JCI Commonly Asked Questions

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What to do:
When you see a surveyor?
Dont attempt to hide, ignore, avoid

or run from them.
Be certain to greet the surveyor
(good morning/afternoon).
Dont be afraid and remain calm
and friendly.
Just remember they too are human
beings and it is not as painful as
you may think to tell them what you
know.
Just in case you do panic, it will still
be okay if you dont know the
answer, and then tell them so.
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What is
The SGH Madinah mission
statement?
Hospital Mission:
To provide professional reliable,
cost effective healthcare services
that is safe to the patients wellbeing to all Madinah region.
Hospital Vision:
To be the center of excellence for
state-of-art healthcare services in
the middle east and Africa built on
evidence-based practices and
human values.
What does your hospital mission

statement mean to you?
Or: whats your role in supporting the
hospital mission?
Any of the following answers are good

but you probably have a much better
answer your self!!!
BE PREPARED TO ANSWER IN YOUR OWN
WORDS!
We serve a culturally diverse population.
Which means we treat patients from all walks
of life, therefore, we must respect their
differences and meet their special needs?
(Examples: 1) elderly patients who have

difficulty hearing, seeing, and may be
frightened, alone, confused etc.
2) Young first time breast cancer diagnosed
woman who may need more education and
emotional support, etc.
Our mission statement tells me how we

define quality .which is providing friendly
service to our customers by doing the right
thing, the right way, the first time. I help
deliver that quality by. (Give a simple example
of what you do that is good.
Mission statement
Cont.
We work hard to be clinically effective
and economically efficient. Which means
we must do well and affordable
Our mission statement tells me our vision
of serving the healthcare needs of
people in our region as we have become
the best regional healthcare facility.
Our mission statement tells me that we
value patients rights, involve our patients
and families in decision making regarding
their care and respect their ability to
make choices including end of life
decisions. We must inform them of the
risks, benefits, alternatives & respect their
decisions
What is your definition of

quality?
Any of the following:

Doing the right things right the first
time, and doing it better every time.
To do the right things to the right
patients at the right time by the right
way in the right place.
Compliance with the standards.
Who are your customers?
Everybody! Patients, Families,

Visitors, Physicians, Co-workers
within my department and other
departments
External Customers:
Patients
Relatives
Visitors
Companies
Governments
Internal Customers: our employee

including doctors, nurses, technicians,
etc
What is a hospital wide patient

plan of care mean to you?
It is a detailed document that

describes the services offered in
each department-(scope of
services), description of
department, location, hours of
operation, staffing plans, etc.
Be sure you know what is included
under your department section of
this plan - (scope of services of
your department).
How do you make certain

the same level of care is provided to
your patients throughout the hospital?
Our staff and Management develop

collaborative policies and procedures
which allows various departments to
work together to maintain consistency
in processes done in different
locations of the hospital. Ongoing
communication and interaction with
other departments is key to our
success.
(You need to be prepared for giving an
example of how something done in
your department that is also done by
others is performed with consistency,
could be as simple as our hospital
wide hand washing techniques to
minimize the spread of infections,
transporting DNR information with all
patients as they visit different
departments/units, etc.)
Who is responsible for

safety at our hospital?
The Safety officer; Mr. Yaran Khan,

and safety committee
But
Safety is an important part of every
employee responsibility
What does
Environment of care
mean?
It is our hospital wide safety program.
1) General Safety:
Visitor/Patient Incidents
Employee Accidents
2) Fire Safety
3) Security: Theft, violence, etc. Workplace Violence
4) Emergency Preparedness:- Disaster, Bomb Threat, etc.
5) Hazardous Materials and Waste:
Right to Know MSDS
Medical Wastes
Mercury
Cytotoxic, radioactive, chemicals.
6) Medical Equipment, Procurement and Maintenance.
7) Utilities Management:
- Electric
- AC
- Phones
- Water
- Sewage, etc.
What is the goal of the Safety

Program?
The goal of the program is

to promote a safe
environment for patients
of all ages, visitors,
employees and all other
people coming in contact
with our organization.
What should you do if you see smoke

coming from a patient room, a fire in a
Wastebasket or any other signs of a
fire?
Follow the R-A-C-E protocol:

R = Rescue all persons from the
immediate area of the fire.
A = Activate the alarm and dial
88 to report the fire.
C = Contain the smoke or fire by
closing all doors.
E = Extinguish/Evacuate by
using the proper fire
extinguisher.
Where are the fire alarm boxes

and fire extinguishers located in
the department?
(Department-specific answer
required.)
Know the locations of fire

extinguishers and fire
alarm boxes in your
area. (You should be
able to point to them 20
feet from an exit.)
How do you use a fire

extinguisher?
P-A-S-S:
P = Pull the pin located

between the two handles.
A = Aim the base of the fire.
S = Squeeze the handles
together.
S = Sweep from side to side
at the base of the fire.
Watch for re-flash and use
extinguisher again if needed.
Which extinguisher can be used for

extinguishing fires involving burning
cloth, paper, or wood?
The red fire extinguisher (ABC)
Which extinguisher can be used for
electrical equipment motors, switches,
and flammable liquids?
The fire extinguisher contain (CO2)
Which fire extinguisher should not be
used on electrical equipment, motors,
and flammable liquids?
Fire extinguisher that contains water.
What is the hospital code for a Fire?

And What to dial to call for fire?
Code Red
Dial Number: 88
Which extinguisher can be

used for extinguishing fires
involving burning cloth, paper,
or wood?
The red fire extinguisher

(ABC)
Which extinguisher can be used

for electrical equipment motors,
switches, and flammable liquids?
The fire extinguisher

contain (CO2)
Which fire extinguisher should not

be used on electrical equipment,
motors, and flammable liquids?
Fire extinguisher that

contains water.
Where is the nearest fire

exit?
(Department-specific answer
required.) Know the fire exit
route for your department. If
you are a person who works in
all areas of the hospital, know
where all of the fire exits are
located.
How would you respond if

told, A fire has broken
out?
Literally, respond as if
there were a real fire,
Initiate R-A-C-E Protocol.
How often do you have fire

drills?
Fire drills are held

annually.
What is the hospital code

for a Fire?
Code Red
What to dial to call for fire?
Dial Code Red Number

88-
Emergency Preparedness:
Where do you find information
regarding employee
responsibilities during a
disaster?
In the Emergency Disaster

plan which is located in each
department.
What does [YOUR HOSPITAL]

consider a disaster?
Any situation which affect

the normal operations in,
i.e. fire, Earthquake, RTA
How do we test our emergency

preparedness program?
The Safety Committee had

2 mock disaster drills per
year.
Where is your departments

Emergency Disaster Plan
located?
Know where your

departments Emergency
Disaster plan is located.
Can you describe your role in

the emergency preparedness
plans?
Discuss this with your
department head and know

