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  • 1. Nuclear Medicine Survey Workbook Version 1.2 © GE Medical Systems Healthcare Services
  • 2. THE NUCLEAR MEDICINE DEPARTMENT SURVEY WORKBOOK TABLE OF CONTENTS Page # The Nuclear Medicine Department Survey 4 Key Nuclear Medicine Department Survey Points to Remember 6 Nuclear Medicine Department Survey Question Categories 8 Nuclear Medicine Department Topics 12 Nuclear Medicine Department - Physical Inspection 14 Nuclear Medicine Department - Focus Issues 16 Nuclear Medicine Equipment Requirements 19 Policy and Procedure Requirements 20 Policy and Procedure Review Form 21 Potential Surveyor Questions for Nuclear Medicine Department Personnel 22 Nuclear Medicine Post Test 28 Bullet Excerpts from Video 31 3 © GE Medical Systems Healthcare Services
  • 3. THE NUCLEAR MEDICINE DEPARTMENT SURVEY The purpose of this workbook is to provide assistance to your Nuclear Medicine Department staff in preparation for your JCAHO Survey. The healthcare professionals at Medical Consultants Network Inc. encourage you to use the information provided as a “working tool”, documenting ways in which your Nuclear Medicine Department can meet compliance. The first step in preparing for the Nuclear Medicine Department survey is to consider which staff members you would like to represent your Nuclear Medicine Department during the actual survey process. It is recommended that staff members who become easily intimidated by the inspection process or those that tend not to answer questions well, should not be scheduled to work on the days of survey. We encourage you to discuss the survey process with all of your Nuclear Medicine Department staff and decide, as a group, which staff members would like to participate in the JCAHO survey process. Utilizing this information, it should then be decided which staff members have the following capabilities: • Concrete knowledge of Nuclear Medicine Department rules and regulations, in accordance with JCAHO, state and federal standards, laws and mandates • An strong understanding of the JCAHO functions as listed in the Comprehensive Accreditation Manual for Hospitals (CAMH) • A good working knowledge of how the Nuclear Medicine Department operates, including knowledge of the department’s policies and procedures • Basic knowledge of your organization’s mission and values, including hospitalwide policies and procedures • Presents themselves with a sense of confidence and assuredness These will be the staff members that you should strongly consider scheduling to work during your survey dates. Objectives At the completion of this video and workbook you will understand: • How the survey process will look and feel • How the surveyor interacts with the department staff • What areas within your department the surveyor will most likely inspect • How to best prepare for a JCAHO survey 4 © GE Medical Systems Healthcare Services
  • 4. In preparing for your Nuclear Medicine Department survey, make a list below of those individuals in your organization whom you feel will be best suited to represent the Nuclear Medicine Department during the JCAHO survey, and list why. After a thorough list has been made, ask these individuals to study the Nuclear Medicine Department Survey Video again, to determine if he or she feels they will be beneficial as an active participant in the survey process. Name Position Choice Rationale Names of Participants Selected: 5 © GE Medical Systems Healthcare Services
  • 5. KEY NUCLEAR MEDICINE DEPARTMENT SURVEY POINTS TO REMEMBER • If you do not understand a surveyor’s question, ask the surveyor to restate the question. Frequently a surveyor’s question is a JCAHO standard, restated in question format. Also, it is not uncommon for a surveyor to provide “clues” to the expected answer within a restated question. • Structure your answers to highlight collaborative endeavors undertaken by your department and the facility as a whole. Review potential question categories prior to the survey, and identify how you, your staff, your department and the organization provide care in a collaborative fashion. • Your surveyor may interview staff singularly or in a group format. It is best to plan for both types of interview processes. If, in the group format interview, it is noted that a coworker seems to be having difficulty answering a surveyor’s question, do not hesitate to provide assistance with the answer. Do not contradict a participant’s answer, even if you feel the answer is incorrect. Try and find a way to supplement their answer with the correct information that does not give the surveyors the impression the answer was incorrect. Examples: ! “What I think Jane is trying to say is …….. give correct answer” ! “Perception is key in understanding this process ……. give correct answer” ! “Conceptually, there is a measure of validity, however we’ve entered a new phase with a new set of processes ……. give correct answer” • Never attempt to answer a surveyor’s question if you do not know the answer, and never try and “bluff” your answer. If none of the interview participants answer a given question, the surveyor will elaborate on the intent of the question, thereby providing the interview participants with an increased understanding of how to approach the answer correctly. • It is acceptable to state to the surveyor “I’m not sure I’m answering your question correctly, but