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					2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________                                              Priority Focus      COMPLIA
                                                                                                              Areas
Question                                                          Answer                                                          Full
ENVIRONMENT OF CARE
Is there any equipment with overdue                               Tag #'s                                     Equipment Use
inspection tags? Write down equipment
numbers for tracing on tracer logs

Does your site use liquid nitrogen? How do                                                                    Equipment Use
you transport it to a patient? Is there
dewars over carpet?
What do you do with defective equipment? Report any failures of patient care                                  Equipment Use
What do you do if the equipment is         equipment immediately to department
involved in an adverse patient event?      heads/nurse managers and promptly
                                           remove problematic equipment from
                                           service and/or label it “Defective” and
                                           attach a Medi-Tech work order to the
                                           equipment item.
Look at alcohol based hand cleaners.       They should not be over an electrical                              Physical
                                           outlet or switch. If they are over                                 Environment
                                           carpeted floors, must have a drip guard

Where is the Safety Manual Located?                               CVMC.ORG\CVMC Root\CVMC Shared              Physical
                                                                  Files\Policies\EOC Manual                   Environment
Do you know where your chemical                                   Inventory is kept at each site/unit. MSDS   Physical
inventory is located?                                             should be available or staff know how to    Environment
                                                                  access in intranet
What do you do in the event of a fire?                            Each area has plan, each employee           Equipment Use
                                                                  should speak to their role
Do you have an Eyewash? Is the log                                                                            Physical
complete?                                                                                                     Environment
Look at stored needles to ensure all are                          OSHA required to have safety needles If     Equipment Use
safety sharps                                                     unable to use safety device, ESIP
                                                                  Exception policy complete

What is your process for rotating stock     Check vacutainers, all forms of betadine,                         Physical
with expiration dates?                      Alcare, IV,Meds                                                   Environment
Where is your nearest fire extinguisher and                                                                   Physical
exit, and pull station?                                                                                       Environment
Where is the Emergency Management           \\Cvmcnt6\cvmc\CVMC Manuals\Disaster                              Emergency
Manual located?                             Plan                                                              Management
Is the AED log complete?                                                                                      Equipment Use
How do you know if a piece of equipment is                                                                    Orientation/
safe to use?                                                                                                  Training
PREVENTION AND CONTROL OF INFECTION
Who cleans patient equipment? How long Equipment is cleaned after patient use                                 Infection Ctl
does the cleaner stay on?                   by clinical staff. Depending on the
                                            cleaner used it must stay in contact for 3-
                                            10 minutes
Look at refrigerator temperature logs, are  Daily temps taken, out of range action                            Infection Ctl
they complete?                              taken, cleaning recorded. Verify High /
                                            Low Thermometer in use.

Look under the sinks - Are they free of                                                                       Infection Ctl
patient supplies and paper products?
Is there anything in the refrigerators that                       No comingling of lab, med, food.            Infection Ctl
doesn’t belong?                                                   Functional separation (shelves, separate
                                                                  containers) allowed if only one fridge.


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2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________                                               Priority Focus      COMPLIA
                                                                                                               Areas
Question                                                          Answer                                                           Full
Look at clean and dirty utility rooms. Are                                                                     Infection Ctl
clean and dirty separated?
Look at saline? Is it labeled and dated?                          Bottles dated with 24 hours. Note: single    Infection Ctl
                                                                  use flush syringes are preferred for
                                                                  diluting drugs and IV flushes - IV bags of
                                                                  saline for this are to be discouraged.

Observation for non-compliance with hand                                                                       Infection Ctl
hygiene?
What do you do if you see a member of    Mutual reminders                                                      Infection Ctl
your team not performing hand hygiene?

How do you decide to use alcohol based                            Alcohol at any time except when hands        Infection Ctl
hand sanitizer or soap?                                           are soiled or patient C Difficile-then it
                                                                  should be soap/water
PATIENT RIGHTS AND ETHICS
How do you carry out your job in such a       Turn over med records, Shredding, Limit                          Rights and
way that protects patient confidentiality? Is Assess                                                           Ethics
it evident in your area?