the answer to this question!
Or revise it through reading
the disaster plan.
Who is trained to evacuate

patients?
Everyone is taught the

principles of evacuation
because all personnel
might be asked to help.
What information should one

attempt to obtain from
someone calling in a bomb
threat?
Exact Language used by

the caller.
Location of the bomb.
When explosion is to occur.
Type of speech of caller.
Background noise noted.
Gender of the caller.
Who should be contacted upon

receiving a bomb threat?
Administrator
Security
Safety Officer
Department Heads
What do you do if someone,

whether a patient, visitor, or
employee becomes extremely
agitated or violent?
Remain calm, allow them to

verbalize, keep distance,
keep exit open, call code
strong *66.
What is the hospital code for

bomb threat?
Code White *44

for a Cardiac Arrest?
Code blue 22

for a chemicals spill?
Code Grey *11

for blood body fluid spill?
Code Grey *11

for radioactive spill?
Code Grey *11
Medical Equipment:
Can you show me where
test sticker is located?
Test sticker is located on

side of equipment.
When new equipment is

bought or loaned to
your unit you should?
Call the biomedical

engineer for a visual and
electrical inspection
before use.
How do you report an equipment

malfunction?
Put an out of order tag

on it and takes it out of
service! Call in a work
order or send directly to
Bio-med for service.
Whose responsibility is it to be
certain the equipment you are
using is functioning properly?
It is your responsibility
prior to using equipment
that it is working properly.
It is your responsibility to
also adequately maintain
equipment in addition to
removing equipment from
service and reporting it
promptly!
where are the oxygen valves

located in your patient care unit?
(Answer will be unit

specific.) Review all
areas of department for
location.
Who is authorized to shut off the

oxygen valves in the event of a
fire or another emergency?
Charge nurse on specific

unit.
Utilities Management:
What happens in the event of a utility
failure (i.e. electric, water, gas, medical
gas, or telephone)?
- We have backup electrical generators
that kick in within 9 seconds of a power
failure. In this situation, but the
equipment defined within the critical load
list of equipments will be automatically
work on UPS.
In the event of a water outage, we have
alternate water resource that can cover
the hospital for almost one week, after
that the external water resource will be
contacted to supply water to hospital. All
employees will make an effort to
conserve as much water as possible.
In the event there is a medical gas
outage, call the Maintenance
Department.
In the event of a telephone outage, use
mobiles, bleeper, paging
Hazardous Materials:
Where can the details about
every chemical used be found?
In the Material Safety

Data Sheet (MSDS)
Manual. Each chemical
used in the department is
in the departments
manual. The Master
MSDS Manual is located
in the Safety Office
Other than the Material Safety

Data Sheet (MSDS), where can
the hazardous material name
and hazard warning for that
material be found?
On the container label.
Do you use hazardous materials

in your area?
(Department-specific
answer required.)
However, all
departments should
have an MSDS Manual.
Can you name at least two

hazardous materials that can be
found in your department?
Ask your department

head to review what
hazardous materials are
found in your
department.
What first aid measures are

necessary when working with
the hazardous chemicals found
in your department?
Check the MSDS for

each specific chemical in
the MSDS Manual
located in your
department.
How is your waste disposed of

in your department?
Medical waste is
disposed of in covered
containers with yellow
bags. The bags are
removed from the
department by
Housekeeping to storage
area for final dispensing
What should you do if you have

a hazardous spill in your area?
Evacuate all personnel

and seal off the area as
best as possible. Pull
material safety data
sheet if aware of
chemical. Call *11 and
inform them about the
location of spill
What by colures do you have for

medical waste and for what
types?
Yellow bags : infectious

waste
Red bags: body parts
and human tissues waste
Blue bags: cytotoxic
waste
Black bags: normal
waste
Where do you dispense needles

and sharps?
In the sharps containers
Safety Management:
What committee is responsible
for the management of the
hospitals safety management
program?
The Safety Committee

chaired by the
administrative officer
_______
Who is the Safety Officer at

[YOUR HOSPITAL]?
Engineer Yaran Khan
How are the safety activities

reported to Administration and
the Board?
The minutes of the

Safety Committee are
submitted to the
CEO/SC members
monthly.

maintaining safe practices in the
hospital?
Everyone is responsible
for safe practice!
Potential safety hazards
should be reported to
your immediate
supervisor!!
What type of safety/environment

of care training have you had
during the last twelve months?
On a yearly basis, all

employees attend mandatory
retraining on Fire Safety,
General Safety, Infection
Control, Hazardous Waste,
and Incident Reporting. In
addition, patient care
employees attend CPR
training EVERY TWO
YEARS
Describe your hospitalwide smoking policy

Patients are not allowed to smoke
in our hospital without a physicians
order to do so. The criteria
followed by our medical staff are
patients that are terminally ill and
the benefits of smoking outweigh
the consequences.
However, if the patient is unable to
be escorted outside, then
arrangements are made through
security department.
All smoker employees are required
to smoke in the designated
employee smoke area only which is
located outside the hospital.
What type of incidents should

you report?
Any patient, visitor,

employee, or physician
incident or unusual
happening. Fill out an
Incident Report obtained
from your supervisor.
How do you report an

employee incident?
Fill out an Incident

Report immediately.
Notify your supervisor
immediately.
Security Management:
What would you do if you are
suddenly involved in a
potentially dangerous situation?
Protect yourself and call for

help as soon as possible call
code strong *66. Remain
calm.
How soon after witnessing a

security incident should an
Incident Report be completed?
As soon as the incident

occurs.
What procedure do you

follow when a theft has
occurred in an area?
Whether hospital or
personal property, make
sure the item has not
been misplaced. Alert
your supervisor. Fill out
an Incident Report. (The
supervisor will contact
Security.)
Human Resources:
How do you maintain your
competency/skills in order to
perform your job?
Educational Preparation,
competency checklists,
on the job training,
certifications, licenses,
etc.
How were you oriented to

your job?
Talk about all orientation activities including: hospital,
departmental, unit,
and job-specific orientation.
General orientation includes:

Mission statement/ Continuous Quality Improvement
Patient Rights
Infection Control issues like hand washing, infectious
waste disposal etc
Environment of Care issues such as: life safety,
utilities, medical equipment, general and safety,
security issues.
Hospital History and Structure
Human Resources Policies and Benefits
Department Specific Orientation:
Job Description
Policies
General Tour
Job Specific Orientation:
Competency assessment checklist
In services/Continuing Education Opportunities
Did you receive training during

department orientation on
equipment used in your area?
Medical equipment used in
assigned areas was reviewed in
department orientation. New
equipment is in-serviced before
used and additional review of
equipment is periodically held.
If I am ever unfamiliar with a
piece of equipment I can go to a
colleague with training on the
equipment, the operators
manual, our biomedical staff or
my manager.
What age of patients do you

care for? Have you received
age-specific instructions and
care for all of these ages?
If the ages of the patients

you serve are from birth death, you will need to
give examples of agespecific competencies
you have completed.
Belen to prepare
example
How is your competency

measured?
It is measured by
performance
evaluations, license
where applicable,
general orientation for
new employees,
competency based
orientation as
appropriate and
continuing education.
Do you have access to

educational materials
related to your profession?
Materials are available

on the unit (textbooks,
journals, etc.), through
Staff Development, the
Internet, and other
educational in-services
and programs.
How are provisions made

concerning assignments
that conflict with your
personal beliefs?
I would voice my concerns to my
manager who would in turn, make
arrangements for the patient to be
cared for by other staff member as
soon as possible.
I would not abandon my patient
until appropriate arrangements
have been made. My patient of
course, would continue to receive
the proper care from me until I am
relieved of those responsibilities.
How do you address your

learning needs?
Attendance to continuing
education Programs
Attendance to in-service
programs, study packets etc.
that provide me with input on
areas to improve upon.
Access to library and
internet
Request to attend special
programs presented at
outside agencies.
Self learning
What are some examples of

training offered as a result of a
learning needs assessment?
Computer Skills Classes

on computer department
JCI standards updates
and issues which are
ongoing to our staff
Need more Examples
How is staffing decided

and adjusted?
Typically, for inpatient

units, it is based on
patient acuity level. In
non-patient care areas, it
depends on volume of
work. (Your supervisor
can give you more
details)
Performance Improvement:
How do you have input on what
should be improved in your area?
Staff meetings, interviews, and

questionnaires are used to provide input
on our performance improvement
initiatives. Department head also
respond to concerns addressed in the
patient satisfaction survey process and
discuss these issues in department
meetings.
Each department has their own initiatives,
based upon their core process and data
identifying opportunities to improve. In
addition, any employee may suggest
quality opportunities
Through measuring the performance of
the department using certain indicators
(give examples from your department)
How does the Hospital establish

priorities for defining which
processes need to be improved?
The Quality Improvement Committee
establishes priorities based on input from
staff, patients, doctors and administrators.
The Quality Improvement Committee requires
that teams to be chartered must involve 2 or
more departments so that they are multidisciplinary! Many good suggestions are
submitted each year, they certainly can still
be projects to work on among the
departments involved!!
Priorities are then determined based on
criteria including but not limited to: high risk,
high volume, high cost, problem prone,
strategically important to the organization, inline with the mission and values,
multidisciplinary nature of the opportunity and
the impact on customer service.
What are some of the teams

and their priorities for 2008
e.g.;
Team 1: central line
device infection, Medical
and nursing
Team 2: bed ulcers,
nursing department
Team 3: turn around time
/lab
What were some of the

accomplishments in the past
year?
Our PI teams have made

changes, big and small,
over the past year.
Examples
What is everyones
responsibility in data
collection?
Everyone is accountable
for information being
accurate. It is our
responsibility to call
attention to apparent
incorrect data for
collection.
What quality initiatives are

in place in your
department?
Check with your

department head for
specific quality efforts,
measurements and also
client relations
improvements.
What is your responsibility in

performance improvement?
To ensure excellent personal

performance; to share ideas about
improvement in and streamlining
of processes; to provide excellent
customer service and to listen to
internal and external customers
To participate in basic
performance improvement
education; to participate in data
collections as requested; and to
participate on performance
improvement teams when
requested.
If our hospital should need to scale

down its efforts for any of various
reasons, what criteria would the
Quality Committee use to prioritize
the minimal efforts to be continued?
As outlined in the Quality

Management & Performance
Improvement Plan (QMP-01), the
following 3 criterion is used to
select the efforts to be maintained:
Processes that affect large number
of our patient population
Processes that place patients atrisk if not performed well
Processes that have been or are
likely to be problem-prone.
Are performance improvement

activities carried out in a
collaborative fashion among
departments and various
disciplines?
Yes! (Be prepared to give examples of
how your department has worked with
one or more other departments to
improve processes).
Department managers plan and carry out
improvement processes with other
departmentsbe prepared to give 1-2
examples of quality teams from last year
and their accomplishments as well as 1-2
examples of quality teams that have just
gotten underway this year!
Hint: Be sure to know about any team (s)
from this year or last year that
Impacts/improves work in your
department
How is data systematically

collected?
Collecting data helps us to assess outcomes or
determine the performance of a function or
process (i.e.; specific work tasks. When data
collection is systematic, the data can be used to:
Establish a baseline when a new process is

implemented
Identify the performance or stability of existing
processes
Measure the dimensions of performance
relevant to functions, processes and outcomes
Identify areas for possible improvement
Determine whether changes improved the
process
We collect data on important processes and
outcomes related to patient care and
organizational functions according to priorities
set by the quality improvement steering
committee.
Can you tell me something that your

department has improved from this
time last year? In other words, why
would I want to be a patient or
customer of in your department today
rather than this time last year?
You and your co-workers need to tell the
surveyors about any departmental
improvements, quality initiatives and/or
guest relations activities that have
improved your department in the last
year.
Be sure you know of any PI teams that
have involved your department last year
as well as the new teams just underway
for this coming year. Also, if our patient
satisfaction survey has information
pertaining to your department, you need
to know what patients have viewed
positively and areas that patients have
shown less satisfaction and what you are
doing as a department to improve
satisfaction in the future!!
What model is used by CQI

teams to improve performance
at your hospital?
FOCUS
F (Find an opportunity)
O (Organize a team)
C (Clarify current knowledge of process)
U (Uncover root problems)
S (Start the improvement cycle):
PDCA
P(lan): Identify the problem, develop a problem

statement, collect data to support solutions, use QI
tools to narrow the problem and decide on a solution.
D(o): Implement a plan, test using a trial run, identify
costs, people and materials, educate staff.
C(heck): Monitor the plans progress, obtain feedback,
compare data with original, use QI tools to monitor,
determine the success or failure of the plan/action.
A(ct): Incorporate the improvement into policy, inform
and educate all parties, distribute new information to all
key players, look for new improvements.
What education have you had

in Performance
Improvement?
Management and / or employee
basic performance improvement
in orientation; PI training for
supervisors and managers;
team leader and facilitator
classes for selected groups of
employees; advanced training
for Committee of Quality
Improvement. Staff education is
provided through Just in Time
Training when you participate
on a hospital PI team.
How is Customer
Satisfaction Monitored?
Through the patient
satisfaction surveys, which
are done monthly using
questionnaires for
outpatients and inpatients,
Results and actions are
discussed in SC, QPS
Committee, doctors
meeting and Department
Meetings.
How is the same level of

care consistently assured?
Through the Patient Bill

of Rights, use of Clinical
Care guidelines, policies
and procedures, Quality
Improvement activities.
What is the Performance

