Survey Readiness

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					        Survey Readiness:
Helpful Guide to Answering Surveyors Questions

                  For Students and Faculty
              of Affiliating Nursing Schools
                               Revised 2010
Who are the surveyors?

 CMS – Centers for Medicare and Medicaid
 TJC – The Joint Commission (they have
  officially changed their title)

   CDPH – California Department of Public
     What does a regulatory survey
            mean to me?
   Surveyors can ask students questions:
    – How were you oriented at the Queen?
    – What is your role in providing patient care?
    – Who is ultimately responsible for the patient?
       • The QVMC staff nurse
    – Key policies and procedures used in your work
    – The environment of care and safety

Surveyors may observe you perform your role!
How do I prepare for the visit?

 Know and follow QVMC policies and
 Wear your Photo ID (above the waist) at all
 Be prepared in case you are observed or
  interviewed by a surveyor
 KNOW YOUR PATIENT! Review history
  and plan of care
If You Are Chosen
 If a surveyor observes you…keep doing what you
  are doing in a confident, competent manner
 If you are asked a question, simply answer the
  question with what you know. If you don’t
  understand the question, tell them and ask for
  clarification. They will understand if you are
  nervous. You may need to hand-off care to
  another provider if interview is lengthy.
 Never walk away from a surveyor or fail to
  answer a question--tell them you will find the
  answer (i.e. ask resource or charge nurse).
Know QVMC Emergency Codes
   Code Triage                       Code Yellow
     – Emergency plan activation        – Bomb threat
   Code Blue                         Code Pink
     – Medical emergency
                                        – Infant abduction
   Code Red
                                      Code Purple
     – Fire/smoke
                                        – Child abduction
   Code Dry
                                      Code Gray
     – Water systems failure
   Code Orange                         – Abusive/assaultive behavior
     – Hazardous materials spill      Code Silver
   Code Shelter in Place               – Person with a weapon/hostage
     – Toxic cloud

        Look for the Rainbow Emergency Guide
    in your area for emergency response instructions
Reduce the Risk of Healthcare
Associated Infections
   Comply with CDC hand hygiene guidelines
 Use soap and water instead of alcohol gel when:
 - Hands are visibly soiled or contaminated with blood
 - After using the restroom
 - When handling food
 - When C-diff is involved
 - When Noro Virus is involved

   Wash before and after caring for a patient
Handwashing                THIS MEANS YOU!

 Applies to everyone
 When in doubt, wash your hands!

   Surveyors will observe to make sure that
    EVERYONE…doctors, nurses, students,
    housekeeping personnel, etc. wash their
    hands when appropriate and use correct
In the Event of a Fire
   Use the acronym RACE to know what to do
    R – Rescue from immediate danger
    A – Activate the alarm
    C – Confine the fire
    E – Evacuate if needed

                                    Where is
                                  the nearest
                         fire extinguisher??
How to operate a fire
extinguisher: P-A-S-S!
 Pull the pin on top of the fire extinguisher
 Aim at the base of the fire
 Squeezer the trigger
 Sweep over the fire
Quality/Performance Improvement

   How have we improved patient safety?
    – Alaris pumps
    – Double checks for high risk drugs
       • Insulin and Heparin
    – Falls Prevention Program
    – New restraint policy
    – Ht, Wt, Allergies on all pts entered in
What Are the Quality Measures

 AMI - we improved door to balloon time:
  less than 60 mins
 CHF - we standardized discharge
 Pneumonia- we give vaccinations and
  antibiotics within 4hrs of DX
 Pregnancy Related - we monitor
QVMC Performance
Improvement Model
 Find a process
 Organize to improve
 Clarify the process
 Understand the issues
 Select a new process
Staffing Effectiveness

   What is it?
    – The Joint Commission requires hospitals to take
      staffing data and compare it to patient outcome data to
      determine if there is any relationship or trend between
      the two sets of data
   What do we measure at QVMC?
    – Medication variance occurrence
    – Falls data
    – Registry hours and nursing hours worked per day
What is a FMEA???

 Proactive approach to reduce adverse events
 QVMC - improved medication security:
    – more Pyxis locations
    – Secured medication room
 Failure
 Mode
 Effects
 Analysis
What is a Sentinel Event?

   A sentinel event is an unexpected
    occurrence involving death or serious
    physical or psychological injury, or the risk
Patient Confidentiality and HIPAA

 Charts are to be closed when not in use
 Xeroxing patient medical records is prohibited.
 Computer monitors should have privacy screens to
  avoid casual viewing

Remember that if you reveal protected information
  to anyone who does not need to know, you have
  violated a patient’s privacy.
Patient Identification

    – Name
    – DOB
 Match the Service to the Patient (bring
  MAR in room and match to ID Band)
 Label blood tubes, specimen containers in
  presence of patient
 Your actions are being observed!
Verbal or Telephone Orders

 First Write it down on the order sheet
 Then Read it back
      and confirm !!

