Joint Commission Prep Questions

Three goals of HCAHPS

- Meaningful comparison between hospitals- Public reporting to provide hospitals incentives to improve patient care- Public reporting to enhance public accountability and investment

What are some examples of internal systems that directly impact the quality and safety of patient care?

- medication usage - Infection control - Surgery and anesthesia - Transfusions - Restraints and seclusion - Staffing and staff compliance - Fire safety - Medical equipment - Emergency management- Security

Name ways that patients can participate in aspects of their care?

-Informed consent process -making decisions with the medical team about pain management -making decisions about end of life care -advance directives -Providing information of the medical team about their history for treatment planning

What information can you obtain from your badge?

-employee number -RACE for a fire -How to report an emergency -The number for obtaining a safety data sheet for a chemical - All emergency codes

What is the hierarchy for the application of policy and procedure? Policy#6

1 Memorial Hospital Policy 2 Critical Note with Lippincott Procedure 3 Lippincott Procedure text

What standing orders are available for the road runner team to initiate while attempting to notify the provider?

1. 12 lead EKG 2. Cardiac monitoring 3. current orders and PRN meds 4 Oxygen application and or titration 5 Establishing IV access 6.Protocols for hyper and hypo glycemia, hypotensive crisis, respiratory distress 7. ABG and or ASAP portable Chest x-ray

What is the criteria for activation of the road runner team (Rapid Response)?

1. Anytime a staff member feels something is not right 2. Staff member, family or patient has an ongoing concern 3. Change in level of consciousness or mental status 4. Change in heart rhythm ,blood pressure, respirations ,SOB, or hypoxemia, chest pain, Acute bleeding.

How much clearance should you have vertically under a sprinkler head?

18inches

How is a fall defined according to policy IV.51 Fall Reduction Guidelines?

A fall is any unplanned and unassisted decent to the floor or extension of the floor for example trash can or any other equipment witnessed or unwitnessed. All types of falls are included whether they result from physiological reasons or environmental.

Single use supplies must be?

ALL single use supplies must be thrown away after one use.

How soon after must a telephone order be authenticated/ cosigned by the provider responsible for the care of the patient?

ASAP but not later than 20 days after discharge

What staff members make up the Rapid Response Team/ Road Runners?

According to Policy #107 the Rapid response team is made up of a Registered Nurse from the ICU, Respiratory Therapist, the Administrative Supervisor (as appropriate) and the RN assigned to the patient.

Are chemical restraints used at Memorial Hospital Gulfport?

According to our policy no, chemical restraints are not used within out hospital system.

Who is responsible for approaching the family initally about organ donation?

According to policy IV.05 the representative from MORA -Mississippi Organ Recovery Association is responsible for counseling the family about their options to donate.

Why should you NOT place a patient with a latex allergy in a negative pressure room?

According to policy IV.65 Negative pressure can draw latex allergens into a room.

What is code silver?

Active Shooter

Describe your falls prevention program.

All patients are assessed for fall risk on admission using the Morse Fall Scale for adults and the Humpty Dumpty scale for pediatric patients and when there is a significant change in the patients condition.

How do we protect private health information?

All requests for medical information goes through HIM We do not discuss patient information in the hallways ,cafeteria or other public areas. We lock our computers when we step away. We secure an authorization to release Information before sending out records.

If you observe a safety hazard whom do you report it to?

Always report it to your immediate supervisor first. if the problem can be fixed correct it immediately if it can not notify the safety office Ken Mcdowell

Good Catch

An adverse event that could have resulted in patient harm but did not.

When is a doctor's order required?

An order is required for all medical interventions and diagnostics

When do medications have to be labeled?

Anytime they are drawn up and not immediately used, if it is transferred from its original packaging to another container.

When should a patient be assessed for a Latex allergy?

As soon as possible but it is preferred that this has been identified in a providers office prior to a procedure.

How soon should a fall assessment be performed (inpatient)?

As soon as possible but with in 12 hours of admission

What are some phrases to avoid when you are answering a surveyor's question?

Avoid saying things like "I think we mostly do it this way "We're supposed to" "On my shift" "I usually do"

Why is TJC accreditation important?

Because TJC surveys us on behalf of the federal government, Centers for Medicare and Medicaid. Accreditation allows us to recieve Medicare and Medicaid reimbursment form our patients. Also accreditation means we are working towards a goal of zero harm

What procedure do you follow for a utility system failure or component failure such as oxygen, medicalgrade gas, hot water,electricity?