Improvement Plan for the
hospital?
It is our plan for

organization-wide
participation in
continuously improving
our work processes to
meet and hopefully
exceed customer needs
and expectations. See
QPS chapter, QPS.1
What are your key processes

(important aspects of care or
service)?
Discuss with your

Department Director the
specific work processes
for your area
What training have you

had on QI?
All employees receive QI
training as part of
mandatory in-service as
well as new employee
orientation. Also, if I serve
on a PI team, then I would
receive training in my team
meetings from our team
facilitator
What are Sentinel Events and

how should you respond?
A Sentinel Event is defined by policy QPS.5

An unanticipated occurrence involving death or
major permanent loss of function, not related to
the natural course of the patients illness or
underlying condition or the event is one of the
following:
Suicide of a patient
Rape of a patient
Hemolytic transfusion reaction involving the

administration of blood or blood products having
major blood group incompatibilities
Surgery on the wrong patient or wrong body part
When the event occurs, as applicable, first treat the
patient as directed by the physician. Second,
notify the Department Director or your supervisor,
fill incident report send the report to QM office,
QM office will call for team formation and
investigations.
What are clinical guidelines and how

do they affect the outcome of the
patient?
Clinical guidelines/protocols are simply a

documentation tool that is pre-printed, preapproved, outlining the course/plan of treatment
for a given diagnosis.
The use of clinical protocols can:
Reduce or eliminate system breakdown
Improve continuity of care
Improve liability management and outcomes
Improve quality, reduce lengths of stay, and
reduce cost
Improving resource utilization and promote quality
patient outcomes through reducing variation
among healthcare practitioners.
Clinical protocols are not:
A substitution or replacement of any physicians
professional judgment in the care and treatment
of a patient
What are some examples of clinical

protocols at our facility that have been
successfully implemented
Pain management protocols,

chemotherapy ordering, and
disease specific protocols
What are some clinical protocols that

we are working on and planning to
implement within the coming year?
Departmental specific answers
MANAGEMENT OF INFORMATION:
What is your role in managing
information?
Protect Our Hospital Computer System by following proper

procedures for protecting records and information from
tampering/damage, unauthorized access or use and
theft.
Make entries in a patients record only if you are
authorized to do so.
Never leave open files on your computer screen or
reports from a printer unattended.
Keep patient information confidential.
For example: Get written permission from the patient
before you share information with any unauthorized
person or agency. Do not talk about patients in public
areas such as the elevator or cafeteria. Never leave
patient files open or unattended where unauthorized
people could see them.
Keep documentation up to date and accurate. All
entries should be signed, dated and checked for
accuracy.
Anytime you see how a process can be improved, tell
your supervisor!
What information do you need to do

your job?
In general, information needs to be timely and

accurate. For all departments, information is
needed during staff meetings, mandatory inservices/orientation and ongoing educational
opportunities.
For specific departments, basic examples include:
Housekeeping: timely and accurate patient
discharge time
Radiology: medical indication for a patient having
a procedure
Laboratory: precautions for sticking a patient
Nursing: results of labs or exams
Nutritional Services: patient medical history for
specific nutritional needs
Patient Accounting: specific information on the
patients insurance plan
What would you do if you were not

getting the needed information to do
your job?
Staff and managers need to

communicate effectively.
Staff has the responsibility to
let his/her supervisor know if
there is a problem.
Management has the
responsibility to determine if
the system can be improved to
provide staff with more timely
and accurate information.
From what sources do you get

information?
Memos sent to your department

Bulletin boards and
communication books/logs
Staff meetings
Other employees
News letters, etc.
Email
Web Site and Internet.
What is knowledge-based
information?
Information that is used in problem

solving can be found in clinical,
scientific and management literature.
On the patient floors are many
reference books, text books, drug
books, journals, etc.
In the medical staff library there are
journals, textbooks, reference materials
and other resources.
In the computer lab and various
departments in the hospital, employees
have access through their supervisor to
access the internet world wide web with
unlimited medical information.
One of your co-workers has forgotten

her computer password and asks to use
your password so she can get her work
complete. What do you do?
Inform your coworker that you

cannot share your password as
you have agreed not to share your
password with anyone else by
signing a form stating you will
keep your password confidential.
You suggest she see her
supervisor to get her password. If
the supervisor is unavailable you
assist your coworker with her work
or find someone who can help her
until the password is received.
You learn, as a result of your work, that a

close friend is on the surgery schedule.
Another friend asks you what you know
about this patient. How do you handle
the situation?
You do not discuss this patient with

your friend.
Our policy states any Information
that is contained in the patients
chart, accessible by computer, or
available through any other written
or computerized source shall be
considered confidential, and shall
not be accessed, reviewed or
discussed unless such information
is necessary for completion of
specific job duties.
What is the vision of our

hospital as it relates to
Management of Information?
Our hospital has a

Management of Information
Plan that outlines how we
are obtaining information
through networking in
addition to the future plans
for our hospital.
See, Management
Information Plan- PLNMOI-01
Is comparative data
available to assess
performance?
Yes, for some areas, for

others we compare our
internal tends
Has your department or staff

been provided with proper
equipment and training to use
the equipment?
Classes are offered in

house on a regular basis
Information Management
can offer suggestions for
training and equipment
needs.
Are department and hospital

policies and procedures
readily available?
There should be a paper

copy in every
department.
Current Policies are
available electronically in
server. All supervisors
have access to this
database.
Hard copies /manuals
available in each floor
How are you informed of

policy and procedure
changes?
Through staff meetings, inservices and posting new

policies.
The latest policies on
server. These can be
viewed, searched, e-mail
all staff about changes.
Replace the old hard
copies from the manuals
When are you given initial

instruction and continue instruction
on how to access necessary data
and instructed on the confidentiality
statement?
Initial instruction is given

during employment
orientation program and
yearly during in
service/continuing
education.
If you have access to confidential

information via computer system,
is it okay to leave it on this screen
while you attend to another task
away from this system?
The proper procedure is

to sign off any screen
that shows confidential
information. This way an
unauthorized person
cannot access this
information while the PC
is unattended.
Information on
hazardous material is
located where?
In the Medical Safety

Data Sheet book located
at each work station.
Patent rights organizational/

Ethics:
What rights and responsibilities do
our patients have?
(Policy Patient and family Rights &

responsibilities .ADT-11)
RIGHTS FOR TREATMENT:

