Assure Organizational Excellence for Our Patients Every Day

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2013 Regulatory Readiness

2013 National Patient Safety Goals

Goal 1 – Improve the accuracy of patient identification.

NPSG.01.01.01: Use at least two identifiers when providing care, treatment, and services.

NPSG.01.03.01: Eliminate transfusion errors related to misidentification.

Goal 2 – Improve the effectiveness of communication among caregivers.

NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis.

Goal 3 – Improve the safety of using medications.

NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

NPSG.03.05.01: Reduce the likelihood of harm associated with the use of anticoagulant therapy.

NPSG. 03.06.01: Maintain and communicate accurate patient medication information.

Goal 7 – Reduce the risk of health care associated infections.

NPSG.07.01.01: Comply with either the current CDC hand hygiene guidelines or the current WHO hand hygiene guidelines.

NPSG.07.03.01: Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals.

NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter PICC lines.

NPSG.07.05.01: Implement best practices for preventing surgical site infections.

NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).

Note: This NPSG is not applicable to pediatric populations.

Goal 15 – The hospital identifies safety risks inherent in its patient population.NPSG.15.01.01: Identify patients at risk for suicide.

Universal Protocol – The organization meets the expectations of the Universal Protocol.

UP.01.01.01: Conduct a pre-procedure verification process.

UP.01.02.01: Mark the procedure site.

UP.01.03.01: A time-out is performed before the procedure2

2013 National Patient Safety GoalsHow do we meet them?

Goal 1 – Improve the accuracy of patient identification.

Use name and date of birth when giving medications, doing procedures or providing care to the patient.

When giving blood have two nurses identify the blood with the blood at the bedside.

Goal 2 – Improve the effectiveness of communication among caregivers.

The green notification value sticker is placed on the chart to document the action taken.Calls to the provider need to occur within 1 hour.

Goal 3 – Improve the safety of using medications.

NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

NPSG.03.05.01: Reduce the likelihood of harm associated with the use of anticoagulant therapy.

NPSG. 03.06.01: Maintain and communicate accurate patient medication information.

Goal 7 – Reduce the risk of health care associated infections.

Wash your hands!

NPSG.07.03.01: Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals.

NPSG.07.04.01: Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter PICC lines.

NPSG.07.05.01: Implement best practices for preventing surgical site infections.

Place Foleys using aseptic technique only when needed.

Remove Foleys per Foley Cather Removal Protocol.

Goal 15 – The hospital identifies safety risks inherent in its patient population.

Screen patients for suicide risk during initial assessment. Documentation on admission assessment.

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Process Improvement Projects for 2013

Core Measureso Acute Myocardial Infarction (AMI) and Cardiac Care Initiatives (STEMI)o CHFo Pneumoniao Surgical Care Improvement Project (SCIP)o Stroke

Trauma Cardiac Care Designation Readmissions Observations Fall Reduction Patient Satisfaction Line Infections in our ICU Areas Medication Errors Pressure Ulcers Patient Satisfaction (HCAHPS) Perinatal Safety Safety Huddles Bedside Reports Purposeful Rounding

Priority Focus AreasPriority Focus Areas (PFAs) are defined as processes, systems or structures in a health care organization that significantly impact the quality and safety of care. They can be used to guide assessment of standards compliance in relation to the patient/resident/client experience.

The Priority Focus Process is a data-driven methodology that consistently uses pre-survey information about healthcare organizations to create priorities for reviewing standards compliance, thus lending consistency to the survey process. Pre-survey information is gleaned from data in your organization’s application for accreditation, your organization's past survey findings, our Quality Monitoring System database of complaints and non-self reported sentinel events, any ORYX core measure data, and certain external data, if available. External data consists of publicly available data that are applicable to the accreditation program(s) being surveyed, such as HCAHPS for Hospitals, Nursing Home

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Compare, Home Health Compare, and failed laboratory proficiency testing data from CMS.

Good Shepherd’s Priority Focus Areas Identified by the Joint Commission are as follows:

• Assessment of Care and Services• Information Management• Physical Environment• Communication

Assessment and Care/ServicesAssessment and Care/Services for patients/clients/residents comprise the execution of a series of processes including, as relevant: assessment; planning care, treatment, and/or services; provision of care; ongoing reassessment of care; and discharge planning, referral for continuing care, or discontinuation of services.Assessment and Care/Services are fluid in nature to accommodate a patient’s/client's/resident's needs while in a care setting. While some elements of Assessment and Care/Services may occur only once, other aspects may berepeated or revisited as the patient’s/clients/resident's needs or care delivery priorities change. Successful implementation of improvements in Assessment and Care/Services rely on the full support of leadership.

Sub-processes of Assessment and Care/Services include:• Assessment• Reassessment• Planning care, treatment and/or services• Provision of care, treatment and services• Discharge planning or discontinuation of services

Information ManagementInformation Management is the interdisciplinary field concerning the timely and accurate creation, collection, storage, retrieval, transmission, analysis, control, dissemination, and use of data or information, both within an organization and externally, as allowed by law and regulation. In addition to written and verbal information, supporting informationtechnology and information services are also included in Information Management.

Sub-processes of Information Management include:• Planning• Procurement

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• Implementation• Collection• Recording• Protection• Aggregation• Interpretation• Storage and retrieval• Data integrity• Information dissemination

Physical EnvironmentThe Physical Environment refers to safe, accessible, functional, supportive, and effective Physical Environment for patients/clients/residents, staff members, workers, and other individuals, by managing physical design; construction and redesign; maintenance and testing; planning and improvement; and risk prevention, defined in terms of utilities,fire protection, security, privacy, storage, and hazardous materials and waste. The Physical Environment may include the home in the case of home care and foster care.