Call engineering at ext 3056

What is a code 7?

Cardiac/Respiratory Arrest

What is a critical result?

Critical result is defined in IV55.A Critical Results Reporting - a critical result is a diagnostic test that results in a value requiring an urgent response by a responsible clinical provider.

How are you competent to care for a patient on anticoagulant therpy?

Education during orientation, specific unit education during orientation, and by way of annual competencies. Also Health Stream modules and testing.

What are places that should not have anything in front of them that might cause an obstruction?

Exits Fire Pull Stations Fire Extinguishers Gas cut off valves eye wash stations anywhere that has a do not block sign posted.

Give examples of interventions for pressure ulcers.

Frequent turning, wound care interventions, clean dry linens, frequent toileting, minimize friction and shear forces.

MIDAS Reporting is used to report?

Good catches, Near Misses, medication errors, patient safety incidents, and lab errors.

What should you do if a patients condition changes and you are unable to contact the on call or current physician?

In this event according to Policy IV.44 Contact the Administrative Supervisor on duty.

What type of patients are at high risk for a Latex Allergy according to Policy IV.65 Latex Allergy/ Sensitivity Percautions ?

Individuals who are at risk include patients who have had multiple abdominal or G.U surgeries, asthma, allergies or uticaria, children with myelodysplasia or urologic anomalies. Healthcare professionals especially females are more at risk. Particular caution should be used in patients with allergies to Bananas, avocados, kiwi and chest nuts.

Code Pink

Infant or child abduction

Describe your program to prevent pressure ulcers.

Initial assessment using the Braden scoring system for skin breakdown. A score of 14 will automatically generate a consult to wound care who will come and evaluate and recommend treatment regimens including consulting the wound care physician as needed.

Give me some examples of fall interventions.

Interventions include hourly rounding, placing the patient close to the nurse station, education, colored wrist band, non slip socks, bed alarm.

What is elopement?

It is when a patient is observed leaving an inpatient unit without having been discharged and has no intention of returning.

Who is the hospital safety officer?

Ken McDowell

Labeling syringes

Label syringe with medication names, strength, amount, (time and date if not immediately administered)

What should you do if a patient brings equipment in from home?

Look for a UL sticker. This indicates it is ok to use. Also, look at the piece of equipment and make sure cords are not frayed and it appears to be in good condition. If you have any questions at all call engineering for personal equipment or biomed for personal medical equipment.

What is stored soiled utility room?

Meant to store dirty linen and biohazardous materials. Nothing can be stored on the floor.

Where must clean linen be stored and how?

Must be kept alone on the highest shelf if liquids are stored in the same cabinet. Must be kept covered at all times.- nothing should be placed on top of a clean linen cart.

Emergency pull cords need to be _______inches from the floor.

Must be plastic coated and 6 -8 inches from the floor. Do not wrap around hand rails.

Is it ever acceptable for fire doors to be held open with, ties, wedges, or other objects or to tape a door or latch?

NO!

During a time out is it ok to continue working and doing tasks?

NO! Every team member needs to be alert and pay attention during a time out including the surgeon. If any team member has a question or concern it should be expressed with out fear.

Can a sharps container be on a counter top with out being in a holder?

No, small to medium sharps containers need to be mounted or secured. - ask if you are unsure

Should supplies be stored on the ground?

No, supplies should be stored on a shelf or something that lifts the supplies 6 inches off of the floor.

Is it OK to tape an ICU patient or child's name band onto a bed or crib if they do not want to wear it?

No, the name band is an essential element to providing safe care for a patient.

Sprinkler heads need to have a clearance of ________? Why?

Nothing should be stored within 18 inches of sprinkler heads. 18 inches lets the sprinkler head work correctly.

when a procedure is over why should you preclean the instruments as soon as possible and not delay the transport to the decontamination area?

Omitting or delaying pre cleaning may cause bioburden to dry on instruments making them challenging to clean and sterilize

Where would you find the Emergency Policy and procedural manual?

On our intranet set under the Policy and procedures tab at the top of the page

Logs

Only current month logs should be visible. Historical logs should be filed and kept for 3 years (TJC cycle).

Medication Room Security

Only staff that administer medications should have access to medication cabinets and drawers.

What makes you qualified to do your job at Memorial Hospital Gulfport?

Orientation, competencies and education /licensing status

Standard Precautions

PPE, hand washing/sanitizer, cough etiquette, and clean rooms and equipment between patients.