Patients have the right to be treated without
discrimination. They cannot be denied
appropriate and necessary services because
of their race, religion, national origin, gender
or ability to pay.
Patients also have a right to care that is
considerate and respectful of their personal
values and beliefs.
Patients have a right to appropriate
assessment and management of pain.
Patients have the right to review their medical
record. They also have the right to have their
questions about their condition answered.
continuation
NFORMED CONSENT:
Patients have the right to know:
Treatment options including alternative options
and the option to refuse treatment
Risks, benefits and alternatives of each option
including the expected length of recovery
Possible side effects of treatments and
medications
Costs including what the patients insurance
may and may not cover
INVOLVEMENT IN CARE DECISIONS:

Patients have the right to be involved in making
decisions which includes informed consent,
withholding resuscitative services, care at the
end of life and other options outlined in various
documents known as advance directives.
Patients also have the right to file a complaint
and receive help in resolving any conflicts.
Continuation
CONFIDENTIALITY:
Information about a patient (medical records, test

results, etc.) must be kept private. Anyone not
directly involved in the patients care, including
family members, must have the patients permission
to get information.
CONFIDENTIALITY:
Staff must not needlessly talk about a patients

personal or medical details! Be cautious of where
and how you discuss patient information!
Remember you signed a confidentiality statement
upon employment that must be taken seriously
PRIVACY:
All care (examinations, tests, etc.) should be given in

ways that respect the patients dignity. Some
examples of how you do this should include:
Knocking before entering the patients room
Keeping curtains drawn during examinations
Discussing sensitive issues in a private area
Asking the patients permission to speak about his or
her condition in front of visitors and/or family
members.
Continuation
ACCESS TO PROTECTIVE SERVICES:
Know our facility policy .
addressing issues of suspected abuse
and neglect. All healthcare workers are
responsible for notifying our Social
Workers .when suspicion of abuse or
neglect exists!
PATIENT RESPONSIBILITIES:
These include giving accurate
information, following instructions,
asking questions when something isnt
clear, showing respect and
consideration for other patients, hospital
staff and visitors, and following hospital
rules such as visiting hours and no
smoking within the building).
How is the patient informed

about his/her rights?
The patient receives patient

information through our
admitting office ext.1542,
which lists/explains patients
services, rights, and
responsibilities.
During their hospitalization, if
patients have any questions
regarding their rights, please
notify the supervisor, who can
access the information for the
patient. The patient rights and
responsibility statements are
also available in English.
How do you ensure the patients right to

confidentiality?
Do not share computer password.

Do not discuss patients in open areas
(i.e., elevators, cafeteria, and hallways).
Use caution when giving information
over the phone.
Share patient information only with
appropriate staff.
Tear up papers that contain patient
information and place in recycling bins
to be confidentially shredded.
Do not use patients name when voice
paging.
Employees, volunteers, students and
affiliated care givers sign an agreement
of confidentiality at time of employment.
Continuation
Only authorized individuals are
permitted to access records (Paper
or via computer)
Job descriptions/evaluations
address confidentiality.
Boards or sign-in sheets with
patients address or diagnosis
should never be visible to the
public.
Also, reclose doors/curtains to
maintain as much privacy as
possible with the patient.
We provide pen/paper to our
patients if they seem embarrassed
or uncomfortable to talk. We move
to a more private area when
possible. We assure patient gowns
fit properly. We close bathroom
doors when occupied, etc.
What is your role in obtaining

informed consent? (Consent
policy, PFR-01)
- The staffs role is to verify with the
patient (by the patients signature on
the consent form) that the patient has
all the information needed regarding
the risks, benefits, and alternatives of
the procedure to make an informed
choice.
Risks, benefits, and alternatives of the
procedure MUST BE ADDRESSED
BY THE PATIENTS PHYSICIAN.
If the patient has questions, the
nursing staff may choose to delay the
consent process until the physician
has satisfactorily answered all the
patients questions and then proceed
with the consent process.
What is an Advance Directive?

(Patients & family rights and
responsibilities , consent
policy-PFR- 01)
A way for a patient to

decide in advance how
he or she wants to
handle life-threatening
situations. Examples
How are patients informed of

their rights regarding Advance
Directives?
Upon admission, registration

personnel in the Admission
office give patients a
pamphlet on Advance
Directives and ask patients if
they have an Advance
Directives. If they do not have
an AD and want more
information or assistance in
formulating an Advance
Directive, they are referred to
Social Services, ext.
. What structures are in place to

address end of life decisions,
resuscitative measures or
withholding life-sustaining
treatments? (DNR policy- ETC-01)
The staff act as patient

advocates and advise the
attending physicians of
patient/family concerns
surrounding these issues.
Refer ethical issues to Ethics
committee.
There is a hospital/medical
staff policy on DNR and end
of life decisions.
How is organ and tissue

donation handled? (Donation
policy- PFR-02)
Organ and tissue

donation is discussed with
the patient/family in
appropriate cases. Refer
to the Organ Donation
policy. If the donation
is granted, consent is
obtained on the
Organ/Tissue Donation
form.
How do you demonstrate

family participation in care
decisions when
appropriate?
Participation is
documented in the plan
of care and in the
nursing notes. Family
involvement is part of
being a patient advocate
while maintaining the
focus on the patient.
How do we evaluate the need

for restrictions such as
telephones, visitors, etc.?
(Visiting hours policy)
Policies and procedures are in

place to govern restrictions
which are patient specific.
When restriction of telephone
calls or visitors is deemed
appropriate,
patients/families/friends are
educated regarding this
decision per policy on patient
rights. Patient/family/friend
education related to practice is
performed on admission.
How does the organization ensure

patients care is not negatively affected if
a staff member asks not to participate in
an aspect of care due to personal,
ethical, cultural, or religious values?
(DNR policy- ETC-01)
There is a policy which defines

conditions by which employees can
refuse to participate in the care of a
patient because of cultural, ethical
or religious conflicts.
The policy addresses the right that
employees have to request a
reassignment of work duties when
conflict arises. The manager and
employee evaluate this request ..
an ad hock committee can be
form, the care of the patient will
continue the same until the issue
solved
How do we help assure the hospital

conducts its business and patient care
practices in an honest, decent and
proper manner?
The hospital has a Code of Ethical which

addresses marketing, managed care,
billing and admitting practices.
Hospital staff has been involved in
developing this policy that makes certain
these issues are all handled in an ethical
manner.
Billing practices are monitored to ensure
that patients are billed only for the
services that were provided, patients are
given an itemized statement and patient
accounting staff is available to answer
patient questions and resolve conflicts.
The hospital mission statement and
annual business plan care used as
guides to provide a consistent, ethical
framework for its business and patient
care operations.
Who can look in a medical

record?
Health care
professionals with a
need to know and who
are involved in the
patients care.
What has been done to

