66033468 booklet kfh final

Kingdom of Saudi ArabiaMinistry of Health

King Fahd Hospital JeddahTotal Quality Management

الـممـلكـة العـربـيـة الـسـعـوديـة

وزارة الصحــةمـسـتـشـفـى الـمـلـك فـهـد بـجـدة

إدارة الـجــودة الـشــامـلـــة

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KING FAHD HOSPITAL, JEDDAH

JCI FAQs(Frequently Asked Questions)

Are you ready for the survey?






About this booklet…

The information in this booklet covers some of the hospital-wide responsibilities. This is what EVERY person who serves at King Fahd Hospital – KFH MUST know minimum to provide the best possible care to all we serve.

• Check with your supervisor about your department-specific and position specific responsibilities.

Goal & ObjectivesGoal: To ensure the best patient outcomes, our JCI Team will…

1. lead the education effort to arm our KFH staff with the knowledge and skills necessary to provide safe, effective, high-quality compassionate care that meets or exceeds standards of care (Excellence, Compassion, Quality)

2. Coordinate the execution of education and communication strategies that will shift our work ethic to a culture of best practice and continual survey readiness (Integrity, Performance, Reverence).

Through this process we will recognize the inherent dignity and worth of all, demonstrate our unity and shared purpose, and develop confident, well-informed, empowered staff who live our core values and manifest our strategic goals of Investing in Excellence: Growth through People, Quality and Performance.Objectives: By survey time…

1. Staff will translate increased cognitive knowledge into practiced behavior that demonstrates consistent compliance with JCI standards, as evidenced by already existing and utilized metrics.

2. Staff will understand the TRACER methodology process and the frontline staff’s role in it, as evidenced by staff participation in survey preparation strategies.

3. Staff will demonstrate successful responses to JCI surveyor TRACER questions.

4. Staff will understand the high priority/frequently asked survey questions and successfully articulate how their job activities relate to them.

5. Staff will recognize the imperative of “continual readiness” and its relationship to both clinical and service excellence on an on-going basis, as evidenced by:

o TRACER participation o Observed practice of patient safetyo Communication excellence, including, but not limited to:

Legibility Use of approved abbreviations Proper patient identification practice Verification of procedure sites Information and best practice sharing across disciplines Articulation of how the International Patient Safety Goals (IPSGs) relate to their

individual jobs.

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About this booklet ……………………………………………………………………1

Goal & Objectives ……………………………………………………………………1

About this survey …………………………………………………………………….3

IPSGs-International Patient Safety Goals ……….............................................. 6

Patient Focused Functions

Access and Continuity of Care – ACC ……….............................................. 10

Patient and Family Rights – PFR ……………………………………………… 12

Assessment of Patient – AOP …………………………………………………. 13

Care of Patient – COP …………………………………………………………. 14

Anesthesia and Surgical Care – ASC ………………………………………… 16

Medication Management and Use – MMU …………………………………… 18

Patient and Family Education – PFE …………………………………………. 20

Organization Function

Quality Improvement and Patient Safety – QPS …...……………………….. 21

Prevention and Control of Infections – PCI ….............................................. 22

Governance, Leadership, and Direction – GLD ……………………………... 24

Facility Management and Safety – FMS ……………………………………… 26

Staff Qualifications and Education – SQE ……………………………………. 29

Management of Communication and Information – MCI …………………… 30

Useful Terms for JCI ………………………………............................................ 32

Survey

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Table of Contents






Q.1: What is JCI Accreditation?

The Joint Commission International is a private organization that measures our performance in many areas against a set of standards requirements designed to improve quality of care. Being “JCI Accredited” means KFH has met or exceeded JCI’s minimum standards.

Q.2: What do the surveyors want to know?They want to know what you do and how you do it.

Q.3: What are the surveyors looking to find?• System disconnects: how well do our systems work and our processes function?• Communication inconsistencies• Differences in levels of care

Q.4: How will this survey be different from previous surveys?This survey will be UNLIKE any survey you’ve ever seen before:

1. It’s an “open book test.”2. Surveyors will do unit-based “Tracers” and very few interview/meetings (see the next question).3. Surveyors will come to YOU directly, the direct patient care staff, and ask you about the care you’re giving.

Q.5: What is a “tracer?” What is “Tracer Methodology?”“Tracer Methodology” is the new way JCI surveyors conduct a survey. It’s a whole new survey process: the surveyors will select a patient (probably a complicated case) and literally trace that patient’s course of care and service from department to department, through the entire hospital.

Q.6: What other kinds of “tracers” will the surveyors do?There are two main types: patient-focused and systems-focused.

Tracers to expect:• Tracer visits in pt. care• Medication management tracers• System tracers• Infection control system tracers• Data system tracers

Q.7: What will the patient care tracers focus on?1. Initial assessments2. Histories & physicals3. Documentation4. Policies & procedures5. Observation of actual patient care6. The integrated plan of care7. International Patient Safety Goals (IPSGs)8. Pain management9. Medication management10. Anesthesia and sedation11. Universal Protocol (time outs)

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Q.8: With such an unpredictable survey process, how can we effectively prepare?We’re doing a lot of practice tracers: patient care, infection control, etc. Treat these like the real deal.Be ready for it, like you’re playing first base—be on your toes and expect the ball (the surveyors) to come to you…because it will.

Q.9: What are the three key things all staff need to be ready to do?---------------------------------------------------------------------------------------------------------------------1. Alert & Notify TELL management and staff the surveyor is here!---------------------------------------------------------------------------------------------------------------------2. Right Person/ Get the right person in front of the surveyor.Right Response • ROLE: S/he may try to “trick” you: s/he might ask a nurse about a patient

medication who is not assigned to that nurse. Tell her/him, “I’m not the person to address this—it’s the Primary RN’s role to manage medications for that patient. Would you like to speak with her/him?”

• STAFFING: Free up the people the surveyor wants to talk to—cover and reassign, quickly.

---------------------------------------------------------------------------------------------------------------------3. Information Facilitate FAST and ACCURATE information retrieval: medical record, Access computer.---------------------------------------------------------------------------------------------------------------------Q.10: What is MY role during the JCI survey?

1. You must wear your KFH photo ID, photo facing out, as always.2. Respond confidently to any question a JCI surveyor may ask you. This booklet will help you

prepare…not only for the survey, but to provide the best care at all times.

Q.11: What is the surveyor most likely going to ask me?• How you in your job support KFHJ’s mission• How you in your job ensure patient safety and support the International Patient Safety Goals• Your unit’s role in performance improvement• How you support and ensure our Patients’ Rights• How you were oriented and deemed competent to your job

Q.12: How should I act if a surveyor questions me?� Be confident, be well-informed, be empowered!� Ask the surveyor to rephrase the question if you’re unclear.� Be honest—if you don’t know the answer, tell the surveyor that you know where to find that info:

“I would rather talk with my supervisor or check the policy…”� Be kind and professional: don’t blame others or other depts.� Keep your work areas clean and organized.

Q.13: What should I say if a surveyor questions me and I work in direct patient care?Here’s what happens: the surveyor pulls the record on a current patient and starts asking questions. If you’re that patient’s RN, start by giving a report. That will brief the surveyor on the patient.

Remember: they want to know what you’re doing and how you’re doing it!

Q.14: What if the surveyor wants to talk to my patient or his/her family?This is OK—it does not violate any confidentiality or privacy regulations as this is part of the Patient Tracer.

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However—you are the caregiver and you know the patient’s condition! You can say, “It’s a bad time to visit this patient—s/he’s resting after a difficult night.”

Q.15: What happens when the survey is over?We will maintain our high level of survey readiness because we are committed to providing the safest possible patient care to help ensure the best possible patient outcomes.Education tools will continue to circulate to support our cultural shift to one of continual survey readiness. Remember! Be prepared!