Sub-processes of Physical Environment include:• Physical design• Construction and redesign• Maintenance and testing• Planning and improvement• Risk prevention

CommunicationCommunication is the process by which information is exchanged between individuals, departments, or organizations. Effective Communication successfully permeates every aspect of a health care organization, from the provision of care to performance improvement, resulting in a marked improvement in the quality of care delivery and functioning.

Sub-processes of Communication include:• Provider and/or staff-patient/client/resident communication• Patient/client/resident and family education• Staff communication and collaboration• Information dissemination• Multidisciplinary teamwork

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The Survey

The Joint Commission (JC) Survey is anticipated to be 4 days in length. Using the patient’s medical record as a road map, surveyors will assess the care provided to patients in both inpatient and outpatient sites. A surveyor will arrive at your practice area accompanied by GSMC leadership. The surveyor will review a patient’s record with caregivers, observe care, tour the unit, interview clinicians, and, in some cases, interview patients.

Patient InterviewWho will be involved? The JC surveyor will ask the nurse caring for the patient if the patient is able to be interviewed. If yes, the JC surveyor will request permission to interview the patient and family without other members of the healthcare team present. The patient has the right to decline.

Question to the patient and family may involve the following subject matter:

• Patient and family education• Advance directives• Patient rights• Participation in planning of their care• Continuity of care• Environment e.g. noise, cleanliness• Pain management• Responsiveness of staff to their needs• Patient identification prior to treatment and procedures• Response to their questions• Preparation for discharge

Who will be Involved? The nurse caring for the patient and the Clinical Unit Director will participate in the record review. Because the surveyor will not know the GSMC patient record, the nurse will help locate the documentation for which he or she is looking. As the surveyor tours the unit and observes care, he or she may interview other members of the healthcare team including therapists, OAs, PTs, PAs, and physicians.

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Remember!

Surveyors know the standards, but YOU know your practice and your patients and families.Relax and take your time answering the surveyor’s questions, but be direct and to the point with your response. Be careful not to start sharing information they are not requesting.You will not be alone, your Director and others will be there to help you.If you don’t know the answer to a question, it’s okay to say “I don’t know but I know where to find it.”Tell positive stories! If the surveyor asks you a question that relates to special project on your unit or in the hospital, tell about it!Take pride in being a part of a great organization and do your very best to impress by being open, sincere, welcoming and listening. Allow them the opportunity to teach you and thank them for sharing their knowledge.

Common Survey Questions

Health Care Associated Infections

Q What are the most common ways you prevent transmission of infections from one patient to the next?

A Hand hygiene before and after contact with the patient and the patient’senvironment (NPSG) and early identification of patients requiring isolation and timely placement on appropriate precautions.

Q How do you know if one of your patients has MRSA, VRE, C- difficile or an MDRO? (NPSG)

A I review laboratory reports; Infection Prevention or Microbiology laboratory notifies the nursing unit; physicians also inform us. I read the history and patients with a history of MRSA/VRE are flagged.

Q What precautions do you use for patients with MRSA or VRE?(NPSG)

A Patients with known or suspected MRSA or VRE are placed onContact Precautions.• They’re placed in a private room and moved out of ward settings as

soon as possible.

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• Gloves are worn on entry into the room; gowns are worn when there is contact with the patient, surfaces, and equipment.

• Equipment is dedicated to the patient if possible. If equipment is shared it is cleaned and disinfected with hospital-approved disinfectant

Q What precautions do you use with patients who have C-diff?(NPSG)

A Patients with known or suspected C. diff are placed on Contact Special Precautions. This is similar to contact precautions with two primary differences. After contact with the patients, hands should be washed with soap and water. Patient rooms and equipment are cleaned daily with bleach-based disinfectant.

Q Describe the procedure for donning precaution gown and gloves. A Perform hand hygiene, place the gown over the shoulders, tie the next strings

so that the gown overlaps, then tie the waist strings so that the gown ends overlap, put on the gloves, pulling them up to cover the cuffs of the gown.

Q If a patient on precautions is leaving the unit to go to x-ray, how does the transporter know the patient is on precautions? How does radiology know? (NPSG)

A A transporter is informed by the sign on the door or by talking with the nurse. The nurse also writes the type of precautions on the Hand-Off Communication (Ticket to Ride) form which is placed on the back of the patient record.

Q What training have you received regarding infection prevention and what does it include? (NPSG)

A I’ve received training about general infection prevention practices such as hand hygiene, blood borne pathogens use of Personal Protective Equipment (PPE) and tuberculosis guidelines; and other practices to prevent healthcare-associated infections such as MRSA, VRE, C-diff, and device associated infections from central lines, urinary catheters and ventilators.

Q When did you receive this training? (NPSG)A During orientation; it is repeated each year as part of required annual training.

Q Describe the steps that are taken to prevent infection when inserting a central line. (NPSG)

A • Perform hand hygiene prior to catheter insertion

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• A qualified individual monitors the insertion for breaks in sterile technique and completes the Central Line Bundle Checklist.

• Use a standardized kit and protocol• Educate patients and families about prevention of infection. Inspect dressing, tubing and scrub hubs with alcohol prior to use.

Q Describes steps that are taken to prevent surgical site infections.(NPSG)

A • Use aseptic technique during invasive procedures; this includes use of sterile equipment, skin preparation, and managing the environment.

• Use aseptic technique during dressing changes and closely monitor wounds

• Educate patients and families about ways to prevent surgical site infections.

Q Describe a few ways you prevent urinary tract infections.A We limit the use of urinary catheters and remove them as soon as possible.