How are Patients/ Families informed of their rights and responsibilities?

Patient registration gives them a copy, Patient Rights and Responsibilities are posted throughout patient care areas.

What is a code 7p?

Pediatric arrest

Where do caregivers document their initial assessment?

Physicians will document on the H&P within 24 hours of admission. If surgery is planned and the H&P is over 24 hours, they must have documented an interim note indicating they have examined the patient. Nurses document on the admission interview and assessment. Policy requires it to be completed within 12 hours of admission.

How do you know who can provide informed consent for an individual?

Policy #IV.08 Informed consent- according to policy , consent must come from the patient, a duly empowered rep, or based on circumstance. The consent must be signed by the patient if the patient is competent AND -18 years or older - married regardless of age - an emancipated minor - pregnant patients regardless of age or marital status may consent for herself in connection with pregnancy and childbirth

Hopsital Consumer Assessment of healthcare providers and systems (HCAHPS)

Provides a standardize survey for measuring patient's perspective on hospital care

Where are the fire alarm pull stations?

Pull stations are located near exits, stairwells, main corridor doors, and in major corridors, make sure to know where they all are on your unit or department.

What is Quality Assurance (QA)?

Quality Assurance is defined as a program that guarantees quality patient care, by tracking the outcomes through scheduled audits. QA included appropriateness, applicability and timeliness of patient care.

What does R.A.C.E stand for? (hint it is on your badge)

Rescue, Alarm, Contain, Extinguish

What should you do if you do not know a question the surveyor asks?

STAY CALM, say something like I know where to find the answer (please be able to find it) or Ask a friend other staff can help, phone a friend (don't literally phone a friend)

Protected Health Information (PHI)

Secure computer screens when not in use, do not disclose PHI with persons not involved in patients' direct care, and keep medical records out of view from outsiders.

Clean supply room

Should remain free from soiled linen, have nothing on the floor, and bottom shelves of racks must have solid plastic liners.

Why is it mandatory that we keep hallways clear?

So that we can safely and quickly evacuate patients and personnel in the event of a fire or other emergency requiring evacuation

What is performed prior to any invasive or surgical procedure?

TIME OUT - is performed to confirm the correct patient , procedure and site using ACTIVE communication. Everyone stops all activity and participated in a time out to ensure the safety of the patient.

True or False. It is critical to maintain/set aside/ save any equipment or tubing involved in a sentinel event.

TRUE.

How do you provide patient and family education if the patient does not speak English?

The Cyraphone System provides translation services. Unit managers have access codes. For nights and weekends, the Administrative Supervisor can assist in getting access.

What Fall risk tool is used for pediatric patients 4 to 17 years old?

The Humpty Dumpty fall risk tool is used for patients aged 4 to 17 years old.

What manual is accepted as a source of information regarding procedures performed by ALL staff (including clinics) at Memorial Hospital?

The Lippincott Procedure Manual - Be sure to know how to access it from the Memorial home page.

For patients 18 and over what fall risk tool does Memorial use?

The Morse Fall Risk Tool is for patients 18 years and older

How do you access an SDS Safety Data Sheet for a chemical or cleaner?

The answer is on your badge call 1800-451-8346

How do you report an emergency on the Main Campus?

The answer is on your badge call 3600

What is Performance Improvement (PI)?

The continuous study and adaptation of the functions and processes of a healthcare organization to increase the probability of achieving desired outcomes and to better meet the needs of patients.

What does a nurse do when a patient problem is identified?

The problem is addressed on the care plan and if necessary the physician is notified.

How can you identify emergency power outlets?

They are RED

How are your refrigerators monitored? (Hospital)

They are electronically monitored by IS 24/7. They notify us if there is a discrepancy.

When should you try to schedule a patient with a latex allergy for a procedure?

They should be the first case of the day if possible. This includes radiological, invasive procedures, Labor and delivery, surgical cases. With the exception of the even there is an urgent case.

How frequently do you assess for pain?

This depends on the patient's condition, peak and duration of interventions.

What do you do when a staff member objects to implementation of a patient's advance directive or health care decision?

This is covered under Withholding and Withdrawing Life support policy # IV.07 Section I. paragraph I -Conscientious Objection . The lead RN will make assignments to facilitate this request. - The staff member will be reassined to another patient as requested.

If the person who labels a medication is not the one administering it, what do you do to ensure the right medication is being administered at the right time?