IPSG – International Patient Safety Goals

Q.16: Who is responsible for Patient Safety?Each of us is!The Patient Safety Program is managed by the Quality Management and Patient Safety Committee (chaired by the CEO, Hospital Director), TQM Director (Mrs. Majdah Shugdar-2643,2641).

Q.17: What are the 2010 International Patient Safety Goals?• Goal 1: Identify Patients Correctly

Use 2 patient identifiers (Full name, Medical Record Number-MRN)

• Goal 2: Improve Effective Communication Write down the complete verbal/phone orders and /or critical test results. Read it back to the ordering person in front of another nurse for confirmation. Confirm that what has been written down and read back is accurate. 2 nurses should sign the verbal / telephone orders. Get the signature of the ordering person within 24 hrs. Report critical test results immediately to appropriate caregiver.

• Goal 3: Improve the Safety of High-Alert Medications All concentrated electrolytes are not allowed in patient care areas. Except, in some areas when

concentrated potassium chloride premixed is not available, it will follow a high secured procedure in handling and storing. Labeling all high risk meds with a red label “High-Alert“. Double check for all steps of dispensing such medications is performed by two pharmacists. The word "unit" must be spelled out in all orders for insulin and heparin. Dosages written in "U" or "u" are not accepted.

Prevent errors from look-alike/sound-alike (LASA) drugs by distributing and posting a list of LASA drug names in pharmacy, all outpatient clinics, and in-patient nursing units, to serve as a reminder for all health care providers.

All Narcotics and Controlled meds to be given only with a written order from a physician and not through telephone order.

• Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery. (also called Universal Protocol) By marking the surgical site, use a clearly understood mark and involve the patient in doing this. Verify the correct patient, site, and procedure before the procedure. Perform the complete documentation of preoperative checklist. Ensure that all relevant documents and images are available, properly labeled, and displayed.

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Verify any required special equipment and/or implants are present and correct and functioning properly before surgery begins.

Conduct a time-out in the location of the operation by the operative team immediately before the procedure.

• Goal 5: Reduce the Risk of Health Care–Associated Infections. Follow the infection control stander precaution

• Goal 6: Reduce the Risk of Patient Harm Resulting from Falls Evaluate the patients’ risk for falls in the initial assessment by evaluating fall history, medications review, gait and balance screening, and walking aids used by the patient.

Elevate the side rails of the bed. Put the bed in the lowest level. Put sign if the floor is wet for any reason Help the patient when he get up or moving out of the bed.

Q.18: As a patient care provider, when do I absolutely need to check the patient’s ID band?Check full name and MRN on the ID band at these times, every time, whether you know who the patient is or not:

• Admission to your unit/department from another unit/department• Medications given• Blood & blood products given• Specimens• Treatments (ex., physical therapy)• Diagnostic test or procedures (ex., radiology)• Operative or invasive procedures• Upon completion of transport, transfer, or discharge.• Upon death

Q.19: Is the patient ID goal important only for nursing staff?NO! The goal requires that everyone who provides treatment or conducts tests must practice patient ID with 2 identifiers (neither to be the pt’s room number). This includes lab, imaging, respiratory, and dietary.

Q.20: Why all the attention on hand hygiene? Aren’t we all washing our hands constantly?Even if we do, we have to remind ourselves of its importance to prevent the risk of nosocomial infections.

Q.21: So when do I have to perform hand hygiene?

� Waterless hand disinfectant or soap and water must be used…• When entering the patient’s room• When leaving the patient’s room• After caring for 1 patient in the room, then moving to care for the other patient in that same room (if applicable)• Before and after touching the patient if the patient is not in a room (ex., in a wheelchair or on a stretcher in Radiology)• After handling any equipment, dirty linens, or specimens

� You must use soap and water…• Before eating• After using the restroom• Any time hands are visibly soiled• After caring for a patient on specific precautions

• When you feel a significant buildup of the waterless hand product on your hands (there is no

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specified # of times you may use it)(For more info on hand hygiene, see Prevention and Control of Infections Policy.)

Q.22: What happens if there is an unanticipated death or major permanent loss of function associated with a healthcare associated infection?We treat it and manage it as a sentinel event.

Q.23: What exactly is a “sentinel event?”

Any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Sentinel Events are also incidents, but as a subset of incidents, they signal the need for immediate investigation.1. The first immediate is to ensure that the patient (if involved) receives immediate medical evaluation and intervention as appropriate.2. Second, is to secure any specimen’s, records, or other equipment related to the event.The entire policy and procedure can be found on the Intranet, and includes the immediate notification of the supervisor and the Risk Manager.

Q.24: What’s the #1 cause of sentinel events?Lack of communication. Communication is paramount!

Q.25: How does KFH investigate a sentinel event?We do a Root Cause Analysis (RCA). Staff involved in the care of the patient review what happened and what system problems may have caused the event by asking “why” until no other causes can be identified. This leads to changes and improvements in the identified process. Always done after a sentinel event.

Q.26: Why do I have to say that “I READ BACK verbal or telephone orders,” rather than say I repeat it back?It is a very important distinction. When you read back, you write it down and then read back what you’ve written. If you simply repeat what you heard, you may make an error when you finally do write it down. This is where many medical errors occur! That’s why this is one of the International Patientwhat you’ve written. If you simply repeat what you heard, you may make an error when you finally do write it down. This is where many medical errors occur! That’s why this is one of the International Patient Safety Goals. Consider it a script that you have to say to best manage others’ perceptions.

Q.27: Will memorizing the list of International Patient Safety Goals make your patients safer?No. Knowing what YOUR role is in keeping our patients safe is what matters. Be able to answer the next question…

Q.28: What do YOU do to maintain a safe environment or ensure patient safety?THINK! Have your answer ready. Here are examples:

• Patient Care: “I verify patient identification each time I provide patient care.” “I always wash or disinfect my hands and follow the standard precautions”

• Non-Patient Care: “I visually inspect equipment before I turn it on” (ex., computers).

“I store files, etc. no less than 18 inches from the ceiling to ensure the sprinklers will work effectively in case of fire.”

Check all the doors if they have signs on them.

Patient’s transferring items (ex. wheel chairs / stretchers) are working and moving smoothly.

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Q.29: What if the surveyor finds an instance where we didn’t comply with a particular International Patient Safety Goal?For that goal, we either comply or we don’t. We have no other option.So comply each and every time!!!

Q.30: What is KFH doing to prevent harm to patients?• Staff education on IPSGs.• Inspection of all areas to make sure they are safe for staff, patients, and visitors.

• Enforcing the implementation of Operating Procedures Standards and Regulations.• Standards Training & On-going Performance Evaluation• Provide education for patients and families.

Q.31: What five things have to be documented before a time out?1. Patient identification4. Marking of the site2. Procedure5. Availability of any implants3. Site

Q.32: What if the time out reveals a mistake?Stop the procedure until all is determined to be correct.

Q.33: How do you assign patients on your unit?Assignment is based on following:• Each staff member’s demonstrated competency with specific patient care practices.• The physical design of the unit (environment)• Patients’ ages, acuity levels, and personal abilities.

Q.34: How do you assure the patient has access to appropriate care settings and level of care?The level of care a patient needs is assessed upon admission and throughout the course of her/his stay. Various criteria are used to assess this.Staff work with supervisors to be sure patients are at the appropriate level of care. Many disciplines are involved: physicians, nurses, supervisors, etc.

Q.35: How are patients told about the need or reason for their transfer to another facility?The patient’s physician tells him/her.

Q.36: If a patient is transferred to another unit or service, what information (patient education) must be provided?

• The reason s/he is being transferred • Alternative to transfer, if any

Q.37: Who facilitates a transfer to another acute care facility?The physician who discussed the patient’s case and arranges for transfer with an accepting physician. KFH nursing staff also discusses the transfer with a receiving nurse. Ambulance transport is arranged by the KFH Nursing Supervisor after hours.