accommodate patients and
visitors with disabilities?
The hospital triage room
entrance is designed for disability
entrance, disability restrooms.
Other needed materials can be
enlarged on a copier or provided
verbally..
Barriers against education assist
on admission (patient education
policy)
The current list of interpreters
who can be called for deaf
patients if the need arises is
available.
What has been done to accommodate

culturally diverse patients and
visitors?
For non- Arabic or English speaking

patients/visitors, arrangements are
made through the Supervisor for a
translator to be available. For patients
with limited education, staff
communicates various ways to make
certain the patient understands to the
best of their ability.
For patients with certain religious or
cultural beliefs that prevent them from
seeking certain treatments, procedures,
etc. we as healthcare workers respect
their rights to refuse treatment. For
elderly patients we communicate in
various ways to make certain they see
and hear what were saying..
If you have an ethical question

on any aspect of patient care
delivery, what resources are
available to discuss the
situation?
There is a hospital
Ethics Committee.
(Ethical consultation
policy- ETC-02)
chairman of ethics
committee Dr. Khalil
Ghandour
How are you as a staff member

made aware of the ethical issues
surrounding patient care and the
hospitals policies governing these
issues?
A multidisciplinary ethics
committee exists and staffs are
made aware through hospital
policies and procedures,
mandatory in-service,
orientation, supervisors, and
communications through the
hospital ethics committee.
(Review our hospital ethics
policies).
What is your departments role in the

development and implementation of
the mechanisms designed to address
patient rights?
All departments are responsible

for making sure that patients
rights have been respected and
departmental input is needed in
developing, implementing and
abiding by policies.
Departments represented on
the Ethics Committee include:
ICU, Nursing Administration,
Social Services, administration,
and medical staff.
How is the patient complaint

managed?
The employee should clarify the nature of
the complaint before contacting their
supervisor, department director,
supervisor or administrator on call. That
individual should promptly investigate and
analyze the situation and notify the
appropriate department director/manager
for assistance. All in-house complaints
must receive a verbal response within. 48
hours patient complain policy)
Outpatient and emergency department
complaints must be responded to within
five days. A patient comment/complaint
form must be completed by the individual
responding to the patient complaint.
Complaints come through suggestions
boxes, process and reported by QMO
How are patients pastoral

(spiritual) needs met?
Staff recognizes that

patients have spiritual
needs and assess their
desire for such services.
Social workers may
discuss spiritual care
with the patients nurse.
How do we inform other

departments that a patient being
transported to their area has valid
DNR orders?
We always send the

patients chart with the
patient. The code status
sheet is located at the
front of every chart and
directly behind the code
status sheet DNR notes
kept if one exists.
What rights do patients have

regarding pain
management?
The patient has the right

to make decisions to
manage pain effectively
and to have an
assessment of pain.
Patients have a right to
information about pain
and pain relief measures.
(Pain management policy)
How is a patients pain assessed

and managed?
The patient is asked about pain

level, location, description on
admission using a scale 0-5.
Policy and Procedures are in
place defining alternatives to
help with pain management.
Surveillance, Prevention and

Control of infection:
Why is there an Infection
Control Program?
To reduce the risk of

infection between
patients, visitors and our
employees
What single action is

recognized by the CDC
(centers for Disease Control
and Prevention) as the most
effective means of preventing
the spread of infection within a
facility
HANDWASHING!!!!!

Infection Control?
ALL of us at PAC are

responsible for
preventing infections.
The director of infection
control program and
Nurses : Infection
Control Nurse Ms. Joy
What does the term Standard

Precautions mean?
[YOUR HOSPITAL] has
adopted the 1996 CDC
Isolation Precautions. Under
these guidelines, standard
precautions are used.
Standard precautions mean
that blood, non-intact skin, and
all body fluids with the
exception of sweat are treated
as potentially infectious, so we
must use personal protective
equipment to protect ourselves
from being exposed to these
body fluids.
What would you do for an

occupational exposure to blood
borne pathogens (needle stick,
splash or spray to eyes, non-intact
skin)?
Go through the needle stick protocol.
Report exposure to your supervisor,
then contact the Employee Health
Clinic), the Infection Control Coordinator
or the House Supervisor to complete an
exposure packet which is available from
any of the above individuals. The
details of the exposure will be reviewed
with you and the risk of transmission of
a blood borne pathogen will be
determined. At this point you will be
instructed further regarding any action
needed. Employee clinic Dr. Yassar
Qutaiba will follow up with you
regarding the results of testing.
What isolation system do we use at

[YOUR HOSPITAL] and what do the
signs mean?
[YOUR HOSPITAL] uses the CDC Isolation

Precautions which mandate standard
precautions are to be used at all times with all
patients. In addition to Standard Precautions
there are three categories of transmission
based precautions:
Three categories:
Airborne - for TB, chickenpox or other airborne
disease.
Droplet - for meningitis, pertussis, influenza or
certain other diseases.
Contact -used for patients with VRE, MRSA or
other drug resistant organisms.
Signs instruct visitors and other persons to report
to the nursing station for information regarding
precautions to be taken before entering the
patients room. Standard precautions are
always used in addition to transmission based
precautions.
What is personal protective

equipment? Name an example
and when you should use it.
Personal protective
equipment protects us
from contact with blood
or body fluids. Gloves,
masks, goggles or face
shields and gowns are
personal protective
equipment
If a patient has an infection

which requires isolation,
where would you find
information regarding the
type of isolation required?
The Manual located in

each department, or
Isolation policies may be
accessed
What are items that go in

Red bags or Red
containers?
Items that are full of blood

or have the potential to
break or splash blood go
into the red bagged waste
containers. Nursing staff
assign to monitor the flows
needles and sharp items
which may puncture bags
go into the sharps disposal
boxes. This is called
Biohazardous waste.
Who monitors refrigerator

temperatures in our facility and
what action should be taken to
correct an out of range
reading?
In the main facility

temperatures are checked
daily and logged by our
Security personnel. Any
variance is reported to
Plant Operations. Nursing
staff a sign to monitor the
floors refrigerator
temperature
What immunizations are

available to our
employees?
All of our employees are

offered the Hepatitis B
vaccine. All employees
are offered the flu
vaccine yearly.
What precautions are taken

for patients with known or
suspected TB?
The patient is placed in a private
room with negative air pressure,
outside ventilation and an isolation
sign is placed on the door.
An employee who has been fit
tested for an approved mask is
assigned to care for the patient.
Patients should not leave the room
unless required for testing or
treatment and then they must wear
a mask the entire time they are out
of the room. Only employees fit
tested with an approved mask may
enter the room.
Do you recap needles?
Generally needles are

never recapped, but if
there should be a
situation where recapping
is necessary then you
must use a one handed
scoop method or a
mechanical device
designed for needle
recapping.
How do you dispose of