We insert using aseptic technique and equipment, clean the catheter per procedure, do not disconnect the catheter from the drainage tube unless necessary to irrigate; avoid irrigations, obtain specimens through the specimen port; avoid kinking of the tube, keep the urine bag lower than the bladder and off the floor. We have a nurse driven removal protocol.

Q How do you prevent hospital acquired pneumonia?A We decrease or prevent aspiration, use hand hygiene and other appropriate

measures to prevent cross-contamination. We also ensure that that respiratory equipment is appropriately cleaned. We administer vaccines against influenza, pneumococcal pneumonia. We also educate patients and families about infection prevention and the use of care bundles such as supporting head of bed (HOB) elevation, CHG mouth care as an example, with ventilated patients.

Q What do you do if a patient is suspected of having TB?A The patient is placed on airborne precautions. They’re placed in a private room

with negative air pressure; the negative air pressure is checked every day either by looking at the pressure gauge or performing the tissue test.

Q What other precautions do you take when caring for patients on airborne precautions?

A I wear an N-95 respirator when in the room. The respirator has been sized and fitted for me.

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Q When must you wash your hands with soap and water?A When hands are visibly soiled, after using the toilet and before eating.

Q When are gloves worn?A Clean, non-sterile, gloves must be worn when touching blood, body fluids,

secretions, excretions, mucous membranes, and contaminated medical equipment.

Q Where are infection prevention policies located?A In the Infection Prevention Manual which is on the GS Net.

Q What is your policy regarding employees and volunteers who have symptoms of, or have been exposed to, infectious disease/illness?

A It is mandatory for employees and volunteers to contact Employee Health Service if they have: Skin lesions and/or rash, especially if lesions are weeping or fever is present; non-intact skin or dermatitis; conjunctivitis or “pink eye”; diarrheal illness; cough of more than two weeks (unless explained by a non-infectious disease); new onset of jaundice; exposure to chickenpox, TB or other contagious condition; diagnosis of a communicable disease by the employee’s primary care provider e.g. chickenpox, staph skin infections, influenza.

Q How do you know that equipment has been cleaned between patients?

A Equipment that is cleaned on the unit is kept in the clean utility room and/or another designated area. Items in the hallway that are covered with a clear bag are clean. Soiled equipment is kept in the soiled utility room. If I am not sure about a particular piece of equipment, I assume it is soiled and clean it prior to patient use.

Q Where are you permitted to have food and drink on the patient care units?A Food is limited to the staff lounge, conference rooms and private offices.

Covered drinks are permitted in the nursing station in the low anterior spaces as long as they are in areas where they cannot be contaminated e.g. where specimens are left for transport. Drinks are not allowed in the hallway e.g. on carts, shelves, etc.

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Patient Safety and Quality Improvement

Q Describe a quality improvement initiative you’ve implemented on your unit during the last year? How has it improved patient care? What data do you have that demonstrates improvement?

A (Varies by unit; example, hourly safety rounds, core measures, patient satisfaction)

Q When do you take verbal orders and telephone orders? Tell me what you do when you take a verbal or telephone order.

A Verbal and telephone orders are only taken in exceptional circumstances when the physician cannot write the order. When taking a verbal order, write down the order as heard and read back and receive confirmation. (Verbal/telephone order must be signed by the physician within 48 hours.)

Q Can you tell me any of the unapproved abbreviations that should not be written in the medical record or on m e d i c a ti o n a d m i n i s t r a ti o n r e c o r d ( MAR)?

A Examples: MS04, MS, MgS04, ss (for sliding scale), U or u (for units), QD, QOD, HS.

Q Tell me how you report an adverse event or a variance report.A We use our Variance Reporting System – Midas to report any event which is out of

the normal expected process or outcome. We also have a safety hotline where incidences can be reported 903 315 -2899 (BUZZ).

Q What is a sentinel event?A A sentinel event is an unanticipated death or permanent loss of function not

related to the patient’s illness. Examples: death after a fall or overdose of a medication.

Q What if a patient safety issue occurs in your organization. How do you report a patient safety concern?

A 315-BUZZ is the hotline and communicate your concern immediately to the House Supervisor.

Q Give an example of a near miss or an occurrence that should be reported and how you would report such an event.

A Examples include: Medication found incorrect on the MAR, patient fall Incorrect patient identification band

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Mislabeling of a lab specimen. The incident should be reported through our variance reporting system on GSNet.

Q If an item is designation for single use only, is it ok to reuse?A No, if an item is labeled for single use only, it should not be reused.

Q When a central line is being inserted. What are two safety events that must occur in an effort to create a safer environment?

A Time Out procedure completed.Checklist completed during central venous and pulmonary artery catheter insertion.

Patient Identification

Q (Inpatient units) How are you sure you are performing a treatment or giving a medication to the correct patient? (NPSG)

A By using two identifiers to match the patient to the treatment or medication. For all patients, the two identifiers are name and date of birth.

Q When is it necessary to label medications and solutions in procedural areas?

A It is necessary to label medications and solutions on and off the sterile field when they are not administered immediately. (NPSG) If there is an intermediate step before administering a medication, it must be labeled, even if it is the only medication being given at that time.

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

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

Scope of Practice

Q When is a doctor’s order required?A A doctor’s order is required for all medical interventions and diagnostics.

Examples include medications, blood tests, urinary catheter irrigations, EKG’s, point-of-care tests except as specified in emergency situations. Otherwise, when

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a clinician (nurse, tech, etc.) implements a medical intervention or test without an order, he or she is practicing out of the scope of their practice.

Q When can oxygen be administered without an order?A In an emergency only. A verbal or written order must then be placed in the chart.