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ACC – Access and Continuity of Care






Q.38: When is discharge planning initiated?On admission in the assessment form by the Discharge Planner. All patients are continually RE-assessed (from the time the initial assessment is made, through Interdisciplinary Rounds, up until discharge) to determine their needs. To follow through with the actual discharge process, a referral is made to home health care, outside hospitals, or long term care.

Q.39: How is discharge planning handled?It begins upon initial assessment by all disciplines. The plan of care is developed as the patient progresses through the course of treatment and plans are revised as needed to transition the patient to the next level of care.

Discharge plans are discussed during Interdisciplinary Rounds to evaluate, prioritize, and implement the patient’s plans.

Q.40: How would a surveyor know that discharge planning has been continually addressed throughout the patient’s hospitalization?Through complete documentation:• On the Patient Admission History form• On the Plan of Care (initiated and continually revised during Interdisciplinary Rounds)• Daily notes on the chart

Q.41: What kinds of education are patients / families given at discharge?• Reason for discharge plus specific discharge instructions• Materials, such as videos, brochures, written instructions• Referrals to other services (such as Home health care of KFH or other hospitals, rehabilitation centers.• Arrangements that can be made with home health staff, support groups, rehabilitation services, etc.

PFR – Patient and Family Rights

Q.42: How does KFH obtain informed consent?The physician talks with the patient/family about risks, benefits, alternatives, and potential complications of the procedure requiring consent and has them sign the required consent form. This must happen in all patient care areas.

Q.43: How does KFH deal with pain management?Pain management is part of the patient’s Plan of Care. Patient care staff assess and routinely reassess each patient’s pain according to the standardized pain scale and intervene if needed.

Q.44: How do you manage complaints from patients, family members, or visitors? First, I try to resolve the concern by using HEART methodology. If the complaint is not �

resolved, thenI involve my supervisor. If still not resolved,�I call the Social worker ext.:�

Q.45: What is HEART methodology?It is a tool that can be used to handle difficult patient interactions.

H = Hear the patient

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E = EmpathizeA = ApologizeR = Respond to the problemT = Thank the patient for bringing this to your attention

Q.46: How are patients/family members asked about organ or tissue donation?Only SCOT (Saudi Center for Organ Transplantation) approaches the patient’s family. KFH policy requires that we call SCOT so they can handle the situation. Donation should not be discussed with the family until all healthcare team members are aware of the plan. This includes SCOT staff, the bedside RN, attending physician, etc.

Q.47: How do we identify patients with “Do Not Resuscitate” (DNR) orders?• If a DNR order has been determined for the patient, it will be found in a visible location in the patient’s chart.• It should be noted that the DNR is a physician’s decision and that the primary physician should be consulted in that regard.AO

AOP –Assessment of PatientP – Assessment of PatientQ.48: When must the admission assessment be completed?

• Medical Staff: admission history for all clinical disciplines is done immediately on arrival and to be recorded in chart within 24 hours of admission.

• Nursing : initial assessment is done on arrival and the full assessment is completed and recorded in patient chart within 24 hours of admission.

• Other disciplines: know your unit / department standards / Policies. Read Policy # KFH-AOP- Interdisciplinary Scope of AOP.

Q.49: Who may complete the nursing admission assessment?The Primary RN is the one who must complete the nursing assessment for patient on arrival.

Q.50: Just what is assessed during a patient’s “initial assessment?”• History of illness.• Physical status, including level of pain• Psychological status (including cognitive and communicative skills)• Social status (including values, beliefs, spiritual orientation)• Nutritional Status• Functional Status• Fall precaution.• Educational background• Discharge Planning Status (The need for discharge assistance)

Q.51: When is the patient reassessed?All patients will be reassessed formally by nursing staff every 12 hours and:• At regularly specified times based upon standards of care,• When a significant change occurs in the patient’s condition,• When a significant change occurs in the patient’s diagnosis,

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• Pre or post operation,• On transfer,• When there is change in the functional abilities, or• As determined by both physician order and the nurse’s professional judgment.

Q.52: How is a patient’s level of pain assessed?We use a pain scale appropriate to the patient’s age and cognitive development:• Numerical scale “0 – 10”• Happy – Sad faces

COP – Care of Patient

Q.53: What is your role in providing patient care?

Describe your job responsibilities and the role you play in patient care. If you are not a direct patient are giver, then provide information to the surveyor how your role may indirectly affect patient care.

Q.54: What is the purpose of the Interdisciplinary Plan of Care (Pathway)?

• To set individualized goals for the patient with the healthcare team• To identify problems impacting the patient’s progress through the continuum• To facilitate communication between patient / staff / physicians• To document patient’s progress / lack thereof• To identify needs for patient education• To identify needs for patient discharge

Q.55: How is the assessment data used?

It drives the care of the patient. We must individualize each patient’s plan of care according to the assessment results. Staff must refer the patient to the specialty s/he needs ex. staff must speak to that (individualize dietary orders, etc.)

Q.56: What is KFH’s philosophy on patient restraints?

KFH is committed to preventing the need for and reducing the use of physical restraints.

Q.57: What have you done to decrease the use of restraints?

• Alternative to restraints: keep eye on the patient, stay in the patient room, or having a family member or sitter stay with the patient.• Restrained patients are monitored regularly to see if the restraints can be removed.

Q.58: What new procedures have been implemented to help prevent falls and/or prevent injury when patients are at high risk of falling?

• Implementation of falls protocol• Low bed• Side rails up• Lock the bed/wheel chair• Wet floor sign.

Q.59: What lab tests does KFH perform on the unit?

If you work in patient care, you must know what and how many “Point Of Care Testing” (POCT) is done on your unit. Examples may include Blood glucose on "AccuChek Inform”.

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Q.60: How does KFH assess a staff member’s competency to perform the Point Of Care Tests?

Staff competency is done after full training from device company engineers. After the training the attendance sheet and competency reports are kept in nursing files. And copy of the training reports are in POC office (in lab).

Q.61: What are the quality control standards for Point Of Care Testing on your unit?Again, know your unit’s specific POCT information. Ex., blood glucose test are quality checked daily (once per 24 hours) prior to first use by using the high and low glucose control. Also it is checked in case of changing strips lot number.

Q.62: How do you collaborate / share info with other patient care providers and protect patient confidentiality?

• Verbally: Interdisciplinary Rounds, telephone, or endorsement report• Written: Referrals, discharge planning instructions

Q.63: Who approves Medical Staff Bylaws, Rules and Regulations?

KFH Medical Executive Committee

Q.64: How do you screen for referrals to Social Worker?

• We use the Initial Nursing Assessment Form to identify patient needs based on specific criteria.• During Interdisciplinary Rounds we continually evaluate, determine, and prioritize patient needs.

Q.65: How do you make referrals to a social worker? Using Social Referral Form. But in case of emergency, we call social worker then we complete the request.

Q.66: Who can make a referral to a dietitian?

Only physicians. This can happen at any time during the patient’s stay. A physician’s order is required.

Q.67: How do you determine that a dietitian referral is needed?

Patients are screened for nutritional risk based on specific criteria.High risk patients are referred for a complete assessment.

Q.68: Who can make a referral to Rehab Services?

Only physicians can order a physical or occupational therapy assessment.• All patients are screened for PT/OT needs during the patient admission process.• If necessary, the physician orders an evaluation prior to treatment.