I believe what you are asking is . . . . .” Often, interview participants are uncertain if their answers will be correct, or if their response will satisfy the surveyor. By prefacing your answer with an honest “I’m not completely sure I’m addressing the intent of your question” and similar statements, the interview participant reduces the risk of being perceived as incorrect by the surveyor. • It is also acceptable to state to the surveyor “I can find the answer to your question by reviewing my policy and procedure manual.” Remember that the surveyor doesn’t expect you to know the answer to every question, verbatim. Retrieving a policy and procedure manual and showing the surveyor where the policy is located that answers his/her question, will meet with surveyor satisfaction. (Note: Ensure your departmental and organizational policy and procedure manuals are current, with all necessary administrative and medical staff approvals – prior to survey). 6 © GE Medical Systems Healthcare Services
  • 6. • The Nuclear Medicine Department staff is expected to be well versed in diagnostic nuclear medicine procedures and radiation safety issues. Make sure all Nuclear Medicine Department staff can discuss all components of the • Nuclear Medicine environment. • Because many Nuclear Medicine Departments deal with a variety of diagnostic equipment, make sure all staff can confidently discuss such issues as the education and training they have received regarding equipment use and maintenance and device failure reporting. • Proper storage and handling of radioactive materials will be a focus point for your surveyor. Carefully inspect both your hot and cold labs, assuring that all safety precautions are in place. 7 © GE Medical Systems Healthcare Services
  • 7. NUCLEAR MEDICINE DEPARTMENT SURVEY QUESTION CATEGORIES • Patient rights, advance directives (such as Do Not Resuscitate [DNR]), protection of patient dignity and confidentiality of patient information • Emergency imaging processes, on-call staff availability and expected response time • Performance improvement activities that have been conducted by the Nuclear Medicine Department staff (in a collaborative manner and interdepartmentally) • Determination of licensed independent practitioner (physician) competency (for example, how are radiologists proctored to assure competency when performing new procedures?) • Reporting of complications • Sentinel event identification, reporting, analysis and resolution • Departmental policy and procedure development and implementation • Infection control issues • Management of radioactive materials • Responsibility for ordering of contrast materials (i.e., Pharmacy or Imaging Department) • Staff safety related to radiation exposure • Disaster planning and the Nuclear Medicine Department’s involvement • Communication to the patient’s family/support group (i.e., communication system for the Imaging Department’s waiting room) • Human resource issues: staffing, recruitment, retention • Restraints management during imaging procedure • Safety and the environment of care • Staff competency, including age related and cultural competencies • Victims of abuse identification and reporting • ORYX and/or core measures that Nuclear Medicine Department staff may be involved in monitoring • Patient assessment and preparation for procedure We suggest that your Nuclear Medicine Department staff review each category, discussing how your department manages each issue. It is recommended that your collective answers be summarized and documented in the space provided in this workbook. Your staff should review these answers frequently prior to survey. 8 © GE Medical Systems Healthcare Services
  • 8. Patient rights, advance directives (such as DNR), protection of patient dignity and confidentiality of patient information: _____________________________________________________________________________ _____________________________________________________________________________ Emergency Nuclear Medicine processes, on-call staff availability and expected response time: _____________________________________________________________________________ _____________________________________________________________________________ Performance improvement activities conducted in the Nuclear Medicine Department: _____________________________________________________________________________ _____________________________________________________________________________ Assurance of physician competency: _____________________________________________________________________________ _____________________________________________________________________________ Reporting of complications: _____________________________________________________________________________ _____________________________________________________________________________ Sentinel events, root cause analysis, corrective action plan: _____________________________________________________________________________ _____________________________________________________________________________ Departmental policy and procedure development and implementation: _____________________________________________________________________________ _____________________________________________________________________________ 9 © GE Medical Systems Healthcare Services