Any verbal order must be co-signed by a physician within 48 hours.

Assessment and Care Planning

Q What is the time frame for assessments to be completed by nursing? A Assessments are to be completed within 24 hours of admission.

Q When should History and Physical Examinations be present on the chart? A History and physicals should be present on the chart within 24 hours of admission.

Q Can you accept a history and physical (H & P) report from the physician office?A Yes, you can accept an H & P from a physician office if it is within 30 days from the

date of admission and as long as the physician reviews the H & P, exams the patient and deems the history and physical represents the patient current condition. The history and physical should then be stamped with the H&P update stamp and signed, dated and timed by the physician.

Q When should care planning begin?A A care plan reflecting the problems identified should be initiated on admission

denoting the problems identified on admission.

Q What do nurses do when a new patient problem is identified post admission?A The care plan should be updated a minimum of every 24 hours or as the

patient’s condition changes including addition of problems, noted resolution of problems, modification, deletion and/or addition of interventions.

Restraints

Q Describe appropriate use of restraints. A Good Shepherd will use restraints or seclusion only when less restrictive

interventions are ineffective and when the patient is at risk of harm or injury to themselves or others.

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Q Describe your training regarding use of restraints? When were you trained and what did your training include?

A Trained during orientation; training is repeated annually. Training included alternatives to restraint, reasons for use, safe application and removal of restraints, assessment and monitoring of response and documentation based on current policy.

Q Give an example of a least restrictive measure you would try before initiating restraints.

A Move the patient to a more visible location, provide an observer, provide a visual/auditory cue not to get up without assistance, use bed/chair alarms, maintain a quiet environment.

Q When the patient’s behavior requiring restraint resolves and you assess that restraints can be discontinued what do you do?

A Remove the restraints; and as soon as possible and regardless of the scheduled expiration of the order. Document the time the restraints were discontinued and the rationale in my progress note or on the restraint document.

Q When a patient is placed in restraints or removed from restraints, should it be noted on the patient plan of care?

A Yes, any change of the patient’s condition should be noted on the plan of care as soon as possible. This may require modifications to both the problem list and to the interventions.

Q Are standing orders for restraints permitted at your facility?A No, standing orders or PRN orders are not permitted for restraints.

Q How long does a restraint order apply when a patient is demonstrating violent and/or self-destructive behavior?

A Every 24 hours a physician must re-assess the patient and re-write appropriate restraint orders.

Q If the behavior recurs and patient needs to be restrained again, do you need a new doctor’s order?

A Yes because this is a new episode of restraint; this is true even if the patient has only been out of restraints a short time.

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Q Can you do a “trial” to see how the patient does out of restraints?A No, if the patient is taken out of restraints and needs to be put back in, this is a

new episode and a new order is required.

Q Are mitts considered a restraint?A Yes, mitts are always considered a restraint because they restrict the use of the

patient’s fingers. This is true even when mitts are not attached to wrist restraints.

Q When are side rails considered a restraint and when are they not considered a restraint?

A Side rails are considered a restraint when the intent is to restrict the patient from getting out of bed; this is true even if there are fewer than 4 side rails.Side rails are not considered restraint if used to prevent a patient from sliding or rolling out of bed; this includes padded side rails for seizure precautions.Overall, it’s the intent and not the number of side rails that determineswhether or not side rails are restraint.

Q Where do you document your assessment and interventions regarding thepatient in restraint?

A On the restraint documentation form. Documentation includes specific behaviors requiring restraint, type and location of restraint, least restrictive measures tried; patient’s response to restrain.

Pain Assessment and Reassessment

Q When do you initially assess patients for pain?A On admission or transfer to the unit, after a procedure requiring

sedation, or when the patient's condition changes.

Q How do you assess for pain? What pain scale do you use?A Describe which pain scale you used based on your patient population.

Examples:• Verbal adults: Numeric pain scale (1 -10 scale)• Pediatrics: Faces Pain Scale, the Face, Legs, Activity, Cry, Consolability

(FLACC)• Non-verbal or critically ill: Faces Pain Scale, the Face, Legs, Activity, Cry,

and Consolability (FLACC)

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Q How frequently do you reassess for pain?A Reassessment is patient specific, depending on the expected onset, peak and

duration of medications and other interventions, but at a minimum once every shift.

Q Describe key information taught to your patients regarding pain management?A Encourage patients to self report pain

Explain the pain scale to the patient “0” being no paint and “10” being the worst possible pain.Discuss pain management options, such as relaxation, distraction, etc.Explain goals of pain management are to keep pain from becoming severe and keep the patient comfortable so that an optimal level of pain management.

Q Where do you document the patient’s response to pain interventions?A Nurses document pain assessments in MAR or on the flow sheet. Other

disciplines document in the progress notes re: current treatment, response to therapy, and adjustments if needed.

Q What should be documented related to pain management?A Document:

Drug/administered dose Alternative measures, the effects of the patient medication

administered Patient/family teaching.

Fall Prevention

Q Describe your fall prevention program.A Patients are assessed for fall risk on admission and each shift using an age-

appropriate scale Morse Scale for adults and ABCS for injury risk.• The score identifies the patient as low (green), medium (yellow) or high (red)

risk for falls.• Interventions appropriate to the fall and injury risk scores and individual

condition are initiated.• Patient/family is instructed about fall risk and interventions using the TIPs

sheets.

Q Can you give me examples of interventions?17

A Purposeful rounding, key messaging, call light within reach, placement near nurses station, consults to PT or OT, toileting, assistive devices, bed alarms, teaching regarding side effects of medications, clutter and obstacle-free floors.

