Download Jeanes Hospital Annual Consumer Survey

Weekly Survey Prep Tip
9/30/13
Staying Survey Ready
Surveyors will look very critically at the environment in which we
care for our patients
• Cleanliness/organization of the facility - all areas
(including mechanical/electrical closets, EVS closets)
• Storage of equipment/supplies; separation of clean from soiled; no
storage on floors or within 18” of the ceiling
• All egress routes must be clear
• No obstructions near fire doors, fire alarm pull stations or
extinguishers; no storage in hallways – remember 8 ft. clearance
rule
• Remove paper signs on doors & walls (along with the tape)
• Remove all expired drugs or medical supplies
• Proper oxygen storage
• Patient Rights Signage
Survey Prep Tip 9-30-13
Surveyors will look very critically at the environment in which we
care for our patients
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No drinks or food at work stations
No door wedges
White boards: contain current information
Confidentiality of patient information
Medication security
Medication storage: Pyxis, med carts, IV carts, etc.
Needle/Syringe security
Clean utility room/Soiled utility room
Refrigerator cleanliness/temperature monitoring –
documentation of corrective actions
Patient food – identification, expiration dates
Crash cart checks; Eye wash station checks
All linen carts must be covered
Infection Control – isolation practices (PPE & hand washing)
Survey Prep Tip 9-30-13
Surveyors will review our documentation
• Open chart reviews
• Date, time, signature for all medical record entries
• Verbal orders signed within 24 hours
• PRN orders complete with an indication
• Assessments / Reassessments
• IPOC up-to-date (reflects patient’s current status)
• Restraints
• Pain Management
• Medication Management / Administration
• Blood Transfusions
• Wound Care
• Patient Education
• Point of Care Testing
• Closed chart reviews
Survey Prep Tip 9-30-13
Surveyors may ask staff questions about the following topics
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Communication with non-English speaking patients
Hand-offs: SBAR, Ticket-to-Ride
Adverse Drug Reactions
Authority to turn off medical gas valves
Negative Pressure Rooms
Role in a Fire; drills, evacuation
Role in a Disaster
Phone Outages; Computer downtime
Smoking Policy
MSDS
What to do for suspected abuse
Ethical Consults
PI activities to improve patient care and patient satisfaction
Your competence to perform your job
Survey Prep Tip 9-30-13
Key Reminders
• Surveyors will interview patients
• All employees must wear their ID badge
• All employees must wash their hands upon
entering and exiting patients’ rooms
• All employees must wear PPE when applicable
• All employees must have current licenses,
certifications, vaccines (such as Hepatitis B &
Influenza) & PPD’s
• A current evaluation and annual mandatory
competencies
• Current BCLS (applicable to specific job
descriptions)
Survey Prep Tip 9-30-13
Questions???
Ask your manager or supervisor.
Survey Prep Tip 9-30-13