  • 9. Infection control issues: _____________________________________________________________________________ _____________________________________________________________________________ Management of radioactive materials: _____________________________________________________________________________ _____________________________________________________________________________ Responsibility for ordering of contrast materials: _____________________________________________________________________________ _____________________________________________________________________________ Staff safety related to radiation exposure: _____________________________________________________________________________ _____________________________________________________________________________ Disaster planning and the Nuclear Medicine Department’s involvement: _____________________________________________________________________________ _____________________________________________________________________________ Communication to the patient’s family/support group: _____________________________________________________________________________ _____________________________________________________________________________ Human resource issues: staffing, recruitment and retention _____________________________________________________________________________ _____________________________________________________________________________ 10 © GE Medical Systems Healthcare Services
  • 10. Restraints management: _____________________________________________________________________________ _____________________________________________________________________________ Safety issues and the environment of care in the Nuclear Medicine Department: _____________________________________________________________________________ _____________________________________________________________________________ Evaluation and verification of staff competency: _____________________________________________________________________________ _____________________________________________________________________________ Victims of abuse identification and reporting: _____________________________________________________________________________ _____________________________________________________________________________ ORYX and/or core measures: _____________________________________________________________________________ _____________________________________________________________________________ Patient assessment and preparation for procedure: _____________________________________________________________________________ _____________________________________________________________________________ 11 © GE Medical Systems Healthcare Services
  • 11. NUCLEAR MEDICINE DEPARTMENT TOPICS The Nuclear Medicine department must deal with a variety of situations that are unique to the performance of diagnostic imaging tests and procedures. Review the topics below, discussing with your Nuclear Medicine staff how your department manages each issue. Write your conclusions in summary format for review by all department members – to prepare your department for surveyor inquiry on these subjects: • Radiation Physicist inspection reports: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • Equipment procurement, maintenance and biomedical certification: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • Use of outside services (including assurance of outside service competency and quality): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • Education and training on new equipment: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 12 © GE Medical Systems Healthcare Services
  • 12. • Quality control activities (equipment calibration, etc.): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • Procurement of radioactive materials in emergency situations: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • Medication management and safe storage within the unit: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • Storage and use of radioactive materials (including record-keeping procedures): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • Other unique circumstances: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 13 © GE Medical Systems Healthcare Services
  • 13. NUCLEAR MEDICINE DEPARTMENT PHYSICAL INSPECTION During the JCAHO surveyor’s visit to the Nuclear Medicine Department, he/she will tour and physically inspect the department. To properly prepare for your survey, it is recommended that you and your staff perform your own departmental inspection of the following areas: • Storage of radioactive materials (storage area is secured and locked at all times) • Assessment of the crash cart(s) ! Crash cart check - per your policy, has the check sheet been completed and initialed ! Does the check include integrity of the lock and documentation of lock number ! Does the check include charging defibrillator to specified jules, both on and off battery pack, per manufacturer’s recommendations ! Assure all medications and sterile supplies do not exceed expiration dates ! Assure that all necessary equipment is available (pediatric scope and paddles, oxygen tank is full, suction machine available, etc.) • The medication refrigerator (if used in your department) is clean and: ! Is refrigerated at the appropriate temperature ! Contains a daily temperature assessment log ! Contains only medications (i.e., no patient or staff food) • Medication supplies are locked, secured from patient or visitor access • Expiration dates on all medications and supplies are not exceeded, this includes medications kept in the medication refrigerator (note: special emphasis on appropriate dating of medication vials – pursuant to hospital policy and procedure) • Narcotics control sheet is complete and accurate for usage and wastage • Any stock drugs or drugs contained in a “transport box” are located in a locked, secure area and are not expired • Sharps disposal containers are filled with sharps only (no paper, empty plastic vials, etc.) and are not overfilled 14 © GE Medical Systems Healthcare Services