Q What is the fall rate on your unit?A (Find out rate from your Nursing Director)

Q When the patient is transferred off the unit to a test or procedure, how does the individual receiving the patient know the patient is on fall precautions?

A The risk is noted on the Hand-Off Communication tool (Ticket to Ride) and the patient has a High Risk Arm Band (Yellow).

Q What initiatives have you implemented on your unit to reduce the number of falls and falls with injury?

A (Varies by unit; includes implementing Safety Huddles, Purposeful rounds, Key Messages.)

Skin Integrity

Q Describe your program to prevent pressure ulcers.A Skin integrity is assessed on admission as part of the nursing assessment; risk for

impaired skin integrity is assessed on admission and daily using the Braden scale. If the Braden score is <18, the patient is considered at risk.

Q Can you give me examples of interventions to prevent pressure ulcers?A Interventions are matched to the specific risk. Examples: To manage nutrition,

consult dietician; to relieve pressure and/or manage sheer and friction, consult WOCN to mobilize the patient, reposition, protect elbows and heels; to manage moisture, clean well with each incontinent episode, scheduled toileting, use absorbent cloth incontinent pads.

Q Describe what you do if the patient has a pressure ulcer?A • Follow the wound care algorithm found on the intranet

• Consult the wound care nurse via Nursing Orders if a pressure ulcer exists• Measure and document the wound on admission and photograph.

Contact WOCN.• Document location; wound bed, exudates and periwound areas with

dressing changes• Document the patient response to treatment• Document measurements within 24 hours of discharge.

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Q What initiatives have you implemented on your unit to reduce the number and severity of pressure ulcers?

A Use wound care protocols to address reduction and severity of pressure ulcers.

Anticoagulation Therapy (NPSG)

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

A I received education during orientation. There are additional online and electronic resources.

Q Describe the steps you take to reduce the harm related to anticoagulation therapy.

A • Assess for potential food interactions.• Infuse premixed infusion bags through a programmable infusion pump• Monitor anticoagulation lab data.• Provide education to patients and their families.

Q What does the patient and family education need to include?A Each patient who is started on anticoagulation therapy receives teaching

materials from the Mosby repository. Key education information includes: Dietary considerations, Required blood testing (INR), Ability to describe the daily dose regime Food-drug-herbal interactions, and Recognize signs and symptoms of complications, such as bleeding and action

actions to take in case of complications.

Q When Warfarin is ordered for a patient, whether home med to be continued or a new order, what is the appropriate process required by pharmacy?

A Prior to Warfarin being dispensed, pharmacy requires a Warfarin Dosing Order for Adults form to be completed.

Medication Reconciliation (NPSG)

Q Describe your process for reconciling medications across the continuum of care.

A Medications are reconciled at admission, upon transfer and at discharge.

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Q Describe your process of reconciling medications on admission.A The process is as follows:

• Within 24 hours of admission, the admitting nurse generates theHome Medication List

• The nurse verifies the list with the physician which medications are to be continued and the physician signs the Home Medication List.

• The pharmacist reconciles ordered medications with the Home Medications to ensure accuracy of drug, dose, frequency and route.

Q Describe your process for reconciling medication upon transfer from one level of

care to another and post-operatively. A Current medication orders are discontinued and medications are re-ordered. The

nurse verifies with the physician which medications are to be continued upon transferred via Transfer Medication Order Reconciliation Form (TMORF), physician designates continuation of medication by marking yes or no and new orders are handwritten on physician order forms.

Q What is the reconciliation process at discharge?A • At discharge, the pharmacy provides a Discharge Medication Order

Reconciliation Form (DMORF) which includes all home medication and all medications given during the hospital stay. Once the physician reviews the DMORF and reconciles with the Home Medication List, the physician designates which medications are to be prescribed at discharge.

• The nurse reviews the DMORF, and compiles a Home Medication list and gives the patient a copy of his/her Home Medication List which includes medication instructions to follow after discharge.

Q What is the reconciliation process when the patient is discharged to another health care facility?

A A copy of the DMORF Medications List is sent to the next health care facility unless it is a Nursing Home transfer, in which case a nursing home form is used. Electronic copies are also available to providers within the health system.

Transfusion Therapy (NPSG)20

Q How do you verify the identity of a patient who is receiving a transfusion?

A Two RNs are required for bedside verification, one who has completed the educational packet and competency packet for transfusion, and one who has completed the verification education process. Or, the bedside verification process may be done by one MD and one RN who has completed the verification education process. The individual administering the blood must be one of the individuals conducting the verification.

Q What is your procedure for monitoring VS before and after transfusion of blood products?

A Temperature, blood pressure, heart rate and respiratory rate are documented on the transfusion record prior to transfusion, then Q15 minutes Xs 2 after the transfusion is started, then every 30 minutes throughout the transfusion, then 30 minutes after the transfusion. (Post procedure monitoring also states to continue monitoring vital signs for at least 1 hour after transfusion of RBCs)

Q What are the signs of a transfusion reaction? A Fever, chills, rigor, changes in vital signs, respiratory symptoms, pain, nausea,

vomiting, flushing, urticaria, and pruritis are possible signs of transfusion reactions.

Q What would you do if you suspected a transfusion reaction? A Steps to follow:

Stop the transfusion Remove the blood product but do not discard Administer Normal Saline IV slowly through the IV line Immediately re-perform clerical check including patient and unit identity,

armband, transfusion form and unit tag Notify lab of unusual symptoms and result of clerical check Notify physician Complete the Normal Saline administration Blood Transfusion Reaction

Report Collect 6 ml blood specimen in a pink top tube; place blood bag, tubing,

and pink top tube in plastic bag along with suspected transfusion reaction paperwork and send to the blood bank.