Two individuals, including the one who will administer the medication will verify the medication both visually and verbally

When your assessment indicates a Braden score of 12 or less, there are certain consults that are generated automatically. To whom are the consults directed?

Wound Care and Nutritional Medicine

How do you take a telephone or verbal order?

Write it down and read it back

Do hospital policies address the prevention of the use of Restraint and Seclusion?

Yes, Memorial is committed to preventing, reducing and striving to eliminate the use of restraint and seclusion. Policy IV.06

Prior to a procedure, is there a History and Physical in the medical record?

Yes, The medical and Staff by-laws require a H&P prior to a procedure.

Are staff educated and assessed for competence in minimizing the use of restraint and seclusion?

Yes, competency for restraint is included in the annual skills review and includes preventive strategies and the use of alternatives to restraints.

Does staff use techniques such as redirecting the patient's focus or verbal de-escalation before employing employing restraints and seclusion?

Yes, guidelines state that alternative interventions should be attempted and fail before the use of restraints except in emergency situations. Alternative interventions are covered in training.

Do you assess each patient's learning needs and determine if they are affected by their culture? Religion? Language? Emotional state? Physical abilities? Motivation? Finances?

Yes, the nurses role in patient education states "The nursing assessment for the education needs of a patient must be performed by an RN using a step-wise approach and should include the patients ability to learn, cultural and religious factors." The admission interview provides additional information regarding specific needs of the patient.

Does the hospital collect data on the use of restraints and seclusion to monitor and improve it's performance?

Yes, the quality department manages this data and the information is reported to NLC meetings.

Are you required to use restraint or seclusion with adequate and appropriate clinical justification?

Yes, the reason needs to be included in the MD order, and the behavior that warrants the need for restraint must be documented.

How are you sure you are performing a treatment or giving a medication to the correct patient?

according to our policy we use two special identifiers to match a patient. At Memorial Hospital we use the patient's full name and date of birth.

What do you use to clean the optical surface of the pulse oximeter?

alcohol is used for the optical surface (where you put your finger) because other cleaners can degrade this area according to the IFU instructions for use.

How do you report an emergency off campus and the South Campus?

dial 9 and then 911 this information is on you badge

What is a sentinel event?

is a patient safety event that results in death, permanent harm, or severe temporary harm.

What are the three types of indicators used to monitor sterilization parameters?

mechanical or physical indicators, chemical indicators, and biological indicators. All three parameters serve a purpose in quality monitoring of the sterilization process.

Is is the policy of Memorial Hospital to _________the use of verbal or telephone orders.

minimize

What can be kept under the sink in patient care areas?

nothing

When can oxygen be administered with out an order?

only in an emergency and a provider order is required as a follow up

What is a code 6?

person is awak but emergency assistance is needed.

What is seclusion?

seclusion is the involuntary confinement of a person alone in a room or an area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self destructive behavior according to our policy.

What do the lights mean on the Medline Intelligent warmer?(wipe warmer) How do you access the IFU or instructions for use?

solid red LED- packs have not yet reached the required temperature Solid Green LED- Packs have reached the the required temperature Green LED Flashes- Pack has been in the warmer for 84 hours. Use first Red LED Flashes- Packs in warmer have been in there longer than 250 hours and should be discarded. One Source is a website that you can obtain the IFU from.

How are oxygen tanks stored?

tanks are segregated as full, partial and empty. This is to ensure that you can grab a full tank in an emergency. anything having 500 or less on the gauage is considered empty- make sure that if they are kept in racks in your department that signs are present on each rack .

What is meant by the flow of instruments or devices? and in which direction should this occur?

this pertains to the cleaning of instruments, the flow is always from dirty to clean with no risk of cross contamination.

What are some examples of a sentinel event?

unexpected death, abduction of an infant, rape while in the facility, hemolytic transfusion reaction, surgery on the wrong body part or patient. And many many more.

When do you initially assess for pain?

upon admission or transfer to the unit, return from a procedure involving sedation/anesthesia, or a change in the patient's condition.

When should you empty a sharps container?

when it is 3/4 full or when it is filled to the line

How soon should a critical result be reported to a provider?

within 1 Hour

Do you assess each patient's learning needs and determine how they are effected by culture? Religion? Language? Emotional sstae? Physical abilities? (blind,deaf) Motivation ? Finances?

yes, the nurses role in patient education states " The nursing assessment for education needs of a patient must be performed using a step-wise approach and should include the patient's ability to learn ,cultural and religious factors". The admission interview provides additional information regarding specific needs of the patient.