PROVISION OF CARE TREATMENT AND SERVICES
Describe how you identify a patient? 2 identifiers - Name + DOB Patients                                       Patient Safety
                                     must self identify
Observe Collection of a Specimen     2 identifiers - Name + DOB - Wristband                                     Patient Safety
                                     has at least 2 indentifiers, if applicable.
                                     Ambulatory patients w/o bands have
                                     them state name/ dob

Medication Administration                    2 identifiers - Name + DOB -                                      Patient Safety
                                             Ambulatory patients w/o bands have
                                             them state name/ dob
Interview a patient (obtain verbal consent   Pateint should have been asked to state                           Patient Safety
for patient interview) - Ask how staff       their name and 2nd id. Specimens
identified them prior to care and treatment. labeled in their presence.

What information is communicated during                            Is there standard information               Patient Safety
patient handoffs?                                                 communicated?

How is the information communicated?                              The process must be interactive and          Patient Safety
                                                                  allow for the opportunity to ask
                                                                  questions.
Are interruptions limited during the                              Quiet place-interactive process              Patient Safety
communication?
 UNIVERSAL PROTOCOL Is there a                                                                                 Patient Safety
verification of the correct person, site and
procedure at time procedure is scheduled?




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2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________                                               Priority Focus      COMPLIA
                                                                                                               Areas
Question                                                         Answer                                                            Full
Is the procedural site marked ? Is a                               Sites that involve intended laterality,     Patient Safety
credentialied provider who will be directly                      Even sites with midline incisions that
involved in the procedure marking the site?                      involve organ laterality need to be
Is the site marked with initials? For spinal                     marked *** NEW, Multiple lesions also. It
procedures, in addition to the preop skin                        is not necessary to mark sites when:
marking on the general region, intraop                           1. The practitioner who will be doing the
radiographic techniques are used?                                procedure does not leave the patient’s
                                                                 side from the time the decision is made
                                                                 to perform the procedure to the time the
                                                                 procedure is performed.
                                                                 2. The site of insertion or incision is not
                                                                 pre-determined
                                                                 3. There is an obvious laceration or
                                                                 lesion
                                                                 4. The procedure is considered routine
                                                                 and not high risk
                                                                 a. Venipuncture for lab specimens or
                                                                 injection of medication
                                                                 b. Insertion of a urinary catheter or a
                                                                 nasogastric tube



Is a timeout conducted? Is it done prior to A time out is performed immediately                                Patient Safety
the procedure?                              prior to starting the procedure with the
                                            patient’s involvement. This is a final
                                            assessment of the correct patient, site
                                            and procedure. The time out is initiated
                                            by a member of the team and is
                                            documented in eClinical Works.

MEDICATION MANAGEMENT
Let's take a look at medications and sharps- Either under constant observation or                              Medication
Are they secure?                             locked up. Narcotics must be locked up.                           Management
                                             Medications now include over the
                                             counter drugs, vitamins, not just
                                             prescription meds
                                             (any product FDA considers a drug).
                                             Saline Flushes, syringes, needles,
                                             scalpels, vacutainers holders, etc..
Are medications and supplies in date?                                                                          Medication
Check outdates. Multidose vials too                                                                            Management
Are medications stored appropriately?        Internal meds seperated from external                             Medication
                                             and topical.                                                      Management
Is there documentation of prescriber, staff, Does patient and family education                                 Patient Safety
patients and family education?               include importance of follow up
                                             monitoring, compliance, diet,adverse
                                             reactions?
For sameday procedures or clinic visits - Is                                                                   Patient Safety
a list of patients current medications
collected?




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2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________                                                  Priority Focus      COMPLIA
                                                                                                                  Areas
Question                                                          Answer                                                              Full
When only short term meds (drops,                                 When short term meds are given-                 Patient Safety
antibiotics) are prescribed, Is the                               (antibiotics, peri procedural meds)-the
patient/family given the short term list?                         list of current meds must be collected,
                                                                  but unless longterm meds or changes in
                                                                  current meds are made-a list does not
                                                                  need to be provided to the patient on
                                                                  discharge. The prescription for short
                                                                  term meds suffices as the short term
                                                                  lists
When changes are made in long term                                                                                Patient Safety
meds, Is the full list provided to the
patient? Family?
Are medications/ solutions which are taken Observe for practice in procedural areas                               Patient Safety
out of their original container labeled with : MPG Procedural Areas. Also in ED or
name, strength? Are they labeled with        bedside procedures
amount if not apparent from container

If the person preparing the medication is    Labels are verified verbally and visually                            Patient Safety
not the person administering, are the labels
verified visually and verbally?
Describe what happens at shift change?       At shift change/relief, a review of                                  Patient Safety
                                             procedural field is done
For procedures: Are the original containers Containers are kept for reference                                     Patient Safety
left for reference until the case is done?