   This applies to every staff member approved to
    take verbal/telephone orders: Nurses, Respiratory
    Care Providers, Pharmacists

   Verbal Orders in emergency situations only!!
Communication: CRITICAL VALUES

  – Write down the results
  – Read back what is written
  – Receive confirmation of your read back

  – Appropriate turn around time: If after 30
    minutes the nurse is unable to reach the MD
    with critical lab results, initiate the “chain of
  – Document contact, time and intervention
Communication: SBAR

   How do you communicate when you are
    handing off a patient to the next care
    provider, or calling a physician?? SBAR!!
    S ituation
    B ackground
    A ssessment
    R ecommendations
Ticket to Ride                           QVMC TICKET TO RIDE
(small green post-it note    DATE:_______________           TIME:_________________
found at nursing stations)
                             PATIENT NAME:____________________________________

                             LOCATION:__________________ DOB:_____________________

    Used by ancillary       BP_________ P_________ R__________ T__________

     personnel               IS THIS PATIENT:
                              ORIENTED            CONFUSED
                              RESTRAINED         FALL PRECAUTIONS
    Required for the
     following               ACTIVITY:
                              AMBULATORY              STAND
                              LIE FLAT/BED REST       NEEDS ASSISTANCE
     interactions:            LOG ROLL REQUIRED       LIFT TEAM NEEDED
a.   Patient’s nurse to      ISOLATION PRECAUTIONS:
     ancillary personnel     NO YES TYPE:_________________________________

     transporting patient.   OXYGEN VIA _____________@______________l/m

b.   Ancillary personnel     RECENT PAIN MED OR SEDATIVE:
                             NO YES TYPE/TIME:____________________________
     to other ancillary
     personnel.              CODE STATUS:
                              FULL CODE  DNR        OTHER_____________________

                             OTHER INFO:__________________________________________

    *Applies to everyone who documents in the medical record

   DO NOT USE these dangerous
    –   U, u
    –   IU
    –   Q.D., QD, q.d., qd
    –   Q.O.D., QOD, q.o.d., qod        If written, they must
    –   Trailing zero (X.0 mg)           be clarified with the
    –   Lack of leading zero (.X mg)     ordering physician
    –   MS                              Write the
    –   MSO4                             clarification order
    –   MgSO4
Medication Safety
 Look alike and sound alike meds are
  identified by Tall Lettering and need to be
  stored Separately
 ALL Medications and solutions both on and
  off sterile field are LABELED
 If found unlabeled - Discard
 2 qualified individuals must verify labels if
  the person administering the medication did
  not prepare the medication
Medication Reconciliation

 Create a list of current medications on
 Compare with those medications ordered
  when there is a change in level of care
 Reconcile: check for omissions,
  duplications, interactions
 Send home list with patient
 Send list to next provider
Medication Reconciliation cont.

   The pt admission med list should be
    compared to the MD orders and the nurse
    should clarify changes as needed.

   Surgeons tend to forget the pt is on regular
    meds that need to be given in the hospital.
   Three elements:
    – Pre-Procedure Checklist
       • Not required to documents elements
    – Time-Out
       • Required to document
    – Site Marking
       • Is to be performed before patient is transported to
         the procedural area
   QVMC has adapted the “Safe
    Surgical Checklist”
   Covers the three elements of
    Universal Protocol
      – Pre-procedure checklist
      – Site Marked
      – Time-Out
     See the next slide
                                QVMC SAFE SURGERY CHECKLIST
      PRE PROCEDURE CHECKS                  PROCEDURE ROOM                              POST-PROCEDURE
(May be done in Pre-Operative Area)        (when patient in the OR suite)            (Done at closing)

      VERIFICATION CHECKS                      BEFORE INDUCTION                            TEAM VERIFICATION
    (see PICIS pre-op checks)

                                      •     Anesthesia needs addressed
      Verify Correct Patient         -Beta Blockers                                      Verify Procedure performed
                                          -Blood Loss
                                          -Airway issues

     Relevant Documentation          •       Introduce the awake patient to         •     Verify Specimens labeled
    -H/P read                                 the procedural team                          correctly

                                                      TIME-OUT
      Procedure Consent signed &               Done IMMEDIATELY prior to
                                                                                     •     Verify Count is correct
                                             SUSPEND activity – MUSIC OFF

      Blood products as ordered
                                      •    Correct Patient
                                      •    Correct Procedure read from
      Diagnostic Test Results                                                                TEAM DEBRIEFING
                                           the Consent
                                      •    Correct Site /Laterality
      Imaging Test Results             (Visible after draping)                           Key concerns addressed