  • 14. • If your facility utilizes sharps disposal containers that include a locking device, assure that the locking device is present and functional • Hazardous materials waste containers are filled with hazardous materials only (i.e., not filled with used paper patient gowns, non-saturated dressings) • Hazardous materials waste containers are covered and protected from patient or visitor access • Radiation exposure equipment (lead aprons, thyroid guards, etc.) is intact, without cracks, rips or tears • All discarded films with patient identifiers are kept in a confidential area, without access to public view • All patient information shown on computer screens is kept out of public view (it is advisable to have a 30 second “walk away” feature on all computer programs where patient information is accessible. This feature returns the user to a blank screen, when accessing patient information, after 30 seconds of unattended use.) • All gurneys have working brakes and side rails – integrity of gurney pad is intact (no rips or tears) • Evidence of Radiation Physicist review and approval via signature is readily available on policy and procedure manuals and all radiation safety and performance improvement (including quality control activities) documentation • All nuclear medicine exam rooms have operational “in use” sign, clearly visible to public and staff • State license for all types of nuclear medicine procedures performed is posted and clearly visible to the public 15 © GE Medical Systems Healthcare Services
  • 15. NUCLEAR MEDICINE DEPARTMENT FOCUS ISSUES Discuss with your staff how your Nuclear Medicine Department would handle the following situations. Document your collective conclusions below: • Management of patients with severe adverse reactions to contrast media: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • What is the procedure for a radioactive materials spill? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • What type of special education and training does the Nuclear Medicine staff receive regarding radiation safety issues? How does the department manager know the staff is qualified to work with radioactive materials? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 16 © GE Medical Systems Healthcare Services
  • 16. • Because conscious sedation is sometimes used in the Nuclear Medicine Department, can you demonstrate to the surveyor that the staff is competent to administer and monitor conscious sedation? (i.e., all staff must meet the same competency requirements when the same service is provided, regardless of location throughout the facility) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • How does the Nuclear Medicine staff manage patients with infectious diseases? Are there any special requirements when performing a procedure on a patient that is in isolation? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • How does the department monitor and adjust staffing levels based on unexpected emergency or “add-on” cases? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 17 © GE Medical Systems Healthcare Services
  • 17. • How do staff assure that the patient is not receiving excessive exposure to radiation (i.e., is there a policy for requiring documentation of last menstrual period on women of child- bearing age to assure there is no chance of exposure during pregnancy?) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ • What types of educational opportunities are provided for Nuclear Medicine Department staff (both physician and other healthcare provider staff)? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 18 © GE Medical Systems Healthcare Services
  • 18. NUCLEAR MEDICINE EQUIPMENT REQUIREMENTS To demonstrate optimal patient and staff safety when Nuclear Medicine equipment is utilized, the JCAHO requires that a qualified physician, qualified medical radiation physicist or other qualified individual monitors the performance evaluations of nuclear medicine therapy equipment at least quarterly. Additionally, your surveyor will want to assure that the hospital’s medical equipment safety program includes evaluation of equipment performance by a qualified medical physicist, including: • Radiation therapy units, radioactive sources and simulators for proper working order. All isodose plans and calculations for each patient are verified by a qualified medical physicist prior to, or shortly after initiation of treatment, and therefore on a weekly basis. There exists a procedure for determining whether dose delivery is consistent with the actual dose prescription and that total doses do not differ from the prescribed does by more that 5%. • Periodic checks of film processors. • A procedure for measuring the uniformity (“flood” tests) and resolution (“bar tests”) of nuclear medicine imaging instruments. • A maintenance program. • Annual accuracy, daily calibration and constancy, and quarterly linearity checks are done on the dose calibrator in Nuclear Medicine. • Routine surveys for radiation levels and removable contamination in patient care areas in which radioactive materials are used. • Review and documentation of all testing results. • Pursuant to the JCAHO Environment of Care Standards for control of hazardous materials and waste, policies addressing receipt, storage, transport, preparation, handling, use and disposal of radionuclides and radiopharmaceuticals. • Documentation exists which demonstrates that there is an active Radiation Safety Committee, comprised of appropriate technical and administrative personnel. 