Describe the safety procedures that are       Not performed together( High alert med                              Patient Safety
required during the administration of a high at bedside against order, 5 rights, pump
alert medication?                            settings, patients ID. Double check is
                                             documented.
Are there sample meds?                       Verify in dates, dispensing logs, check                              Medication
                                             forprohibited abbreviations on logs/pads                             Management

LEADERSHIP
Do you know what a Sentinel Event is?                             A sentinel event is an unexpected         601   Patient Safety
                                                                  occurrence involving death or serious
                                                                  physical/psychological injury or the risk
                                                                  thereof. The phrase "or the risk thereof"
                                                                  includes any process variation for which
                                                                  a recurrence would carry a significant
                                                                  chance of an serious adverse outcome.

At this clinic, have there been any                                                                         604   Patient Safety
significant patient issues or unanticipated
outcomes?




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2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________                                                               Priority Focus      COMPLIA
                                                                                                                               Areas
Question                                                         Answer                                                                            Full
How do you report a safety concern?                              If we had one we would report it via the     652              Patient Safety
                                                                 CVMC incident reporting system. The
                                                                 event or near miss is investigated. For
                                                                 serious or sentinel events or potential
                                                                 events, a Root Cause Analysis is
                                                                 conducted. Aggregate data is reviewed
                                                                 by managers and directors and
                                                                 corrective actions taken. If an employee
                                                                 id's a safety issue that they cannot
                                                                 resolve, they should take it to the
                                                                 department manager or supervisor and
                                                                 complete a safety report in the incident
                                                                 reporting area (955) in meditech


CREDENTIALING
If a patient provider wants to do a                                                                           609              Credentialing
procedure, how do you know if he is
privileged to do it?
AMBULATORY Record Review
Instructions: Choose 3 records that                               For scoring - Look for trends.
represent services offered at that site.
Review with staff familiar with patient or
patient type.
PATIENT RIGHTS AND ETHICS                                        Guidelines / Education helps                                  Priority Focus      Scoring
                                                                                                                               Area
Can you tell me What Medication                                  Collecting a complete and accurate list                       Patient Safety
Reconciliation is? (271) - MOVE TO                               of all patient medications including over
RECORD REVIEW SECTION                                            the counter medications, herbals and
                                                                 dietary supplements. Comparing
                                                                 discrepancies between any list: office
                                                                 list, HISS discharge medication list in
                                                                 Maple, patient's own list/recall,
                                                                 medication passport. Updating the list
                                                                 at every encounter (visit).
                                                                 Communicating the list to the next
                                                                 provider and concurrent providers.
                                                                 Provide the patient with a reconciled list
                                                                 of medications at the end of every
                                                                 encounter (visit).
Is there documentation that the patient                                                                                        Patient Safety
received the copy?
When only short term meds (drops,                                (Prescription)                               Patient Safety   Patient Safety
antibiotics) are prescribed, Is the
patient/family given the short term list?
When changes are made in long term                                                                            Patient Safety   Patient Safety
meds, is the full list provided to the
patient/family?
Are the daily emergency meds and                                                                                               Medication
controlled drug logs complete?                                                                                                 Management
PERFORMANCE IMPROVEMENT
What measurable improvements have you                             Area specific                                                Quality
made in your department over the past 12
months?
MANAGEMENT OF INFORMATION

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2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________                                              Priority Focus      COMPLIA
                                                                                                              Areas
Question                                                         Answer                                                           Full
When taking telephone orders or critical                         results written down, READ back,             Patient Safety
results SHOW ME what do you do?                                  confirmation by caller