sharps?
Needle/sharps boxes are

where all contaminated
sharp items are
disposed of.
Care of Patient:
Can restraints be initiated by
an R.N.?
Yes, if the physician is not

available, with the approval
of the House Supervisor
based on appropriate
assessment of the patient
and sound clinical judgment.
The physician must be
contacted for a written or
verbal order as soon as
possible but within 12 hours
of the restraint application.
What must the

physician order include
for the use of
restraints?
The condition present

that warrants the use of
restraints.
Type of restraint
Time of the order
Date
Physician's signature
How long is a Med / Surg

restraint order good
for?
No longer than 24 hours.
If a patient is restrained for sudden

aggressive behavior, how soon
must the patient be assessed faceto-face by the physician and how
long is the restraint good for?
If a patient exhibits sudden aggressive
behavior and poses an imminent danger to
himself or others and restraints are applied, a
physician must see and evaluate the need for
restraint within ONE hour after the
intervention.
Each written order for a physical restraint for
aggressive behavior is limited to four (4)
hours for adults, two (2) hours for children
and adolescents age 9-17 and one (1) hour
for children under the age of 9.
When the time span for the original order is
close to expiring, a nurse is to telephone the
physician, report the results of his/her most
recent assessment and request that the
original order be renewed for another period
of time.....not to exceed the time limits set by
the original order. The physician does not
have to perform another face-to-face
assessment until the 24hr. maximum is
reached.
Name alternative
interventions to
restraint application
Sitters
Bed check system
Family staying with
patient
Frequent toileting
Ambulation
Leaving lights on

monitoring resuscitation
(Code blue) outcomes and
how often is this
performed?
The house supervisor

conducts a review of all
Code blue after the code
has ended. Completed
sheets are forwarded to
CPR committee with
reports presented
quarterly at Medical
board meeting
How can you be certain

that a crash cart on a
different unit is stocked
the same as the crash cart
on your unit?
All crash carts are

restocked by the
pharmacy using the
same criteria for each
and every crash cart
How often does the

pharmacy check the
contents of all crash
carts?
The pharmacy checks

the content of all crash
carts on a monthly basis
for completeness and
expiration dates.
Conscious Sedation:
What is conscious
sedation?
A drug-induced depression of
consciousness during which
patients respond purposefully
to verbal commands, either
alone or accompanied by light
tactile stimulation. No
interventions are required to
maintain a patient airway, and
spontaneous ventilation is
adequate. Cardiovascular
function is usually maintained.
What is the difference between

conscious sedation and
?
other types of sedation
Minimal sedation is defined as a druginduced state during which patients

respond normally to verbal commands.
Although cognitive function and
coordination may be impaired, ventilatory
and cardiovascular functions are
unaffected.(such as medication given for
pain or pre-operative medication).
Deep sedation/analgesia is defined as a
drug-induced depression of
consciousness during which patients
cannot be easily aroused, but respond
purposefully following repeated or painful
stimulation. The ability to independently
maintain ventilatory function may be
impaired. Patients may require
assistance in maintaining a patent airway
and spontaneous ventilation may be
inadequate. Cardiovascular function is
usually maintained.(these patients will
have an anesthetist in attendance)
What equipment is to be
readily available in monitoring
the patient for conscious
sedation?
The following equipment and supplies must be
available for the administration of intravenous
conscious sedation:
Continuous monitoring non-invasive blood
pressure and pulse oximetry; and cardiac
monitoring (only if known cardiac patient)
during and immediately following in the
recovery period of the procedure. In case
cardiac monitoring is not available, at least
pulse oximetry should be available
Continuous intravenous infusion of an
appropriate solution functional suction
apparatus with appropriate suction
catheters.Telephone or some other system so
as to be able to activate the emergency medical
system if required Duct number 8060
Conscious Sedation
An emergency crash cart which includes
respiratory emergency equipment.
Reversal agents/medications.
Sedation and analgesia medications as ordered
by M.D.
Who is responsible for assessing

and/or reassessing the patient
immediately prior to
administering anesthesia when
a nurse anesthetist is not
involved in the procedure?
The RN
How do you know if a

physician or other licensed
independent practitioner
has privileges to do a
certain procedure in your
area?
There is policy number

ANT02
How do you ensure

emergency meds are
consistently available,
controlled & secure?
Every shift, during normal

hours the department is
open, the staff verifies that
the red numbered lock is
intact and that the lock
number matches that
recorded on the orange
sticker affixed to the cart.
This shows that the cart is
complete.
What would you do if you

found that the emergency
box or crash cart was
unlocked ?
During pharmacy hours (8a8p M-F, 8a-6p SS) call

pharmacy. After pharmacy
hours, call house supervisor
to obtain emergency
replacement cart from night
cabinet. Red Box is to be
returned to Pharmacy via
dumbwaiter when they reopen (8am).
How are medications

distributed, stored,
secured?
Inpatient Areas:
Pharmacy uses unit dose distribution
system. Deliver a 24hr supply of meds
and IV products every day. Medications
are locked in carts. DEA scheduled
meds (Controlled substances) are kept
double locked in carts or cabinets.
Outpatient Areas:
Drugs routinely used are kept as floor
stock. Once used, the charges are sent
to Pharmacy for replacement and
billing. Meds are kept locked; controlled
substances are kept double locked.
Doses are signed out on control sheets
as used.
Describe how the medication

orders are processed for
your hospital.
Practitioners write orders in

patient chart. Nurse verifies order
and order is copied onto med
administration record (medix).
Copy or order goes to pharmacy
via dumbwaiter. Pharmacy sends
up enough doses until time of cart
exchange, when a new 24hr
supply is delivered. Pharmacy
and nursing reconcile drugs being
delivered at cart exchange against
nursing medix.Use chart to clarify
discrepancies.
How are pharmacy

services provided when
pharmacy is closed? Who
has keys to pharmacy?
only pharmacists may

have keys to pharmacy.
After pharmacy closes,
night cabinet is available
to nursing supervisors
for new orders/admits
How are drug storage

areas checked?
Pharmacy staff checks

all areas monthly for
expiration dates.
How do you monitor the

effects of medications on
patients?
Depends on the drug. If analgesic, go

back and ask patient to rate their pain,
using pain scale. If anti-hypertensive,
take blood pressure. If antibiotic, check
WBC, temp, confirm C&S for bug and
drug. Etc. Overall there is a
Multidisciplinary approach
Multidisciplinary
Pharmacy screens for drug-drug
interactions, drug-food interactions.
Lab reports sub therapeutic or toxic
levels/labs.
Everyone evaluates patient for
suspected adverse reactions.
Nursing documents SE, effects.
Physician, monitor outcomes.
Describe how you are