19 © GE Medical Systems Healthcare Services
  • 19. POLICY AND PROCEDURE REQUIREMENTS Pursuant to the JCAHO, policies and procedures are to reflect a department’s goals and scope of services, as well as the staff’s knowledge and skill. Policies and procedures are to describe how the department assesses and meets the care needs of the patients and patient populations. Departments must show that the following elements have been considered in the development of policies and procedures: • Types and ages of patients served • Methods used to assess and meet patient’s care needs • Scope and complexity of patient’s care needs • The appropriateness, clinical necessity and timeliness of support services provided directly by the hospital or through referral contracts • The availability of necessary staff • The extent to which the level of care or service provided meets patient’s needs • Recognized standards or practice guidelines, when available In most instances during the provision of patient care, more than one discipline interacts with the patient. Therefore, it is expected that policies and procedures are collaborative in nature. It is recommended that your staff become prepared to explain this during the surveyor’s visit to the Nuclear Medicine Department, as well as verify this in written format. Your organization can achieve compliance with this important requirement in several different ways: • Development of a policy and procedure review committee (whose membership is interdisciplinary) • Documentation that the policy/procedure (either formal or informal) has been reviewed by the appropriate disciplines • Evidence in various committee meeting minutes that the policy/procedure has been reviewed in a collaborative format Note: It is highly recommended that there be a general policy and procedure on how your organization and/or departments develop and implement policies and procedures. 20 © GE Medical Systems Healthcare Services
  • 20. POLICY AND PROCEDURE REVIEW FORM List types and ages of patients served: _____________________________________________________________________________ _____________________________________________________________________________ List methods used to assess and meet patient’s care needs: _____________________________________________________________________________ _____________________________________________________________________________ What is the scope and complexity of the patient care needs? _____________________________________________________________________________ _____________________________________________________________________________ List the appropriateness, clinical necessity and timeliness of support services provided directly by the hospital or through referral contracts: _____________________________________________________________________________ _____________________________________________________________________________ What is the availability of necessary staff, (does the department ever require nursing staff)? _____________________________________________________________________________ _____________________________________________________________________________ Describe the extent to which the level of care or service provided meets patient’s needs: _____________________________________________________________________________ _____________________________________________________________________________ List recognized standards or practice guidelines that pertain to the policy/procedure: _____________________________________________________________________________ _____________________________________________________________________________ List all departments involved with the policy/procedure: ________________________ _________________________ ________________________ ________________________ _________________________ ________________________ ________________________ _________________________ ________________________ 21 © GE Medical Systems Healthcare Services
  • 21. POTENTIAL SURVEYOR QUESTIONS FOR NUCLEAR MEDICINE DEPARTMENT PERSONNEL Review the list of possible surveyor questions, providing your answers in the space provided: 1. How is latex sensitivity addressed in the Nuclear Medicine environment? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. How do you recover patients if they have received conscious sedation? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. How do you involve the patient in participating in care decisions? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. How are pharmacy services provided to the Nuclear Medicine Department when the Pharmacy is closed? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5. How do you manage pediatric medication/contrast dosing in the Nuclear Medicine Department if you only occasionally treat pediatric patients? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 22 © GE Medical Systems Healthcare Services