Send first voided urine sample marked “Transfusion Reaction” to lab.

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Monitor vital signs as ordered by the physician orQ15 min Xs 1 hour, then Q 30 minutes Xs 1 hour, then Q 4hr for 24 hours.

Critical Results (NPSG)

Q What is a critical result? A A critical result, also called a critical value, is a result that, if left untreated, could be

life threatening or place the patient at serious risk, e.g. elevated K+.

Q What is your process when the laboratory reports a critical result by phone?

A The person receiving the critical result writes it down and reads it back to verify with the laboratory personnel and receives confirmation. The RN notifies the physician as soon as possible. The nurse documents in the progress notes the action taken by the provider, even when the decision is no action.

Q What is “Delta Check” result? What tests are involved?A Delta check occurs when the current patient result does not match the previous

patient result of the same constituent. The tests are: PT, APTT, H/H, K and Ca.

Q What is your process when Lab calls with a delta check value?A The patient’s nurse should look in the chart to see if there was a change in the

patient’s medication to cause an increase or decrease in the patient result. Lab must document this in Meditech before the result can be verified. (Example: A PT result is lower than what it was because the patient stopped the medication.)

Patients at Risk for Suicide (NPSG)

Q What is done at GSMC-L to protect patients who may be at risk for suicide?

A All inpatients are screened to identify those who may be at risk forsuicide. Those screened to be potentially at risk are fully assessed by the responsible physician or psychiatric consult and next steps are determined. If a nurse assesses a patient to be at immediate risk for suicide, he or she may institute suicide precautions and contact the responsible physician who will determine next steps while the patient is in the hospital. When a patient at risk for suicide leaves the care of the hospital, the hospital provides the appropriate referrals and information to the patient and family such as crisis hotlines.

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Q What measure would you take to assure the safety of the suicide patient?A Measure to be taken includes:

Room near nurse station• Security room sweep• Sitter• Potential hazards, such as curtains, cords, etc removed• Phone removed• Remove sharps/sharps container• Place patient in green snap gown

Universal Protocol

Q How do you know a surgical or invasive procedure is being done on the correct patient?

A Universal protocol: Pre-procedure verification, Site Marking and Time Out where everyone involved in the procedure/surgery is engage and verifying verification, right patient, right procedure, right site, right side (if appropriate). Note: Site marking should be visible after patient is prepped and draped.

Q Which procedures require universal protocol to be followed?A Generally invasive procedures that require an informed consent. There

are some exemptions, for example procedures done during a code.

Q Can you give me an example of procedures on a general unit that require universal protocol?

A Insertion of a PICC line, chest tube insertion.

Response to Change in Patient’s Condition

Q What do you do if the patient’s condition begins to worsen and you need additional assistance?

A Call the Rapid Response Team (RRT) by dialing 5798. I also notify the patient’s nursing care team if they don’t already know.

Q How do you know when to call the RRT?A GSMC-L has identified early warning signs for adult, pediatric patients and

newborns that should trigger a call to the RRT.

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Patient Rights Q How are patients informed about their rights and/or methods of filing complaints? A There are a variety of methods

Patient handbook Signage in waiting areas Guest Relations Specialist Rounds Patient Rights information provided at registration

Q If a patient or family wishes to file a complaint with the organization, what process should occur?

A Take the complaint by listening to the patient/family, repeat their concerns, and handle the complaint if possible immediately. If unable to resolve, forward to Guest Relations at 903 315-2630 or pager 903 232-5589. After hours, contact the house supervisor.

Q Where should you document patient complaints?A Patient/Family complaints/grievances should be documented on the

Patient Compliant Form via the confidential complaint management system accessible on GSNet.

Q What do you do if you have a patient present that is not able to communicate information about the status of their advance directive?

A Check with the family; if patient does not have one, note it in the patient’s record on the admission assessment form.

Q How do you communicate with a non-English speaking patient or a patient who is deaf or hard of hearing? What resources are available to you? What do you do on weekends and off shift?

A For non-English speaking patients, interpreter services; (available 24/7) via the CYRACOM (blue phone). For deaf or hard of hearing patients, we use deaf talk. Contact the House Supervisor for assistance in locating equipment.Note: The Interpreter Policy is being updated and new equipment for interpretation is being trialed in the Emergency Department and Labor and Delivery. MARTTI is a mobile device that can provide video and over the phone interpreter services for limited English proficient and dear/heard of hearing patients. After an initial trial, consideration will be made for the purchase of MARTTI for multiple sites in our organization.

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Q If you suspect your patient (child or adult) has been the victims of abuse, what steps should you take?

A Document signs of abuse and notify social work.Note: Licensed staff has a duty to report abuse per Texas law.

Q What is the name of the program designed to provide a safe place for unwanted newborn babies in lieu of abandonment, injury, or death?

A Baby Moses

Q If you find an abandoned infant, or someone hands you an infant (estimated age < 60 days) and indicates they cannot care for the infant, what should you do?

A You should do the following: Accept without question and do not pursue the individual. Notify your supervisor immediately and follow the Baby Moses policy

Q What resources are available to you for ethical issues?A Any patient, patient advocate (related or not related), staff member or

physician may make an Ethics Committee referral by completing the Ethics Consult Referral Form and notifying any one of the following:

Office of Medical Staff Vice President of Nursing Director of Case Management Risk Manager Chaplain Chairperson of Ethics Committee Member of Ethics Committee

Interdisciplinary Communication

Q How do you communicate with other members of the health care team?A Multidisciplinary Rounds and one-on-one discussion with other providers along

with documentation in the medical record and hand-off communication tools (Ticket to Ride).