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ASC- Anesthesia and Surgical Care

Q.69: What are the requirements for a patient to receive sedation?1. A documented history and physical prior to receiving Conscious Sedation.2. Patient assessment, will include but not limited to:

• NPO status,• Baseline vital signs (blood pressure, temperature, pulse, pain score),• Age,• Weight,• Airway status,• Current Meds,• Allergies to medications (with specific reference to sedatives, local anesthetics and contrast dyes, if applicable),• Patient’s medical and anesthetic history. Any previous experience with conscious sedation or Anesthesia,• Mental status,• Lab studies per hospital policy,• Any history of impaired cardiac, renal or hepatic function or other serious systemic disease (e.g., sickle

cell disease, diabetes),• Indications for the procedure requiring conscious sedation,• American Society of Anesthesiology (ASA) classification.

3. Informed consent for both the procedure and the sedation.

Q.70: What is required to monitor a patient during sedation?

Monitoring during sedation requires:• Constantly monitoring for at least the following:

1. Level of consciousness.2. Oxygen saturation.3. Temperature, pulse, blood pressure and respirations.4. Cardiac monitoring (when indicated).

• Documentation in the Sedation Flowsheet for Patient’s dosage tolerance and response to conscious sedation, change in patient response necessitates reassessment by nurse/physician and adjustment of dose as ordered by physician, and any untoward reactions.• Recovery criteria must be met, and all patients and families are given the Sedation Discharge Instructions sheet.

Q.71: What policies and procedures have been established to guide the care of those patients undergoing moderate or deep sedation, if used in the area?ORN-APP-045E (3) Conscious Sedation

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Q.72: What are the qualifications of the physician responsible for moderate or deep sedation?Conscious sedation can be administered only by Consultants whom are privileged to do so by the credentialing & privileging committee at KFHj.The privileges are granted by the committee based on:1. Review by the Consultants of the self study guide of conscious sedation.2. A score of 90% on the test provided by KFHj. Those Consultants who do not score 90% or better shall be asked to review the guide again and retake the test. 173. The Consultants assigned to conscious sedation areas demonstrate annual competency in the following requirements:

• Valid BCLS and ACLS Certification.• Successful completion of conscious sedation training program.

MMU –Medication Management and Use

Q.73: What do you do with medication brought in from home?

• Patient Own Medication is not allowed at KFH. We ask that meds be sent home with family members.• If the meds can’t be sent home, nursing staff send them to the pharmacy where they will be placed in a plastic bag labeled with patient addressograph and kept in the designated place away from the regular stock until the patient is discharged.• If one of the patient's medication must be used & is not available in the hospital, and there is no alternative:

A doctor must write an order for the patient to take his/her own meds with clearly stating “patient’s own medication”.

Nursing staff sends the meds to KFH pharmacy for verification. The pharmacist clearly and properly labels the meds and dispenses them in bulk to nursing unit. Nursing staff stores them and administers the doses as written in the order. All doses must be recorded in the Medication Administration Record (MAR).

Q.74: How do you know the Crash Cart will have what you need?

• Crash carts contain the necessary supplies for responses to Code Blue situations as approved by CPR Committee.• Code boxes inside the locked crash carts contain the emergency drugs and are locked with a white numbered lock and maintained by pharmacy staff.• Expiration dates of medications are identified prior to locking the cart (label at the outer side of the code box is placed with the first to expire drug name & expiration date.)• Crash carts are checked daily using the designated audit sheet by nurses.• The Code Box is maintained by the inpatient Pharmacy Services (replenishment and exchange of expired items).• Pharmacy is maintaining the records of all code boxes.• The Code Box is inspected at least once monthly by pharmacy staff in addition to any time the lock on the Code Box has been broken.• The crash cart, which contains a locked Code Box, is the responsibility of Nursing Services to maintain.

Q.75: What should you do if you have an order you cannot read, incomplete, or seemed inappropriate?

• Clarify with the prescribing physician through telephone operator, pager, or mobile.• Write clarification on an order sheet and read back to the prescribing physician.

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• Pharmacist should inform the Nurse in-Charge if the patient is admitted about the clarification or the patient him/her self, if outpatient.• A Notice of Medication Clarification & intervention should be filled and submitted with the dispensed medication to the nursing unit.

NOTE: Remember! When taking a verbal / telephone order, you MUST write the order onto an order sheet and read it back to the prescribing physician.

Q.76: Can you name a medication that is classified as “high risk” at KFHj?

The top 5 high alert medications are:1. Insulin,2. Heparin,3. Hypertonic Sodium Chloride,4. Concentrated potassium, and5. Narcotics.Other high alert medications are written in the pharmacy policy PH-APP High Alert Medications.

Q.77: What special precautions are taken when administering these medications?

1. Double checking by 2 RNs or 1 RN and 1 MD of labels and product content upon administration.2. Double checking of the infusion pumps settings for correct rate of infusion upon starting.3. Documentation of the double check in the Medication Administration Record (MAR).

Q.78: Describe how patient identification is done.Look for 2 identifiers – full patient name and Medical Record Number – on 2 different documents. E.g. compare the Patient ID Band with the Medical Record.

Q.79: How does the hospital differentiate look-alike / sound alike medications?1. The list of look-alike/sound-alike (LASA) drug names is posted in pharmacy, all outpatient clinics, and in-patient nursing units, to serve as a reminder for all health care providers.2. Physicians are requested to clearly specify the dosage form, drug strength, and complete directions on prescriptions, as requested by policy of medication order as these variables may help staff differentiate products.3. All LASA drugs are clearly identified in pharmacy dispensing areas, either by spacing or by color coding of similar products.4. For medications with more than one concentration, the highest concentration is marked with a fluorescent red label, to avoid mix-ups during dispensing.

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PFE: PATIENT AND FAMILY EDUCATION

Q.79: Who is responsible for patient and family education?All members of the health-care team, as well as patients and families, are responsible. The health-care team evaluates learning needs during the initial assessment that occurs at each patient visit and on admission. Using input from these assessments, an education plan is developed. The plan may be revised as subsequent assessments are made.Patients and families are responsible for following care instructions, asking questions about instructions they don’t understand, and expressing any concerns about their ability to follow the plan of care.

Q.80: What must be assessed prior to educating a patient?Each patient has individual learning needs that we must assess before we can effectively educate them. Learning needs/styles are influenced by things like:� Cultural and religious beliefs

� Language� Patient Age� Emotional barriers� Desire and motivation to learn� Physical or cognitive communication limitations / barriers

Q.81: What patient education is required?We teach each patient about his/her disease, plan of care, and treatment, but as per each patient requirement we should also include:• Basic health practices and safety• Safe and effective use of medications and equipment• Potential food-drug interactions• Nutrition and dietary needs• Risk, assessment, importance of and ways to manage pain.• Referral options and available services in the hospital• Available community resources if needed• Rehabilitation techniques to improve life style

Q.82: After identifying the patient’s learning needs, what must be done?• Coordinate with other disciplines.• Content is presented in an understandable way.• Use different teaching methods.• Evaluate comprehension and get the feedback from the patient and his/her family.

Q.83: How do you document patient and family education?By using the Multidisciplinary Patient and Family Education Documentation Record.

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It is essential to document your assessment, interventions and the outcomes of education. This promotes clear communication, coordination of care and successful transition to home and community. Documentation includes not only the assessment and interventions but also the family’s level of understanding and ongoing learning needs.QQ.84: Who is responsible for KFHJ’s quality of care?All Staff !!!

Q.85: Who prioritizes the performance improvement needs of the medical center?Quality Management and Patient Safety Committee (QMPSC).

Q.86: How is the prioritization of performance improvement projects done?Based on:1. High Risk2. High Volume3. Problem Prone4. Cost Effectiveness5. Newness of the Service6. Results form the PI Process7. Effects on Patient and Family Satisfaction.8. Effects on Staff Satisfaction9. Effects on Patient and Family Rights.10. Requirements of Governmental Laws and Regulations.

Q.87: What is the PI process KFH follows?