  • 22. 6. How does the Nuclear Medicine staff ensure that all services are available in a timely manner to meet the needs of the patient population? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7. How does the Nuclear Medicine Department Manager determine if staff is competent to perform assigned duties, and when appropriate provide care for the special needs and behaviors of specific age groups? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8. How does the organization provide for security of patients and personnel in the Nuclear Medicine Department? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 9. Describe processes conducted in your hot laboratory: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 10. Describe processes conducted in your cold laboratory: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 23 © GE Medical Systems Healthcare Services
  • 23. 11. Describe what elements must be included on a request (order) for a nuclear medicine procedure: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 12. Describe safety processes conducted to assure safe receipt and transport of radioactive materials: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 13. How is the Nuclear Medicine staff informed about the patient’s advance directive? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 14. Describe the process for performing a test on a patient with a behavior management problem? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 15. How does the Nuclear Medicine Department collaborate with other departments to improve patient care and/or organizational services? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 24 © GE Medical Systems Healthcare Services
  • 24. 16. What types of performance improvement activities are conducted in the Nuclear Medicine Department? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 17. What does your staff do if there is no informed consent for procedure on the patient’s record prior to procedure? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 18. Describe how the patient is educated about, and prepared for, Nuclear Medicine procedures: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 19. Describe what steps are taken in the care of the immunosuppressed patient undergoing Nuclear Medicine procedures: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 20. Describe all quality control procedures conducted in the Nuclear Medicine Department: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 25 © GE Medical Systems Healthcare Services
  • 25. 21. Describe what processes are in place in the Nuclear Medicine Department to assure there is no excessive radiation exposure to patients or staff: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 22. Describe how peer review is conducted by Nuclear Medicine physician staff: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 23. List the members of the Radiation Safety Committee: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 24. What types of activities are conducted during the Radiation Safety Committee? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 25. Who is your Radiation Physicist? How often does the Radiation Physicist review your equipment evaluation quality control activities? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 26 © GE Medical Systems Healthcare Services
  • 26. 26. Describe the requirements for your Nuclear Medicine Department mandated by the Nuclear Regulatory Commission. Is your state one of the “In Agreement States” regulated by Title 10 of the Codified Federal Register? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Notes: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 27 © GE Medical Systems Healthcare Services
  • 27. NUCLEAR MEDICINE POST TEST (Circle the most correct answer) 1. Staff that are assigned to work during the JCAHO survey: A. Should have a concrete knowledge of Nuclear Department rules and regulations B. Should have “no nonsense” personalities C. Should be well groomed and attractive D. It doesn’t make any difference who is assigned to work 2. Guidelines to remember during survey include the following EXCEPT: A. Follow the department dress code, wear your name tag B. Maintain patient privacy and dignity C. Take a short lunch in case the surveyor has questions D. Follow all radiation safety regulations for Hot and Cold laboratories 3. Fire safety guidelines to remember during the JCAHO survey include: A. The acronym for what to do in a fire, the code for fire, who is charge of the Safety Committee B. The date of the last fire drill, what RACE stands for, who was working during the last drill C. The code for fire, the locations of fire extinguishers, where fire pull stations are D. Locations of fire extinguishers, the date of the last fire drill, the date of the next fire drill 28 © GE Medical Systems Healthcare Services