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Handoffs

Q What information do you receive about a patient when they are transferred to your unit from another unit?

A Patient history, all active problems, status of the problems and next steps, information about the family/significant others and additional critical information to provide a safe transfer of care, such as special equipment needs, isolation, unique circumstances or pending procedures or orders. (Specialty areas such as OR may have additional handoff requirements.)

Q How do you receive information about the patient condition from the previous shift prior to assuming responsibility for the patient?

A Walking rounds afford us the opportunity to ask questions of the off going shift or if your unit does not do walking round you could say I ask the nurse handing off the patient to me. The nurse doesn’t leave until I’m certain my questions are answered.

Q How do you communicate pertinent patient information to staff in procedural and testing areas?

A The nurse completes the Hand-Off Communication (Ticket to Ride) form which contains relevant information that the receiving area needs upon arrival of the patient.

Patient/Family Involvement in Education

Q How do you encourage patient’s active involvement in their care?A Teach the patient and family how to report concerns about their care, hand

hygiene, and respiratory hygiene. We evaluate their understanding and document it in the record.

Q What do you consider when you are teaching the patient and family?A The patient and family’s ability to learn, preferences, desire, motivation, and

readiness. We also consider cultural and religious practices and emotional, physical, cognitive, or language barriers.

Q Where do you document the patient’s understanding of t eaching?A In the nurse’s notes or on specialized forms, such as the discharge form.

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Medication Administration

Q What does your pharmacy do to prevent errors with sound- alike/look-alike drugs (SALAD)? Can you give me examples of these drugs?

A Pharmacy uses tall man lettering, visual warnings such as “shelf talkers”. The pharmacy also physically separates sound-alike/look alike medications. Examples include: oxyCONTIN and OXYcodone; hyrdoCODone and hydroMORPHone.

Q Does a patient who receives a new medication receive special monitoring during the first dose?

A Patients are monitored after a first dose for adverse effects and anaphylaxis. The patient’s response is documented in the progress notes.

Q When there is a range order for pain medication, how do you knowwhich dose to use?

A We do not accept range orders. If a range order is written, we clarify the order to a clearly indicate of what dose is to be administered under what criteria.

Q What date needs to be noted on the insulin multi-dose vial?A The expiration date on the multi-dose insulin that pharmacy has applied (28 days

from the date place in Pyxis).

Q What must be noted on all other multi-dose vials?A For other multi-dose vials – like labetalol and betamethasone – the same is true.

Note the expiration date pharmacy places on the multi-dose vial prior to placing in the Pyxis.

Q When medications are ordered for a pediatric patient, what safety measures are taken to assure accuracy?

A Medication orders are checked and verified by two pharmacists, prior to dispensing pediatric medication, it is checked by two pharmacist and prior to administration of the medication, the drug and dose is checked by two nurses.Note: Unit dose should be used if available at all times.

Competency and Credentialing

Q How do you demonstrate competency to perform your job responsibilities?A Through basic education, orientation, continuing education, annual training and

other training related to new technology.

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Q What happens if you fail to renew your licensure required for your job? A Failure to maintain active licensure will be administrative suspension until Human

Resources is able to verify by primary source.

Q If a physician shows up on your unit to do a procedure, how do you know he or she is credentialed?

A Through the GSNet you can find out the procedures each attending physician is credentialed to perform. If the physician is not listed on GSNet, contact Medical Staff Services at extension 1803 or after hours contact the house supervisor.

Specimen Collection and Point of Care Testing (POCT)

Q Describe your procedure for obtaining specimens? (NPSG)A Match the patient’s name, date of birth and account number on the label with

the name and date of birth on the patient’s wristband. Label the specimens with the provided label in the presence of the patient. Label the container (if it is a urine sample), not the cap. Label the blood tubes appropriately.

Q What point of care testing do you perform on your unit?A Example: Blood glucose (This varies by department, but you should know in your

particular area). You must be checked off prior to being able to perform point of care testing.

Q Who performs phlebotomy on your unit? When and how are they trained? How is competency evaluated?

A Lab assistants or nursing perform phlebotomy. During orientation, the RN performing phlebotomy is checked off on competencies. Competency is maintained through frequent performance of blood draws.

Q How are you competent to perform POCTs?A I demonstrate competency during orientation and as part of annual required

training. Annually I complete a training module and complete the required quiz.

Q How do you prevent spread of infections while performing POCTs?A Hand washing between patients and equipment wiped with a hospital-

approved disinfectant.

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Q How do you know the glucometer is working properly?A Our glucometers have a lock out procedure requiring quality controls to be

performed before patient testing. The machine will not allow patient testing until this is completed.

Q How long are glucometer controls and test strips good for?A Controls are labeled with the date when opened and are good for 90 days.

Q What doe s i t m e a n w h e n y o u h a v e a g l u c o s e r e s u l t o f > 6 0 0 a n d w h a t d o y o u d o ?

A This means the result is out of the meter’s reading range. Repeat the test using the meter and if the reading is still the same, notify the physician for further orders unless there is a written protocol for lab glucose confirmation.

Q What is the glucose value for critical low and critical high for adult population?A Critical low is <50 and critical high is >500. When obtaining critical low or high

results, the test should be repeated on the meter before treatment. If there is any question, get a lab draw to confirm the glucose result. Follow the Hypo or Hyperglycemic protocol for treatment.

Q Why is it important to perform a quality control check (glucometer, urine dip machine)?

A To ensure the equipment and test strips are performing properly.

Q What is the operating HCT (hematocrit) range for the glucose meter and what happens if the patient’s HCT is not within this range when performing a glucose test?

