Helpful Guide to Answering Surveyors Questions
For Students and Faculty
of Affiliating Nursing Schools
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
– Child abduction
– 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
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
How to operate a fire
Pull the pin on top of the fire extinguisher
Aim at the base of the fire
Squeezer the trigger
Sweep over the fire
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
Find a process
Organize to improve
Clarify the process
Understand the issues
Select a new process
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
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.
We have TWO PATIENT IDENTIFIERS
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
WRITE IT DOWN, READ IT BACK & CONFIRM
– 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
How do you communicate when you are
handing off a patient to the next care
provider, or calling a physician?? SBAR!!
Ticket to Ride QVMC TICKET TO RIDE
(small green post-it note DATE:_______________ TIME:_________________
found at nursing stations)
Used by ancillary BP_________ P_________ R__________ T__________
personnel IS THIS PATIENT:
RESTRAINED FALL PRECAUTIONS
Required for the
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_____________________
*Applies to everyone who documents in the medical record
DO NOT USE these dangerous
– U, u
– 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
Look alike and sound alike meds are
identified by Tall Lettering and need to be
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
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,
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.
– Pre-Procedure Checklist
• Not required to documents elements
• Required to document
– Site Marking
• Is to be performed before patient is transported to
the procedural area
QVMC has adapted the “Safe
Covers the three elements of
– Pre-procedure checklist
– Site Marked
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
Relevant Documentation • Introduce the awake patient to • Verify Specimens labeled
-H/P read the procedural team correctly
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
• Correct Site /Laterality
Imaging Test Results (Visible after draping) Key concerns addressed
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
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)
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
– 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
TIME - OUT
– Correct Patient
– Correct Procedure
– Correct Site is marked and visible after draping
•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.
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
Medical history and physical within 24 hrs of
RN completes nursing assessment within 24 hrs of
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
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.