FOCUS PDCA• Find an opportunity for improvement • Plan the action for improvement• Organize a team • Do the action for improvement• Clarify the current process • Check the results• Understand the resources of the problem and the process variation

• Act to hold the gain and monitor the improvement

• Select an action for improvement(You will find more details in the policy # KFH-TQM-009(2) Initiating a PI Project)

Q.88: What PI activities have YOU been involved in?Prepare and know your answers. Have an example from your department / unit and for the hospital. Ask your supervisor if you don’t know.

Q.89: What is YOUR role in PI activities?Examples can include:• How you have been involved in improving patient satisfactions• Your role and understanding about Core Measures • Your participation in a departmental PI team

PCI

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– Pre–– vention and Control of Infections

PCI – Prevention and Control of Infections

Q.91: What is THE best way to prevent the spread of germs and infections?Proper hand washing or hand disinfection

Q.92: Do stored linens need to be covered?YES, to minimize contamination from contact with soiled surfaces or exposure to airborne germs.

Q.93: As an employee, how do you protect yourself from blood borne pathogens?1. Practice “standard precautions:” protect yourself from anything wet on a patient.2. Wear personal protective equipment (PPE) as needed, properly, and consistently.3. Use safe work practices and safe needle devices.

Q.94: What personal protective equipment is available?

gloves masks goggles face shields

surgical caps gowns booties N95 respirators

� They must be removed before you leave your work area.� The only exception is when transporting a specimen or a patient in isolation!

Q.95: What transmission-based isolation precautions are taken at KFH?• Contact Precautions (ex., MRSA, ESBL, VRE)• Droplet Precautions (ex., bacterial meningitis & Influenza)• Airborne Precautions (ex., PTB, Measles, SARS, Chickenpox, & Bird Flu)• Reverse Precautions (Immunocompromized patients)

Q.96: What “signage” do you use to indicate isolation precautions?• Color-coded sign indicating the type of isolation precautions:Contact Precautions - GreenDroplet Precautions - PinkAirborne Precautions - BlueReverse Precautions - White (Follow the Infection Control Guidelines and P&Ps)

Q.97: What must be thrown away in sharps containers?• Anything sharp, and…• Anything potentially sharp if it has been contaminated with blood and/or body cavity fluids.

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Q.98: What unit-based performance improvement data related to Infection Control does your unit monitor?Examples:• Handwashing / hand hygiene compliance• Hospital-associated MRSA or VRE rates• Surgical site infection rates

Q.99: What procedure do you follow for bloodborne pathogen exposures (sharps, needle stick, or splash)?1. Wash the wound or exposed area with soap and water.2. Flush splashes to nose, mouth or skin with water.3. Irrigate eyes with water, saline or sterile irrigants for 10 minutes.4. Report incident immediately to your supervisor and Infection Control Department, and fill an OVR.5. Go to Staff Health Clinic (or, after hours, go to the Emergency Department) for post exposure evaluation and treatment.

Q.100: How do you handle waste disposal?1. Nurses put the waste in bags according to the waste type and leave them for housekeeping collection:

• Regular: Black or White bag.• Medical Waste (infectious): Yellow biohazard bag.• Sharp container: Placed in yellow biohazard bag.• Human Tissues: Red biohazard bag.

2. Housekeepers collect the bags from the units and transport them to waste collection area contained in covered trolleys and Human Tissues are transported to morgue.

GLD- Governance, Leadership, and Direction

Q.101: What are KFHJ’s values?

• Excellence: Exceeding expectations. Honesty : Fostering sincerity in service Perfection : Precision in delivering service Integrity: Reliability

Q.102: What is KFHJ mission: Provide unique specialized health care to our patients through safe and healthy practices. Q.103: How do YOU contribute to KFHJ’s mission?Be honest. Tell them how great you are. Tell that surveyor how hard you work for our patients, their families, and each other as co-workers. Say:“I deliver safe care by _____ ” -or-“I deliver quality care by ____”

Q.104: What document describes the type of care or services offered by a department?Scope of Service

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Q.105: What are some ways that management and staff gather information and share it with each other?• E-mail • Unit / Department Meetings• Bulletin Board • Hospital Committees• KFH Publications • Staff Forum• Reports • Ideas bank• Rounds • Telephone

Q.106: What does KFHJ do to facilitate the communication of information?Examples include:• All staff and physicians have KFH outlook e-mail and telephone line.• Multidisciplinary committees and Teams (Quality Management and Patient Safety Committee, Medical Record Review Committee, Patient and Family Education Team, etc).• Hospital Director-Staff Forum every three months

Q.107: Does KFHJ have a system or process related to organizational ethics / maintaining ethical business practices?Yes. The Hospital has TQM-APP- Code of Conduct and Ethics for all hospital staff to follow, otherwise the staff are referred to Medical Ethics Office.

Q.108: Do you know how many hospital wide committees do you have in KFH and what they are?

s Titles Chairman/Team Leader1. Blood Utilization Review Dr. A. Qadi2. CPR Dr. Mohd Rajab3. Credentialing & Privileging Dr. Salem Basalama4. Hospital Executive Dr. Salem Basalama5. Hospital Morbidity & Mortality Dr. Sami Bukhari6. Infection Control Dr. Mohamed Abbas7. Medical Executive Dr. Salem Basalama8. Medical Records Review Dr. A. Qadi9. Pharmaceutical & Therapeutic (P&T) Dr. Tawfik Al-Bassam10. Quality Management Council Dr. Salem Basalama11. Operating Room & Tissue Committee Dr. Salem Basalama12. Facility Management & Hospital Safety Dr. Adnan Sabbahi13. Quality Council Dr. Salem Basalama 14. Patient Safety Dr. Salem Basalama

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FMS – Facility Management and Safety

Q.109: Where is the KFH Emergency Management Plan?We have the external and internal emergency preparedness plans available in the Safety manual and KFH intranet.

Q.110: What is the KFH Emergency Management Plan?All staff must know:• Your specific role in any emergency, based on your dept/unit and your particular position• How to do it: know information and skills needed to effectively respond to any emergency• How KFH shares communication during emergencies (cell phones, bravo phones, emergency call tree, PA (public address system, etc.)• How to get supplies / equipment during an emergency (the normal way, call the Command Center, etc.)

Q.111: How do you contact Security?Call ext. 6868 and 6888, 24 hours a day, 7 days a week.

Q.112: What are the “codes” to signal an emergency and what numbers do you call to report one?

Code Definition Ext

Red Fire / Internal Disaster

1111

Blue

CPR or a Medical Emergency:(adult, child, infant) in the Main Hospital / Administrative Building

Mr. Strong

Violence Control

OrangMajor Spills (chemical, biological, and radiological)

PinkInfant or Child Abduction

WhiteBomb Threat

YellowExternal Disaster (called by the Command Center)

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Q.113: What do you do if you find a fire?Practice RACE!• Rescue anyone in immediate danger.• Activate the fire alarm (pull station and call ext. 1111)• Confine the fire (close doors, windows).• Evacuate (extinguish if trained by using the PASS procedure).(Remember to evacuate horizontally to the next unit, then down steps if necessary.)

Q.114: Where do you get information about hazardous substances used in YOUR work area?• MSDS (Material Safety Data Sheets) available in 2 ways:- Online via the KFH intranet (under Services Tab)- Manuals (know where YOUR dept. keeps them!)• Labels (in lab & housekeeping)• Training — General and department orientation

Q.115: What does an MSDS tell you?

• What hazardous substances I may use in my work area• How to store the material, handle it, and safe use for it• How they can harm me• How to protect myself from the substances (ex., what personal protective equipment to wear while using the stuff)• Emergency First Aid• Spill Clean upEach unit must have a hard copy of the one utilized in there area.

Q.116: Who is permitted to shut off the oxygen zone valve in your unit?