                                             Allergies
      Implants, devices, & special
                                             Antibiotic given                       •     Opportunities for improvement
       equipment for the procedure
                                             Meds on the table (labeled properly)
                                             Surgeon Reviews critical steps
                                              & safety concerns:
      SITE MARKED                                                                        Preference card updated
                                      -SCD stockings turned on
                                      -Warming measures
Pre-Procedure Checklist
 Verify Correct Patient
 Verify Procedural Consent is accurate and signed
 Verify relevant documentation is available:
    – History and Physical (less than 30days old with day of event
      update by physician)
    – Diagnostic exams and results
    – Laboratory results
    – Radiologic results (labeled properly)
   Ordered blood products are available
   Implants and devices are available
   Correct site is marked by individual performing the
    procedure or operation (involve patient if possible)
Pre-Procedure Checklist
   Where is the Pre-Op checklist in your department?
    – TJC will ask you this
    – Look for the “safe surgical checklist”
   Elements of this checklist are NOT required to be
    – At QVMC, many departments choose to include these
      elements into their documentation
   Standardized application of all of these elements to
    all surgical/procedural areas
    –   Surgery
    –   Cath Lab
    –   Procedure Center
    –   Invasive Radiology
   Who must mark the site?
    – The individual performing the procedure
    – Surgeon or proceduralist's
   Where shall they mark the site?
    – Close to the site, visible after draping
   How shall they mark the site?
    – With the surgeon’s initials or line
    – No longer will RN mark laterality with “YES”
   When shall they mark the site?
    – With the patient awake and actively involved
    – Prior to moving patient to the procedural area
   Mandatory elements:
    – Correct Patient
    – Correct Procedure
    – Correct Site is marked and visible after draping
                      •Music Off
                      •Stop all activity

                  •WHO must participate in the time-out?
                      •Every member of a team involved with the
                      •Anesthesia, nursing, surgeon assistant (PA,
                      RNFA), scrub technician, Surgeon
What are the Criteria
for Identifying Abuse??

   Review policies on the following:
    – Domestic Abuse
    – Elder/dependent adult neglect or abuse
    – Child neglect or abuse
   Know the signs that are reportable!
    – In fact, it is our legal duty to report abuse!
    – Nurses are mandated reporters!
Reducing Fall Risks

   Fall Reduction Program
    – Treat all patients as a potential fall risk.
    – Identify “standard” and “high fall risk” patients and
      implement and document interventions per policy.
    – Involve all hospital staff in ensuring a safe environment
      free from hazards.
    – Educate patient and family regarding fall prevention.
      AND DOCUMENT in the medical record that patient/
      family education has been done.
Restraints Philosophy:
Patients have a right to be restraint free

   Restraint use is a LAST RESORT
   Every alternative is tried prior to restraint use
   A comprehensive assessment is done
   Restraint use is based on a clinical or medical indication
   A physician’s order is obtained prior to restraining except
    in emergency situations and every 24 hours.
   For violent or self-destructive behavior, a face to face
    assessment must be done by a physician or trained RN
    within an hour of restraint application
Clinical Alarms Response
   Assure that alarms are activated with appropriate
    settings and are sufficiently audible with respect to
    distances and competing noise within the unit.
   IV pumps, ventilators, pulse oximeters, telemetry,
    apnea alarms, bed alarms, etc.
   Know which alarm is sounding
   Respond in a timely, appropriate manner
   If the alarm is not working properly, notify the
    patient’s RN immediately.
Surveyors will observe to make sure the alarms are
 audible and are responded to in a timely fashion.
Encourage Patients’ Active Involvement
in Safety Strategy

 Educate patients and families on how to
  report a concern related to care, treatment,
 Communicate with patient and families
  about importance of a safe culture
    – “we will check your identification several
Patient Assessment

 Medical history and physical within 24 hrs of
  inpatient admission
 RN completes nursing assessment within 24 hrs of
  inpatient admission
 A nutritional screen is completed within 24 hrs
  (send referral to dietary via Meditech)
 A functional screen is completed within 24 hrs (if
  indicated, then obtain physician order for consult)
When do you RE-assess?

 Evaluate responses to all care and treatment
 Reassess and document patient’s pain
    – 30 minutes after IV pain med given
    – 60 minutes after po pain med given
   Reassess in response to significant changes in

As a student, when in doubt, ASSESS YOUR
  PATIENT and get help from a qualified staff
How do you develop a plan of care?

 Assess patient’s needs
 Integrate those findings in the care plan!!!!
    – Very important that there is connection to
    – Individualize the care plan
 Create reasonable, measurable patient goals
 Evaluate and document in the progress
Ethics and Patients Rights

   Does your patient have an advance directive?
    – Document on assessment yes or no
    – Refer to Social Services if more information is
      requested by patient

   How would you handle an ethical issue?
    – Identify the “Ethics ACE” in your area
    – Use the “Ethics at a Glance” reference book, which
      contains helpful tools:
       • Resolving Ethical Issues in Patient Care
       • The Ready Reference Grid
Student and Faculty Roles

 QVMC is happy to support education at our local
  nursing schools
 We ask that you become familiar with the
  information presented here so that you can be
  confident in your response to surveyors’ questions
 We are expecting a survey in July
 However this power point presentation reflects our
  daily practice expectations here at the Queen.

                              Be Prepared!

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