Survey Readiness: Helpful Guide to Answering Surveyors Questions

1. Survey Readiness:Helpful Guide to Answering Surveyors Questions For Students and Faculty of Affiliating Nursing Schools Revised 2010

2. Who are the surveyors? • CMS – Centers for Medicare and Medicaid Service • TJC – The Joint Commission (they have officially changed their title) • CDPH – California Department of Public Health

3. What does a regulatory survey mean to me? • Surveyors can ask students questions: • How were you oriented at the Queen? • What is your role in providing patient care? • Who is ultimately responsible for the patient? • The QVMC staff nurse • Key policies and procedures used in your work • The environment of care and safety Surveyors may observe you perform your role!

4. How do I prepare for the visit? • Know and follow QVMC policies and procedures • Wear your Photo ID (above the waist) at all times • Be prepared in case you are observed or interviewed by a surveyor • KNOW YOUR PATIENT! Review history and plan of care

5. If You Are Chosen • If a surveyor observes you…keep doing what you are doing in a confident, competent manner • If you are asked a question, simply answer the question with what you know. If you don’t understand the question, tell them and ask for clarification. They will understand if you are nervous. You may need to hand-off care to another provider if interview is lengthy. • Never walk away from a surveyor or fail to answer a question--tell them you will find the answer (i.e. ask resource or charge nurse).

6. Code Triage Emergency plan activation Code Blue Medical emergency Code Red Fire/smoke Code Dry Water systems failure Code Orange Hazardous materials spill Code Shelter in Place Toxic cloud Code Yellow Bomb threat Code Pink Infant abduction Code Purple Child abduction Code Gray Abusive/assaultive behavior Code Silver Person with a weapon/hostage Know QVMC Emergency Codes Look for the Rainbow Emergency Guide in your area for emergency response instructions

7. Reduce the Risk of Healthcare Associated Infections • Comply with CDC hand hygiene guidelines • Use soap and water instead of alcohol gel when: • - Hands are visibly soiled or contaminated with blood • - After using the restroom • - When handling food • - When C-diff is involved • - When Noro Virus is involved • Wash before and after caring for a patient

8. Handwashing THIS MEANS YOU! • Applies to everyone • When in doubt, wash your hands! • Surveyors will observe to make sure that EVERYONE…doctors, nurses, students, housekeeping personnel, etc. wash their hands when appropriate and use correct technique.

9. In the Event of a Fire • Use the acronym RACE to know what to do R – Rescue from immediate danger A – Activate the alarm C – Confine the fire E – Evacuate if needed Where is the nearest fire extinguisher??

10. How to operate a fire extinguisher: P-A-S-S! • Pull the pin on top of the fire extinguisher • Aim at the base of the fire • Squeezer the trigger • Sweep over the fire

11. Quality/Performance Improvement • How have we improved patient safety? • Alaris pumps • Double checks for high risk drugs • Insulin and Heparin • Falls Prevention Program • New restraint policy • Ht, Wt, Allergies on all pts entered in computer

12. What Are the Quality Measures • AMI - we improved door to balloon time: less than 60 mins • CHF - we standardized discharge instructions • Pneumonia- we give vaccinations and antibiotics within 4hrs of DX • Pregnancy Related - we monitor complications

13. QVMC Performance Improvement Model • FOCUS-PDCA • Find a process • Organize to improve • Clarify the process • Understand the issues • Select a new process • PLAN-DO-CHECK-ACT

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

15. What is a FMEA??? • Proactive approach to reduce adverse events • QVMC - improved medication security: • more Pyxis locations • Secured medication room • Failure • Mode • Effects • Analysis

16. What is a Sentinel Event? • A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

17. Patient Confidentiality and HIPAA • Charts are to be closed when not in use • Xeroxing patient medical records is prohibited. • Computer monitors should have privacy screens to avoid casual viewing Remember that if you reveal protected information to anyone who does not need to know, you have violated a patient’s privacy.