Basically the treating nurse, treating physician, respiratory therapist, the hospital safety officer, biomedical, and gas technician.Read the instructions posted at the valve site.

Q.117: What do you do with broken or expired medical equipment?

Call Bio-Med for service. Then the assigned engineer will come and tag it with a “defective – don’t use” sticker.

Q.118: Where can someone smoke on the KFH campus?

Staff, patients, and visitors are not allowed to smoke inside KFH hospital and may do only in one designated place located in the basement near the west gate.

Q.119: What MUST you be able to locate in YOUR work area?

• Pull stations• Fire extinguishers• Red emergency power outlets (if applicable)• Emergency Evacuation Plan• Assembly points• Fire exit way• Manuals: Safety, MSDS, Infection Control• Personal Protective Equipment (if applicable).(Again, there is intranet access to the Safety policies, MSDS inventory, and Infection Control policies.)

Q.120: When to activate Code orange?

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• If the spill is hazardous, radioactive, too big (more than 100 cc), dangerous to handle, or some one is injured, then call 1111 and restrict access to area.• But if it is a minor spill, then control access to area and use Material Safety Data Sheets (MSDS) as you have been trained. Proceed with department cleanup procedures, using personal protective equipment (PPE).

Q.121: What should you do in case of code pink?

• If a baby/child lost in your area please announce the code Pink by shouting in your unit and activate the code pink by calling ext number 1111.• Secure all entrances and exits of your area don't allow any one to enter or exit to your area.• Make an inspection round in the area.• Report to security on ext 1111 about any suspicious person that you’ve seen.• Assist safety and security personnel by all means when requested to do so.

Q.122: What to do if faced with a Bomb threat?

By Telephone• Keep the caller on the line as long as possible, recording every word spoken by the person.• Ask the caller to repeat the message to get more information such as location of bomb and time of possible detonation, etc.• Advise the caller that many innocent people may suffer seriously if a bomb is detonated.• Call Safety & Security Control Room tel. 1111 and give your Name, ID No., extension No. and clear information about threat.• Proceed to the Command Center and complete “Bomb Threat Report”.

By Mail• Read message being received carefully, do not handle more than necessary, and try to avoid or add your fingerprints.• Immediately place the page(s) and envelope between pieces of blank paper.• Call Safety & Security Control Room tel. 1111 and give your name, ID No., extension No. and clear information about threat.• Proceed to the Command Center and complete “Bomb Threat Report”.

Suspicious Package:

• If a package is received or found notify the Safety & Security Department.• Do no handle package and clear the area immediately.• Keep the area clear until safety & security and/or “Bomb Squad arrive for inspection.

Q.123: What should you do in case of Mr. Strong code?

• When you have a case of a violent aggressive person you need to inform your immediate supervisor.• Your area immediate supervisor shall handle the case and he is the authorized person to announce the Mr. Strong code.• We have a special team for incidents of violence when occurs the security ext# 1111

* Information to remember during emergency codes:• Do not panic – keep calm.• Do not give any information to anyone other than those in charge.• Make sure that the required policies and forms for the emergency codes are available in your Department.• Our emergency command center in the KFH is The Safety and Security Command center located at the ground floor next to the religious affairs office, complaint office, and the main auditorium.

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SQ.125: How were you oriented to your job?Surveyors love to ask this. You know the answer: tell them, with all the details!

• RNs might say: “I attended General Hospital Orientation (GHO) for 2 days, and then I attended General Nursing Orientation (GNO) for 2 weeks. Then I took assessment to allow my preceptor and Clinical Educator to customize my orientation. Then I oriented on my unit by shadowing another RN for 2 weeks until everyone confirmed that I was competent to perform my duties independently.”

• Staff in business areas might say, “I attended General Hospital Orientation (GHO) for 2 days, then my supervisor met with me and oriented me to my physical work area, department policies and procedures. My orientation period lasted 90 days. Then I had my initial performance appraisal and my probationary period officially ended.”

Q.126: Does KFH have a process to evaluate and maintain staff competence on an on-going basis?YES. With RNs, they are initially assessed upon hire.For all staff, we assess competence on an on-going basis through:• Verification of current licensure/certification (where applicable)• The initial staff orientation process• Job descriptions and Competency Assessments• Probationary period performance evaluation after 3 months of hiring.• Annual Performance Evaluation• Employee handbook• Various on going training and education opportunities specifically by relevant departments and generally by Institutional Advancement, e.g. CPHQ, English Language Training.

MCI –Management of Communication and Information

Q.127: Which patients can you access information about?Only patients you are caring for (for example, on your unit). Follow these important rules:• Only access patient information on a “need to know” basis.• Access only the “minimum” amount of information you need to do your job.

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SQE – Staff Qualification






Q.128: Who can make entries in the medical record?Only those individuals permitted by medical staff bylaws, rules and regulations, these include but are not limited to:Physicians, dentists, nurses, physical therapists, social workers, respiratory therapists, nutritionists, speech pathologists, audiologists, psychologists, optometric, pharmacists, radiologists, admission clerks, paramedics, ophthalmic assistants, dental hygienists, radiology technicians, cardiovascular technologists, home care providers.

Q.129: What does KFHJ consider “sensitive” or “confidential” information?• Anything that has patient Information and/or health information”.• Health Information = any information- document created, maintained or received by KFHJ about a person’s physical or mental health or condition, the provision or care to a person, or payment for such care. It also includes personal identifying information, such as names, addresses, ID #’s, phone #’s, facial photos, e-mail addresses, etc.• Health information includes information in paper, verbal, audio, video, electronic or computer generated form.• Any KFHJ “proprietary information,” such as budget information, renovation or expansion plans, etc.

Q.130: How do I dispose of KFHJ sensitive or confidential information?

All proprietary information, paper, patient labels, arm bands, etc. with patient information or health information must be placed in the shred bins.

Q.131: How are you protecting Patient privacy?

At KFH we are all responsible for managing information so that patient privacy is protected. Here are ways you can protect patient privacy:

DO:• Conduct conversations with or about patients as privately as possible. Avoid hallway, elevator and cafeteria conversations.• Keep patient lists and medical records in a secure location. If a patient or appointment list, medical record or chart is on a desk, make sure it is out of the view of others (under a cover sheet, in a notebook, etc.).• Provide information on a need-to-know basis only.• • Report privacy concerns by talking to your supervisor.• Seek out only the information you need to know to do your job.• Know how to help patients and families with their privacy rights.• Lock or log off a workstation each time you leave it.

DO NOT:• Share your password or use anyone else’s.• Surf computer systems or scan paper records for information you don’t need to know.• Answer questions or talk about a patient without consent from the patient/family.• Access KFHJ health information, or anyone’s PHI, that is not required to perform your job.

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Useful Terms for JCIUseful Terms for JCIAbuseIntentional maltreatment of a patient which may cause injury, either physical or psychological.

ACCAccess and Continuity of Care chapter in JCI standards manual

AccreditationDetermination by the Joint Commission's accrediting body that an eligible health care organization complies with applicable JCI standards.

Acquired infectionRefers to an infection acquired while receiving care, treatment, and services in a health care organization.

ADEAdverse Drug Event for definition (see adverse drug event)

ADRAdverse Drug Reaction for definition (see adverse drug reaction)

Adverse Drug EventA patient injury resulting from a medication. (Pharmacological reaction to a normal dose or from a preventable adverse reaction resulting from an error).

Adverse Drug ReactionUnintended, undesirable, or unexpected effects of a prescribed medication.

AdvocateA person who represents the rights and interests of another individual.

AnesthesiaThe administration of medication to a patient to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure.

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AOP Assessment of Patient chapter in JCI standards manualASCAnesthesia and Surgical Care Chapter in JCI standards manual

BiologicalsMedicines made from living organisms and their products including serums, vaccines, antigens, and antitoxins.