Is it written down/entered into a computer? Log or patient chart check                                        Patient Safety

Is it read back?                                                 Is this documented?                          Patient Safety
Does the indidual gining the order or result                     Is this documented?                          Patient Safety
confirm that the info was read back
(document) ( (109.3)
Consent Questions                                                                                                                 Full
Is consent documented for procedures                             Can staff talk about when consent is         Patient Rights
requiring it?                                                    obtained in opt (outpt list of               and Ethics
                                                                 procedures)? If dictated, were risks,
                                                                 benefits and alternatives discussed?
Is the consent dated?                                                                                         Patient Rights
                                                                                                              and Ethics
Is the consent timed?                                                                                         Patient Rights
                                                                                                              and Ethics
ADVANCE DIRECTIVE QUESTION
Can you tell me if this patient has an                                                                        Patient Rights
advance directive? If so is there one in the                                                                  and Ethics
record? Whose responsibility is it to get a
copy for the medical record?
PROVISION OF CARE TREATMENT AND SERVICES
Medical Practice Group Is waived testing                                                                      Patient Safety
performed-use waived testing checklist

Are orders dated and signed? (169)                               Need to be able to locate orders. Can be     Information
                                                                 in dictated notes etc..                      Management
How do we document pain in clinics? Is it                        All patients                                 Assessment &
documented? (170)                                                                                             Care /Services
Are there any prohibited abbreviations in                        See attached list; Note Can't be in orders   Patient Safety
the chart?                                                       (medications/other) + medication related
                                                                 documentation this includes: H&P,
                                                                 Discharge Summary, Progress notes.

Outpatient sedation/anesthesia                                   Full H&P or look for sedation for            Assessment &
procedures; is there a current H&P in the                        procedure form. Section I or II must be      Care/Services
chart?                                                           completed. Form needs to be
                                                                 signed/dated.
If a patient is being admitted to CVMC, how                                                                   Information
is that coordinated? If a patient is being                                                                    Management
referred how is that coordinated? What is
documented?
If a patient is discharged to be followed up                                                                  Information
at your clinic, how is that communicated?                                                                     Management
What information do you receive? What is
documented?




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2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________                                               Priority Focus      COMPLIA
                                                                                                               Areas
Question                                                          Answer                                                           Full
                                                                  Patient education documentation should       Communication
Is there documentation of learning needs                          include all of the following:
assessment which included barriers and                            Date education occurred
readiness to learn and is there                                   Topic of education
documentation of patient education? (175)                         Taught to (patient, family, caregiver,
                                                                  other)
                                                                  Barriers (none, physical, cognitive,
                                                                  cultural/religious, desire/motivation to
                                                                  learn, other)
                                                                  Outcomes/Level of Comprehension
                                                                  (independent, requires assistance, needs
                                                                  practice, verbalized understanding,
                                                                  return demonstration, unable to learn
                                                                  Signature of educator
                                                                                                               Communication
Is there documentation of assessment of
the patient's level of comprehension and
need for reinforcement and/or follow up?

For behavior health patients: Is there a                          NEW In Psychiatry and General Clinics -      Patient Safety
suicide risk assessment documented?                               Ask staff what would they do/ utilize if a
                                                                  patient presented with behavioral health
                                                                  diagnosis - For Behavioral Health Areas:
                                                                  Is there documentation that supports the
                                                                  assessment ?

For behavioral health patients: Are the                                                                        Patient Safety
immediate safety needs addressed?
For behavioral health patients: Is a crisis                                                                    Patient Safety
hotline provided to individuals and their
family members for crisis situations?)

INFORMATION MANAGEMENT
Is there a summary list and medication list                       List should have medications - Check         Information
in the chart? Is it complete?                                     progress notes etc. … to be sure that the    Management
                                                                  list reflects what has been prescribed




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2009 Ambulatory - Outpatient Services CVMC
General Staff Member Questions and Observations
 CLINIC/LOCATION ___________DATE:__________Surveyors:___________           Priority Focus      COMPLIA
                                                                           Areas
Question                                                        Answer                         Full
MOCK SURVEYOR NOTES

Topic                                                            Issue




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