18. Patient Identification • We have TWO PATIENT IDENTIFIERS • Name • DOB • Match the Service to the Patient (bring MAR in room and match to ID Band) • Label blood tubes, specimen containers in presence of patient • Your actions are being observed!

19. Verbal or Telephone Orders • First Write it down on the order sheet • Then Read it back and confirm !! • This applies to every staff member approved to take verbal/telephone orders: Nurses, Respiratory Care Providers, Pharmacists • Verbal Orders in emergency situations only!!

20. Communication: CRITICAL VALUES • Write down the results • Read back what is written • Receive confirmation of your read back WRITE IT DOWN, READ IT BACK & CONFIRM • Appropriate turn around time: If after 30 minutes the nurse is unable to reach the MD with critical lab results, initiate the “chain of command”. • Document contact, time and intervention

21. Communication: SBAR • How do you communicate when you are handing off a patient to the next care provider, or calling a physician?? SBAR!! S ituation B ackground A ssessment R ecommendations

22. QVMC TICKET TO RIDE DATE:_______________ TIME:_________________ PATIENT NAME:____________________________________ LOCATION:__________________ DOB:_____________________ CURRENT: BP_________ P_________ R__________ T__________ IS THIS PATIENT: ORIENTED CONFUSED RESTRAINED  FALL PRECAUTIONS ACTIVITY: AMBULATORY STAND LIE FLAT/BED REST NEEDS ASSISTANCE LOG ROLL REQUIRED LIFT TEAM NEEDED ISOLATION PRECAUTIONS:  NO  YES TYPE:_________________________________ OXYGEN VIA _____________@______________l/m RECENT PAIN MED OR SEDATIVE:  NO  YES TYPE/TIME:____________________________ CODE STATUS: FULL CODE DNR OTHER_____________________ OTHER INFO:__________________________________________ NURSE:_______________________________EXT:____________ Ticket to Ride(small green post-it note found at nursing stations) • Used by ancillary personnel • Required for the following interactions: • Patient’s nurse to ancillary personnel transporting patient. • Ancillary personnel to other ancillary personnel.

23. DO NOT USE these dangerous abbreviations: U, u IU Q.D., QD, q.d., qd Q.O.D., QOD, q.o.d., qod Trailing zero (X.0 mg) Lack of leading zero (.X mg) MS MSO4 MgSO4 If written, they must be clarified with the ordering physician Write the clarification order DANGEROUS ABBREVIATIONS*Applies to everyone who documents in the medical record

24. Medication Safety • Look alike and sound alike meds are identified by Tall Lettering and need to be stored Separately • ALL Medications and solutions both on and off sterile field are LABELED • If found unlabeled - Discard • 2 qualified individuals must verify labels if the person administering the medication did not prepare the medication

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

26. Medication Reconciliation cont. • The pt admission med list should be compared to the MD orders and the nurse should clarify changes as needed.  • Surgeons tend to forget the pt is on regular meds that need to be given in the hospital.

27. UNIVERSAL PROTOCL • Three elements: • Pre-Procedure Checklist • Not required to documents elements • Time-Out • Required to document • Site Marking • Is to be performed before patient is transported to the procedural area

28. UNIVERAL PROTOCOL • QVMC has adapted the “Safe Surgical Checklist” • Covers the three elements of Universal Protocol • Pre-procedure checklist • Site Marked • Time-Out • See the next slide

29. QVMC SAFE SURGERY CHECKLIST

30. Pre-Procedure Checklist • Verify Correct Patient • Verify Procedural Consent is accurate and signed • Verify relevant documentation is available: • History and Physical (less than 30days old with day of event update by physician) • Diagnostic exams and results • Laboratory results • Radiologic results (labeled properly) • Ordered blood products are available • Implants and devices are available • Correct site is marked by individual performing the procedure or operation (involve patient if possible)