Blood componentA fraction of separated whole blood (red blood cells, plasma, platelets and granulocytes).

Blood borne PathogensAny microorganism, virus, or other substance causing disease which is transmitted by the blood.

CDCCenters for Disease Control and Prevention

Code BlueCardiac Arrest. In case of Code Blue - Call 1111

Code Mr. StrongAggression. This code is used to summon assistance when it is -or may be- necessary to manage a potential assailant. In case of Mr. Strong – Call 4444

Code OrangeChemical / biological / radiological Spills, in case of Code Orange – Call 2121

Code PinkChilde Abduction. In case of Code Pink – Call 9999

Code RedFire (Internal Disaster). In case of Code Red – Call 3333 (see PASS and RACE definitions)

Code WhiteThis code is used when there is a (Bomb Threat) situation. In case of Code White – Call 4444

Code YellowExternal Disaster. In case of Code Yellow – Call 3333

Common CausesInherent in a process overtime. Cannot be avoided but can be improved. (see variation and special causes definitions)

Conscious sedationSee also moderate sedation. is the use of medication to minimally depress the level of consciousness while allowing the patient to continuously and independently (1) maintain a patent airway and (2) appropriately respond to verbal command and/or gentle stimulation.

ContinuityThe degree to which the care, treatment, and services of patients is coordinated among practitioners, among organizations, and over time.

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Continuum of careMatching the patients’ ongoing needs with appropriate level of care, treatment, and services with or across multiple organizations.

Controlled MedicationInclude a variety of psychotropic and other locally restricted agents by the Saudi MOH. Such drugs are identified by (C) in KFH Formulary.

COPCare of Patient Chapter in JCI standards manual

Deep sedationAlso called Monitored Anesthesia Care (MAC), is the use of medication to induce a state of depressed consciousness or a state of unconsciousness in which the patient may experience partial or complete loss of protective reflexes including the ability to continuously and independently maintain a patent airway. The deeply sedated patient may not appropriately respond to verbal or gentle stimulation. *This form of sedation may be administered by anesthesiologist only.

DietarySee nutrition therapy

DieteticSee nutrition therapy

Disaster planA written document describing the process of managing a natural disaster or other emergency that could possibly disrupt the hospitals ability to provide care.

DischargeThe point at which a patient's active involvement with the hospital is terminated and the hospital no longer maintains active responsibility for the care of the patient.

DisinfectionEliminating virtually all recognized pathogenic microorganisms but not necessarily all microbial forms on inanimate objects.

DNRDo Not Resuscitate

DPUDay Procedure Unit

EMDEmergency Medicine Department

Endemic infectionA level or presence of an agent or disease in a defined population during a defined period.

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Enteral nutritionNutrition provided via the GI tract. Routes of nutrition delivery include oral and tubal/catheter.

Epidemic infectionA higher than expected level of infection by a common agent in a defined population during a defined period.

ERGEmergency Response Group

FMEAFailure Mode and Effects Analysis (A proactive risk assessment)

FMSFacility Management and Safety Chapter in JCI standards manual

FormularyA list of medications and associated information about medication use.

General anesthesiaConsists of anesthesia and spinal or major regional anesthesia. It is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.

GLDGovernance, Leadership, and Direction chapter in JCI standards manual

HECHospital Executive Committee

H&PHistory and Physical

ICInfection Control

ICDInternational Classification of Diseases.

InfectionThe transmission of a pathogenic micro-organism to a host, with subsequent invasion and multiplication, with or without resulting symptoms of disease.

Informed consentAn interaction with a patient and physician in which the patient has the opportunity to accept or reject medical , surgical, and allied health interventions and services in an informed and voluntary manner.

InterdisciplinaryCommunication; discussion; planning; evaluation; and care, treatment, and service activities that occur formally and informally between team members who are representatives of multiple disciplines.

Invasive procedure

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A procedure involving puncture or incision of the skin or insertion of an instrument or foreign material into the body.

IPSGsInternational Patient Safety Goals

ITDInformation Technology Department

IV admixtureMixing of ingredients to prepare a medication for patient use.

JCIThe Joint Commission International for Accreditation of International Healthcare Organizations

JCRJoint Commission Resources

Life Safety CodeA set of standards for the construction and operation of buildings intended to provide a reasonable degree of safety to life during fires.

MalpracticeImproper or unethical conduct or unreasonable lack of skills by a holder of a professional or official position; often applied to physicians, dentists, or nurses to denote negligent or unskillful performance of duties when professional skills are obligatory.

MCIManagement of Communication and Information chapter in JCI standards manual

MECMedical Executive Committee

MIDMedical Imaging Department

MMUThe Medication Management and Use chapter in the JCI standards manual

Moderate sedationSee conscious sedation

MRMedical Record

MSDSMaterial Safety Data Sheets list detailed information about the hazards of a chemical and how to use it safely. Chemical suppliers provide the sheets to users of the chemicals, which are in turn made available to the employees.

MultidisciplinaryA group composed of representatives of a range of professions, disciplines, or service teams.

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NarcoticAgents which are classified and included in the list of such agents compiled by the World Health Organization (WHO) and identified by the letter (N) in KFH Formulary.

Near missAny process or variation that did not affect an outcome, but for which a recurrence carries a significant chance of serious adverse outcome.

Nosocomial InfectionInfections acquired from hospitals.

Nutrition therapySee also dietary or dietetic services. It is the delivery of service, care, and treatment pertaining to the provision of nutrition and food services to patients.

OccurrenceAny occurrence that is not consistent with the routine operation which happens at KFH premises and adversely affects or threatens the health or life of a patient, visitor, employee, trainee or volunteer or which involves loss or damage to personal or hospital property. Also include any event violates the KFH code of conduct or a claim against the hospital.

Occurrence Variance ReportAn internal form used to document the details of the unusual event, the investigation, and the corrective actions taken.

OTOccupational Therapy

OVROccurrence Variance Report

PACUPost Anesthesia Care Unit

Parenteral nutritionNutrients provided by an IV bypassing the digestive tract. (See also TPN) Total Parenteral Nutrition.

PASSIs an acronym explaining how to extinguish fire. Pull the pin, Aim the hose, Squeeze the handle, and Sweep to base of fire. (see RACE and Code Red Definition)

PCIPrevention and Control of Infections chapter in the JCI standards manual

Performance ImprovementA method for analyzing performance problems and setting up systems to ensure good performance.

PFEPatient and Family Education chapter in JCI standards manual

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PFRPatient and Family Rights chapter in JCI standards manual

PhoenixKFH’s computer system used to make appointments and provide and collect demographic information.

PIPerformance Improvement

POCTPoint of Care Testing

PrivacyA patient's right to limit the disclosure of personal information.

PTPhysical Therapy

QMPSCQuality Management and Patient Safety Committee

QPSQuality and Patient Safety chapter in JCI standards manual

RCARoot Cause Analysis

SOSScope of Service

Scope of servicesThe activities performed by managerial, clinical, or support staff/department.

SESentinel Event

Sentinel EventAn unexpected occurrence involving death or serious physical or psychosocial injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "the risk thereof" includes any process variation for which a recurrence would carry a significant change of serious adverse outcome.

Special CausesNot an inherent part of a process and arise because of special circumstances that can be avoided. (see variation and common causes definitions)

SQEStaff Qualifications and Education chapter in JCI standard manual

STSpeech Therapy

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STATAt once and immediately

TATTurn Around Time

TelemedicineThe use of medical information exchanged from one site to another via electronic communications for the purpose of improving the heath and education of the patient or the health care provider and for the purpose of improving patient care.

Total Parenteral Nutrition

Is the provision of IV nutrients solution which usually includes a source of protein, carbohydrates, electrolytes/ minerals, and vitamins in amounts sufficient to meet caloric and protein needs. Fat an trace elements can be included to in TPN regimen.