A HCT range is 20% - 65%. If the meter cannot read and measure the HCT in the patient’s same, a Flow Error or Sample Error code is generated and the meter will NOT give a glucose result. Lab glucose must be drawn to confirm.

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Environment of Care

The JC surveyor will tour the unit or department accompanied by the GSMC escorts, unit or department leadership, e.g. Nursing Director. During the tour, the surveyor will observe practice and will ask different staff questions about the work environment and fire safety.

What the surveyors are looking for as they round?• Food and drink with lids are limited to designated areas only• No food or drink in patient care areas, clean supply or soiled areas, or

where specimens collected• Hand hygiene and Standard Precautions being done by staff per policy• Protective equipment and supplies available and being utilized Transmission-based precautions (Contact, Contact Special, Airborne Droplet

etc.)• Aseptic technique must be used at all times• Isolation/precaution gowns worn properly and tied at the neck.• Gloves pulled over cuff of gown• Gloves and gowns removed before leaving the room• Needle boxes present and not overfilled• Equipment cleaned and disinfected between patients with hospital-

approved disinfectant (Kill Time: Purple top – 2 minutes; Gray top – 3 minutes and limited to nursery, HBO and Cath Lab; Orange top- bleach – 4 minutes)

• Clean supplies/linen on covered cart with a solid bottom shelf on linen carts or in cabinet/container or clean supply room

• Clean and soiled utility rooms doors closed• Clean equipment identified and properly stored• High-touch surfaces in patient rooms cleaned daily Authorized cleaning supplies being utilized and a MSDS on file.• No expired supplies, no external shipping boxes; no supplies on floor,

windowsill or underneath sinks – Please make certain they do not find these in your area.

• Sterile water and sterile saline labeled when opened and replaced every24 hours

Biomed checks completed and in date.

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Clearance from ceiling in all areas – Must be 18 inches of clearance from the ceiling.

Compliance with HIPAA regulations• Security of medications and IVs (med carts, med and IV closets locked)• Medication refrigerator temps logged; includes action if out of range• Nourishment refrigerator temperatures checked and out of

range action documented, check items for dates and removal of expired food items. Please archive all previous month’s logs and keep for 3 years.

• Crash Cart, defibrillator and pacer checked each shift. Please archive all previous logs and retain for three years.

• Fire extinguisher not blocked by equipment• Oxygen tanks secured and stored per standards• Access to exit doorways not blocked• Corridors kept clear. If equipment is in hallway, it must be moved every 30

minutes. (Exceptions are crash carts and isolation carts) Proper use of Cidex OPA – area used, ventilation, solution temperature and logs for both test strips and disinfection. Fluid warmers temperature logs Eyewash logs must be checked weekly by department• Response to clinical alarms and call lights• Employee name tags present on all employees for the purposes of

identification.

Equipment

Q What do you do if you if a piece of medical equipment malfunctions or fails?

A Remove the device, sequester, and call Biomedical Engineering to report;submit a variance report, complete.

Q How do you know a medical device is safe to use?A Each piece of equipment has a sticker which shows when it was

inspected by Biomedical Engineering.

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Q What is the process if there is a recall or hazard alert on a piece of equipment?

A Biomed and Materials Management work together to act on the alert.

Q What is your policy regarding checking the defibrillator and pacer on the general units?

A Nursing staff check the defibrillator and the pacer every shift. This includes checking to see that the defibrillator is plugged in and that all the needed supplies are there e.g. paddles, pads, gel, and that the pads are not expired.

Medication Storage and Security

Q How do you ensure that medications are secure in all locations?A Medications not under direct observation of the RN are secured in

closets, Pyxis, etc., not left on the counters. This includes IV's.

Q How do you know none of the medications on the code cart are expired?

A The date of the first medication to expire is noted on the outside of the cart.

Spills

Q What do you do if there is a blood spill on this unit?A The blood spill kit, which is available on the unit, is used to clean it up.

The materials used to clean it up are placed in the packet.

Q Show me your MSDS (Material Safety Data) sheets.A MSDS sheets for drugs are available through pharmacy. MSDS sheets for

other chemicals are available on the GSNet

Disaster and Fire Safety

Q What is your role in a disaster that results in an influx of patients to your organization?

A Follow directions of my director or supervisor.

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Q What would you do if you saw smoke coming out of a patient’sroom?

A I would implement the hospital’s fire plan which, is R.A.C.E., by "R"escuing the patient, sounding the "A"larm, "C"ontain the fire by closing the door to the room after the patient has been evacuated, and, finally, if it is safe to do so, "E"xtinguish the fire.

Q Show me the fire extinguishers and fire alarms on this unit.A (Fire alarm pull stations are usually located by exit doors and by the

nurse's station.)

Q Where are the oxygen shut off zone valves for your area? A This will vary depending on your unit, but it is the staff’s

responsibility to know where these valves are located.

Q Who is authorized to shut off oxygen zone valves?A The Charge RN, House Supervisor and Respiratory Therapist are the

only ones authorized to shut off the primary oxygen valves in your area because the valve will shut off multiple rooms as identified on the medical gas shut off panel.

Q Under what circumstances would the oxygen shut off valves need to be turned off.

A In case of a fire in that specific zone or damage to the oxygen outlet systems or connectors (such as a broken flow-meter resulting in oxygen freely releasing).

Unit Refrigerators

Q How long can patient food remain in the refrigerator before you must throw it away?

A One day

Q What do you do if you find out that the temperature in the refrigerator has been out of range?

A Note on the temperature log the temperature and the action taken, such as Maintenance called.

Original: 2/6/13 – PBrandon #3

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