31. Pre-Procedure Checklist • Where is the Pre-Op checklist in your department? • TJC will ask you this • Look for the “safe surgical checklist” • Elements of this checklist are NOT required to be documented • At QVMC, many departments choose to include these elements into their documentation • Standardized application of all of these elements to all surgical/procedural areas • Surgery • Cath Lab • Procedure Center • Invasive Radiology

32. SITE MARKING • Who must mark the site? • The individual performing the procedure • Surgeon or proceduralist's • Where shall they mark the site? • Close to the site, visible after draping • How shall they mark the site? • With the surgeon’s initials or line • No longer will RN mark laterality with “YES” • When shall they mark the site? • With the patient awake and actively involved • Prior to moving patient to the procedural area

33. TIME - OUT • Mandatory elements: • Correct Patient • Correct Procedure • Correct Site is marked and visible after draping • PAUSE!! • Music Off • Stop all activity • WHOmust participate in the time-out? • Every member of a team involved with the procedure: • Anesthesia, nursing, surgeon assistant (PA, RNFA), scrub technician, Surgeon

34. What are the Criteria for Identifying Abuse?? • Review policies on the following: • Domestic Abuse • Elder/dependent adult neglect or abuse • Child neglect or abuse • Know the signs that are reportable! • In fact, it is our legal duty to report abuse! • Nurses are mandated reporters!

35. Reducing Fall Risks • Fall Reduction Program • Treat all patients as a potential fall risk. • Identify “standard” and “high fall risk” patients and implement and document interventions per policy. • Involve all hospital staff in ensuring a safe environment free from hazards. • Educate patient and family regarding fall prevention. AND DOCUMENT in the medical record that patient/ family education has been done.

36. Restraints Philosophy: Patients have a right to be restraint free • Restraint use is a LAST RESORT • Every alternative is tried prior to restraint use • A comprehensive assessment is done • Restraint use is based on a clinical or medical indication • A physician’s order is obtained prior to restraining except in emergency situations and every 24 hours. • For violent or self-destructive behavior, a face to face assessment must be done by a physician or trained RN within an hour of restraint application

37. Clinical Alarms Response • Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit. • IV pumps, ventilators, pulse oximeters, telemetry, apnea alarms, bed alarms, etc. • Know which alarm is sounding • Respond in a timely, appropriate manner • If the alarm is not working properly, notify the patient’s RN immediately. Surveyors will observe to make sure the alarms are audible and are responded to in a timely fashion.

38. Encourage Patients’ Active Involvement in Safety Strategy • Educate patients and families on how to report a concern related to care, treatment, services • Communicate with patient and families about importance of a safe culture • “we will check your identification several times”

39. Patient Assessment • Medical history and physical within 24 hrs of inpatient admission • RN completes nursing assessment within 24 hrs of inpatient admission • A nutritional screen is completed within 24 hrs (send referral to dietary via Meditech) • A functional screen is completed within 24 hrs (if indicated, then obtain physician order for consult)

40. When do you RE-assess? • Evaluate responses to all care and treatment interventions • Reassess and document patient’s pain • 30 minutes after IV pain med given • 60 minutes after po pain med given • Reassess in response to significant changes in condition As a student, when in doubt, ASSESS YOUR PATIENT and get help from a qualified staff member

41. How do you develop a plan of care? • Assess patient’s needs • Integrate those findings in the care plan!!!! • Very important that there is connection to assessment • Individualize the care plan • Create reasonable, measurable patient goals • Evaluate and document in the progress notes!!

42. Ethics and Patients Rights • Does your patient have an advance directive? • Document on assessment yes or no • Refer to Social Services if more information is requested by patient • How would you handle an ethical issue? • Identify the “Ethics ACE” in your area • Use the “Ethics at a Glance” reference book, which contains helpful tools: • Resolving Ethical Issues in Patient Care • The Ready Reference Grid

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