addressing the patients right
to pain management.
First of all, the patient is informed of the right
to pain management in the admission
brochure. Upon admission, the nursing
assessment is used to assess pain. A
standard pain scale (0 pain free-5 worst ever
pain) is used to document the pain..
Medications are ordered by the physician and
administered according to the instructions.
Appropriate selection and dose of drugs are
monitored by pharmacists. When doses are
administered, the nurse re-checks the patient
and documents pain after the analgesic dose
(or non-pharmacologic) intervention
Care plans include the pain scale. The
physician is informed if the pain regimen
prescribed is not effective at managing the
patients pain. In addition, PCA pumps are
now available at PAC. This allows the
patient to assist in their pain management.
Patients are educated about their pain meds
by the nurse when given the med and before
being discharged home on a pain med.
Are there any therapeutic

interchanges/drug
substitutions in place at PAC?
Yes. Pharmacy & Therapeutics

committee has approved several
automatic substitutions.
H2 blocker (po)= Zantac 150 bid
(for any oral H2 ; Axid, Pepcid,
Tagamet)
H2 blocker (iv)= Pepcid 20mg iv q
12h ( for any inj H2)
Proton pump inhibitor= Prevacid
15mg qd (for Prilosec 20mg)
Antacid= Maalox Plus
(for
Mylanta)
Maalox Plus XS (for Mylanta II)
Multivitamins= Theragran M qd
How are those

substitutions
documented?
Pharmacy sends up
sticker noting interchange
to be placed in chart (with
order)Nursing unit staff is
to note drug patient
actually receiving on med
administration record.
How long is a multiple dose

drug good for?
Multiple dose vial for injection

30 days from date opened, as
long as not visibly
contaminated. Staff is to write
date and initials on vial when
opened.
Bulk or multi use container
liquid, etc
Up to manufacturers expiration
date as long as no visible signs
of contamination and proper
dispensing/administration
techniques are used
Where do you get the red

numbered locks for
crash carts?
Pharmacy controls locks.

They sign them out in
Pharmacy. Issue with
new sticker for cart/box
(with new lock number).
How are samples used at

PAC?
- Pharmacy does not keep

samples for inpatients. If
a doctor supplies
samples for a patient,
they are delivered to
pharmacy and pharmacy
will distribute via normal
cartfill procedure.
How are herbal products

used at PAC?
Pharmacy & Therapeutics
committee approved a
policy that states the PAC
pharmacy will not
stock/dispense herbal
products for inpatients.
Nursing assessments do
include a question for the
patient about use of herbal,
food supplements or OTC
products at home.
What has been done at

PAC to minimize risk of
medication errors?
Re-implemented cartfill exchange
reconciliation. Developed an IV potassium
protocol -removed undiluted Kcl vials from
floor stock and crash carts.
Standardized iv drip Concentrations
Use of routine orders (annually review &
revise)
Converted from heparin to saline lock
(flushes)
Reduced drugs available in night cabinet
Focus articles in Pharmacy newsletters on
steps to reduce med errors.
Held CE program, How to avoid the
Headlines: Medication Error Prevention.
Review of P&P for safety related to med
distribution, administration, dispensing
Performance improvement looking at
prescribing (completeness of orders)
Evaluating house wide computerized charting
software
Analyze and trend medication errors
Is there an automatic stop

policy at PAC? How does
it work?
Yes. It requires the practitioner

to re-evaluate the use of certain
types of drugs every 5 days and
either re-order (to continue
therapy) or discontinue . Antiinfective agents, inj.
corticosteroids, controlled
substances. Pharmacy sends
notice to unit secretaries about
drugs which are reaching the 5
day limit and they write note in
chart asking Dr to renew or d/c
the drug.
What MUE (medication use

evaluations) have been
done this year?
Allergy reporting, CHF, B

blocker+ ASA in post MI
patients, Epogen, Pain
management
Nutritional Services:
nutritional needs
assessed and monitored?
Patients are screened and if
needed assessed. The
assessment includes a plan of
care, documented in the chart in
the multi-dis. plan of care. This
plan of care is undated and
redefined dependent on each
individual patient and their
individual needs. Therapies are
monitored by nutrition services,
nursing, pharmacy and other
disciplines. These may include:
intake, weight change, lab values,
wound healing
How is nutrition services

triggered to see patients?
Each inpatient has a screening

tool completed by nursing staff
to identify problems on
admission. The tool has 4
copies, one for the chart, one
for nutrition, one for social
services, and one for PT. This
alters these disciplines to
review the charts. Nutrition can
also be consulted via
physician, nursing, pharmacy,
other disc. or via discharge
planning group.
What happens to patients

needing trays between
meals of in off hours?
Nursing may call down for

trays anytime during
operating hours. The trays
are filled and placed on the
dumb-waiter.
During off hours there are a
variety of food stuffs
available on the floors,
juices, soups, Jell-O, frozen
dinners, milk, crackers,
nabs, fruit.
What are you doing to comply

with Food guidelines for
enteral support?
We use a closed system, with RTH
( ready to hang) formula when ever
possible. This allows the formula to be
hung for a 24 hour period.
There are several formulas not
available in the RTH , these are poured
into containers, with enough for only 8
hours at a time, the containers are then
rinsed before new formula is added.
We do not manipulate our formulas
with dye, but have color pelled systems
which allow the formula to be colored
without manipulation.
Formula is dated and timed by nursing.
We also have an enteral feeding form
which alerts nutrition to assess patients
on enteral support.
Are dietitians available on

weekends?
Yes, our dietitians rotate

weekends
How are you sure patients

get the correct diet?
Nursing services verify

the trays/ diet orders
with food service staff
prior to trays being
passed. This is repeated
for each meal.
EACH OF US HAS THE

RESPONSIBILITY OF
MAKING SURE THAT
WE ARE
KNOWLEDGEABLE
ABOUT THE
INFORMATION THAT
HAS BEEN SHARED
TODAY
LETS BE
PREPARED

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Dont attempt to hide, ignore, avoid

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What does your hospital mission

Any of the following answers are good

(Examples: 1) elderly patients who have

Our mission statement tells me how we

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What is your definition of

Any of the following:

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Who are your customers?

Everybody! Patients, Families,

Internal Customers: our employee

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What is a hospital wide patient

It is a detailed document that

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How do you make certain

Our staff and Management develop

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Who is responsible for

The Safety officer; Mr. Yaran Khan,

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What is the goal of the Safety

The goal of the program is

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What should you do if you see smoke

Follow the R-A-C-E protocol:

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Where are the fire alarm boxes

Know the locations of fire

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How do you use a fire

P = Pull the pin located

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Which extinguisher can be used for

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What is the hospital code for a Fire?

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Which extinguisher can be

The red fire extinguisher

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Which extinguisher can be used

The fire extinguisher

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Which fire extinguisher should not

Fire extinguisher that

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Where is the nearest fire

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How often do you have fire

Fire drills are held

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