TPNTotal Parenteral Nutrition

TQMTotal Quality Management

TrendA generally consistent movement in the same direction over a long period in a time series.

VariationA change in data, characteristic, or function caused either by special causes or common causes. It represents the difference between an ideal and an actual situation. (see common causes and special causes definitions)

Prepared withA compassionate care and hope to get all the benefit from it

BYThe Family MembersOfTotal Quality Management Department

When I got home that night as my wife served dinner, I held her hand and said, I've got something to tell you. She sat down and ate quietly. Again I observed the hurt in her eyes.

Suddenly I didn't know how to open my mouth. But I had to let her know what I was thinking. I want a divorce. I raised the topic calmly.

She didn't seem to be annoyed by my words, instead she asked me softly, why?

I avoided her question. This made her angry. She threw away the chopsticks and shouted at me, you are not a man! That night, we didn't talk to each other. She was weeping. I knew she wanted to find out what had happened to our marriage. But I could hardly give her a satisfactory answer; she had lost my heart to Jane. I didn't love her anymore. I just pitied her!

With a deep sense of guilt, I drafted a divorce agreement which stated that she could own our house, our car, and 30% stake of my company.

She glanced at it and then tore it into pieces. The woman who had spent ten years of her life with me had become a stranger. I felt sorry for her wasted time, resources and energy but I could not take back what I had

34






said for I loved Jane so dearly. Finally she cried loudly in front of me, which was what I had expected to see. To me her cry was actually a kind of release. The idea of divorce which had obsessed me for several weeks seemed to be firmer and clearer now.

The next day, I came back home very late and found her writing something at the table. I didn't have supper but went straight to sleep and fell asleep very fast because I was tired after an eventful day with Jane.

When I woke up, she was still there at the table writing. I just did not care so I turned over and was asleep again.

In the morning she presented her divorce conditions: she didn't want anything from me, but needed a month's notice before the divorce. She requested that in that one month we both struggle to live as normal a life as possible. Her reasons were simple: our son had his exams in a month's time and she didn't want to disrupt him with our broken marriage.

This was agreeable to me. But she had something more, she asked me to recall how I had carried her into out bridal room on our wedding day.

She requested that every day for the month's duration I carry her out of our bedroom to the front door ever morning. I thought she was going crazy. Just to make our last days together bearable I accepted her odd request.

I told Jane about my wife's divorce conditions. . She laughed loudly and thought it was absurd. No matter what tricks she applies, she has to face the divorce, she said scornfully.

My wife and I hadn't had any body contact since my divorce intention was explicitly expressed. So when I carried her out on the first day, we both appeared clumsy. Our son clapped behind us, daddy is holding mommy in his arms. His words brought me a sense of pain. From the bedroom to the sitting room, then to the door, I walked over ten meters with her in my arms. She closed her eyes and said softly; don't tell our son about the divorce. I nodded, feeling somewhat upset. I put her down outsidethe door. She went to wait for the bus to work. I drove alone to the office.

On the second day, both of us acted much more easily. She leaned on my chest. I could smell the fragrance of her blouse. I realized that I hadn't looked at this woman carefully for a long time. I realized she was not young any more. There were fine wrinkles on her face, her hair was graying! Our marriage had taken its toll on her. For a minute I wondered what I had done to her.

On the fourth day, when I lifted her up, I felt a sense of intimacy returning. This was the woman who had given ten years of her life to me.

On the fifth and sixth day, I realized that our sense of intimacy was growing again. I didn't tell Jane about this. It became easier to carry her as the month slipped by. Perhaps the everyday workout made me stronger.

She was choosing what to wear one morning. She tried on quite a few dresses but could not find a suitable one. Then she sighed, all my dresses have grown bigger. I suddenly realized that she had grown so thin, that was the reason why I could carry her more easily.

Suddenly it hit me... she had buried so much pain and bitterness in her heart. Subconsciously I reached out and touched her head.

Our son came in at the moment and said, Dad, it's time to carry mom out. To him, seeing his father carrying his mother out had become an essential part of his life. My wife gestured to our son to come closer and hugged him tightly. I turned my face away because I was afraid I might change my mind at this last minute. I then held her in my arms, walking from the bedroom, through the sitting room, to the hallway. Her hand surrounded my neck softly and naturally. I held her body tightly; it was just like our wedding day.

But her much lighter weight made me sad. On the last day, when I held her in my arms I could hardly move a step. Our son had gone to school. I held her tightly and said, I hadn't noticed that our life lacked intimacy.

I drove to office.... jumped out of the car swiftly without locking the door. I was afraid any delay would make me change my mind...I walked upstairs. Jane opened the door and I said to her, Sorry, Jane, I do not want the divorce anymore.

She looked at me, astonished, and then touched my forehead. Do you have a fever? She said. I moved her hand off my head. Sorry, Jane, I said, I won't divorce. My marriage life was boring probably because she and I didn't

35






value the details of our lives, not because we didn't love each other anymore. Now I realize that since I carried her into my home on our wedding day I am supposed to hold her until death do us apart.

Jane seemed to suddenly wake up. She gave me a loud slap and then slammed the door and burst into tears. I walked downstairs and drove away.

At the floral shop on the way, I ordered a bouquet of flowers for my wife. The salesgirl asked me what to write on the card. I smiled and wrote, I'll carry you out every morning until death do us apart.

That evening I arrived home, flowers in my hands, a smile on my face, I run up stairs, only to find my wife in the bed - dead.

My wife had been fighting CANCER for months and I was so busy with Jane to even notice. She knew that she would die soon and she wanted to save me from the whatever negative reaction from our son, in case we push thru with the divorce.-- At least, in the eyes of our son--- I'm a loving husband....

The small details of your lives are what really matter in a relationship. It is not the mansion, the car, property, the money in the bank. These create an environment conducive for happiness but cannot give happiness in themselves. So find time to be your spouse's friend and do those little things for each other that build intimacy. Do have a real happy marriage!

If you don't share this, nothing will happen to you.

If you do, you just might save a marriage.

Many of life's failures are people who did not realize how close they were to success when they gave up.

eau beau, bureau

ew sew

o joke, smoke, woke

oa coast, coat, soap, throat

oe toe

oo brooch

ou although, shoulder, soul

ow blow, grow, low, mow

calm blond cot doll

palm drop spa hot

job not on top

bit bin chip pit

hill hit busy inch

it building mitt sit

any said says get

head friend many tell

jealous ten pleasure test

any said says get

head friend many tell

jealous ten pleasure test

after an animal bag

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bland fast hat jam

lamb pan ran stand

wolf book could full

woman cook should pull

good would sugar look

call audience awful cost

bought talk clause lawn

lost cough walk raw

call audience awful cost

bought talk clause lawn

lost cough walk raw

lunch double company does

run much country honey

fun couple money luck

time type pie bye

height aisle mile buy

night sky pile find

sound now round crowd

mountain brown house crown

mouse cow cloud clown

toy choice employ noise

enjoy coin royal moisture

joy point annoy spoiled

near beer peer beard

steer here year cheer

cashmere appear pioneer atmosphere

hair bear mare there

prayer pair wear stare

fair square despair glare

are far smart barn

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carp guitar party garden

star car guard part

poor tour sure moor

your insure tourist endure

detour assure contour manure

port four roar war

floor score sport course

door more report pour

her first turn worst

pearl were bird work

learn writer skirt earn

pet pass pat putt

pit punch pouring pack

peach pill pest peak

bet bass bat but

bit bunch boring back

beach bill best beak

ten top tell tip

town tame time tin

tam tile tore tine

den dot dell dip

down dame dime din

dam dial door dine

cut cot coat cane

cage collie came come

cave card coal cap

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66033468 booklet kfh final

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