes loss of limb or function. examples
- Death that is unrelated to the natural course of the patient’s illness/underlying condition
- Death of a full-term infant.
- Suicide.
- Major permanent loss of function unrelated to the patient’s natural course of illness or
underlying condition.
- Wrong-site, wrong-procedure, wrong-patient surgery.
- Transmission of a chronic or fatal disease or illness as a result of infusing blood or
blood products or transplanting contaminated organs or tissues.
- Infant abduction or an infant sent home with the wrong parents
- Rape. - Workplace violence such as assault.
• Near Miss: is a sentinel event that almost happened or circumstances happened but
didn’t reach the patient.
• Root cause analysis (RCA): is a systematic method that uses problem solving tools that
tries to identify the real cause of a problem. CQI&PS will create RCA Team as indicated.
• What you will do when an Incident occurred:
- Primary focus is for the patient
- Get help
- Immediate mitigation for the harm
- Disclosure of the error
• All employees are required to report all incidents that jeopardize patient safety even if
the incident almost happen or if it occurred but didn’t reach the patient.
• Reporting of incidents must be done through one of the following:
- Online PSMMC incident reporting system (You may be asked to demonstrate how you
can access the system and report an incident)
- Manual via completing an incident reporting form.
- Calling CQI&PS extension # 25637
• Which Incidents to be Reported:
- All Sentinel Events, Near Miss. - All serious adverse drug events,
- All medication errors.
- All confirmed transfusion reactions.
- All In-patient falls.
7 Standard
Quality
Improvement
& Patient Safety
(QPS)
Cont......
11. Staff,
Qualification and
Education
(SQE)
Common Questions & Explanation
- All major discrepancies between preoperative and postoperative diagnoses
- Adverse events or patterns of adverse events during moderate or deep sedation and
anesthesia use.
- Other adverse events; for example, health care–associated infections and infectious
disease outbreaks.
• Hospital wide and Departmental Policies & Procedures and Forms:
Policies and procedures go hand-in-hand to clarify what your organisation wants to do
and how to do it.
- Policies:
Policies are clear, simple statements of how your organisation intends to conduct its
services, actions or business. They provide a set of guiding principles to help with
decision making.
- Procedures:
Procedures describe how each policy will be put into action in your organisation. Each
procedure must outline:
§ Who will do what
§ What steps they need to take
§ Which forms or documents to use.
§ Procedures sometimes they work well as forms, checklists, instructions or
flowcharts.
- Policies and their accompanying Procedures will vary between departments/services
because they reflect the values, approaches and commitments of each
department/services, but they share the same role in guiding the organisation.
• You may be asked to demonstrate how you can access any of the Hospital Wide and
departmental Policies & Procedures and Forms, using the hospital ego-portal.
It is important to train yourself for easy access of the policies site.
• You will may be asked for the following to match clinical staff knowledge, skills, and
competency with patient care and needs:
- Your hospital ID Badge (Hang it in a place everyone can see) as all providers of patient
care must be identified and other trained in cardiac life support are identified.
- What is your qualifications?
- Did you received the desired level of training requirements, where and when?
- Are you registered from Saudi Commission for Health Specialties and must possess a
valid license (up-to-date)?
- In case your license is outdated ?
- Renew of your license as soon as possible.
- Failure to renew will result in suspension of contract renewal and you will be subject
for withdrawal of your clinical privileges.
- How you will conduct your daily work?
Healthcare providers that don’t have a valid and updated license must work under
supervision until their license is renewed. - Did you receive CPR training and what is its level (Mandatory BLS) for all staff.
- Job Description of the staff member - when applicable (For Head of Divisions).
- Did you receive ongoing in-service and other education and training to maintain or to
advance your skills and knowledge? JCI Team will look for evidence.
- What in-service education attended by the staff member?
- What is your clinical privileges, (be aware of its contents). How did you obtain them,
either by providing evidence of training or receiving in-service treating?
• Did you see your Annual Staff Evaluation, and if was discussed with you, as indicated.
• For New clinical and trainees staff members: Did you received orientation to the
hospital, to the department or unit to which you are assigned, and to your job
responsibilities and any specific assignments.
• Are you aware of staff vaccination and immunization hospital program? Did you
receive any vaccination?
8 Standard
Staff,
Qualification and
Education
(SQE)
Cont......
Common Questions & Explanation
• Are you aware of all necessary requirements to work/practice in PSMMC?
All healthcare providers are required to ensure that their employee file is completed and
updated to include the following:
1. Copy of their CV
2. Copy of their certificates
3. Copy of their Saudi license
4. Copy of their BLS & other advance live support
5. Copy of work history
6. Copy of job description/ clinical privileges
7. Copy of evaluation
8. Copy of in-service training
• Are you aware what is your evaluation process as medical staff work in PSMMC?
- Medical staff evaluation in PSMMC is data driven.
- Medical staff are evaluated for their behaviours, professional growth commitments
and clinical results/outcome related to their scope of clinical privileges.
ü Behaviours: committed to hospital code of ethics
ü Professional Growth: actively participated in continuous medical education
activities and updates such as grand rounds, symposiums, forums.
ü Clinical Results: patient care outcomes based on clinical privileges
• You may asked how do you participate in the hospital’s quality improvement activities:
The Minimum Participation is:
Attending the Monthly Paediatric Management Team Meeting.
Attending the Monthly paediatric Mortality& Morbidity meetings.
Reporting any occurred incidents.
Attending CQI&PS Lectures, Workshops, Symposia, etc.
The Ideal Participation is:
-Started or jointed in any of the Quality Improvement Projects in the department or
hospital wide.
- Conducted any departmental or Hospital wide education sessions.
- Joined in any hospital /public health education companies.
- Member in any of the hospital CQI&PS Committees.
- Obtained any education degree in CQI&PS
∗ This is Not an inclusive list of common questions & explanation, as you cannot read the JCI Survey Assessor Mind.
∗ But for more detailed information, Please refer to the lectures conducted by the Paediatrics JCI Trainers.
They are available in the hospital-ego-portal and to access them is as follow:
1- Go to All departments.
2- Select Continuous Quality Improvement and Patient Safety (CQI&PS)
3- Press on Quality training program (yellow colour).
4- Select JCI training the trainer workshop.
∗ Also the Joint Commission International (JCI) Standards 5th Edition is available on the site.
Thank You For Your Continuous Cooperation In The CQI&PS Process In Our Department
Good Luck
Compiled By: Dr. Fayez Banna – Chairperson of Paediatric Management Team – December 2014
Please See Attachments Below.
9 Attachments:
Time Frame For Reporting Medication Error & Near Misses
THE R.A.C.E. ACRONYM AND FIRE EXTINGUISHER USE
If you are involved in a fire, remember R.A.C.E. to help you respond safely and correctly:
R = RESCUE:
Any patient in immediate danger from the fire, if it does not endanger your life.
A = ALARM:
Sound the alarm for “Code F”, by calling ext. “555” and activating a pull station
alarm box.
C = CONFINE:
The fire by closing all doors and windows.
E=
EXTINGUISH:
The fire with a fire extinguisher, or EVACUATE the area if the fire is too large for
a fire extinguisher.
PROPER USE OF FIRE EXTINGUISHERS - (P.A.S.S.)
To use fire extinguishers correctly, remember the P.A.S.S. acronym:
P = PULL the pin on the fire extinguisher.
A = AIM the extinguisher nozzle at the base of the fire.
S = SQUEEZE or press the handle.
S = SWEEP from side to side until the fire appears to be out.
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