  • 28. 4. During the review of the department, medication supplies will be inspected for: A. Expiration dates, secure access, number of drugs in “transport” boxes B. Complete narcotic control sheet, number of expired drugs, if a medication refrigerator is used C. Availability of “transport” boxes, expiration dates, temperature of medications D. Medications do not exceed expiration dates, complete and accurate narcotic control sheet, medication refrigerator contains only drugs 5. During the physical inspection of the department, the surveyor will NOT: A. Tour the Hot and Cold labs B. Inspect lead aprons and gloves for tears C. Ask about preparing and disposing of radioactive materials D. Question patients without their consent 6. Which of the following is NOT a competency issue required for all areas that provide clinical care: A. Age-specific care, as appropriate to the populations served B. Restraint application and monitoring C. Knowledge of theory related to procedures/treatments D. Knowledge of Human Resources polices and procedures 7. It is not necessary to follow Standard Precautions with patients in Nuclear Medicine because the radiation would kill any dangerous organisms. A. True B. False 29 © GE Medical Systems Healthcare Services
  • 29. 8. Medical records in the Nuclear Medicine Department: A. Must be in an area that is secure and confidential, yet allows staff accessibility B. May be stored on the floor but have proper space between ceiling and top of storage cabinets C. Should be color coded to indicate the patient’s primary doctor D. May only contain notes from the current admission 9. If conscious sedation is used in the department, all of the following is true EXCEPT: A. It must be given by an anesthesiologist so that the same level of care is provided throughout the facility B. Patients must give their informed consent C. Must be physician directed, may be RN administered D. Physician and registered nurse must have demonstrated competency 10. The surveyor will be interested in how performance improvement activities are conducted in the department. The surveyor will want to know: A. It is done on a bi-monthly basis B. That the Nuclear Medicine Department conducts collaborative, interdisciplinary PI activities C. If the physicians have agreed to Peer Review in the department D. How many indicators the department has monitored over the last six months 30 © GE Medical Systems Healthcare Services
  • 30. What You Will Learn From The Nuclear Medicine Department JCAHO Survey Video: • How the survey process will look and feel • Surveyor interaction with staff and participants • Areas that will likely be inspected • Types of questions asked by surveyors • How participants are expected to respond • How best to prepare for Your actual JCAHO Survey © GE Medical Systems Healthcare Services NUCLEAR MEDICINE DEPARTMENT ACCREDITATION SURVEY PROCESS © GE Medical Systems Healthcare Services Survey Guidelines to Remember: • Wear your name tag • Follow your departmental/organizational dress code • Maintain all radiation safety regulations for Hot and Cold Laboratories • Maintain patient privacy and dignity • Know organizational lines of authority • Maintain a pleasant and friendly manner • Answer surveyor questions honestly © GE Medical Systems Healthcare Services 31 © GE Medical Systems Healthcare Services
  • 31. Surveyor Arrival in Your Department © GE Medical Systems Healthcare Services GENERAL QUESTIONS ASKED OF STAFF © GE Medical Systems Healthcare Services Fire Safety Guidelines to Remember: • Know your organization’s code to be paged in the event of a fire • Know what methodology your organization follows in the event of a fire (ie. R.A.C.E.) • Be prepared to describe what R.A.C.E. means: !Rescue !Activate alarm !Contain fire !Extinguish (if possible and safe) © GE Medical Systems Healthcare Services 32 © GE Medical Systems Healthcare Services
  • 32. Fire Safety Guidelines to Remember: • Know location of fire extinguishers and fire alarm pull station • Know whom to call (telephone number) to have fire code paged • Know approximate date of latest departmental and organizational fire drill © GE Medical Systems Healthcare Services PHYSICAL INSPECTION OF DEPARTMENT © GE Medical Systems Healthcare Services Radiation Safety Guidelines to Remember: • Be prepared to describe your department’s policy on patient and staff radiation protection • Assure that your Hot and Cold Laboratories are secured (locked) at all times • Assure that all radioactive materials are stored according to state and federal regulations © GE Medical Systems Healthcare Services 33 © GE Medical Systems Healthcare Services
  • 33. Radiation Safety Guidelines to Remember: • Be prepared to discuss which areas must be lead lined, and explain why • Be prepared to discuss your radioactive material preparation and procedure completion processes (including wipe down, substance documentation “logging” and clean-up/disposal) • Be prepared to explain the Nuclear Medicine’s hazardous materials management program © GE Medical Systems Healthcare Services PATIENT SAFETY © GE Medical Systems Healthcare Services CLINICAL COMPETENCY OF STAFF © GE Medical Systems Healthcare Services 34 © GE Medical Systems Healthcare Services
  • 34. Clinical Competency Requirements Include: • Physical performance of procedures/treatments • Knowledge of theory related to procedures/treatments • Age specific care • Cultural/religious issues • Social issues • Restraint application • Identification and reporting of abuse victims • Safety and security issues • Infection control practices © GE Medical Systems Healthcare Services MEDICAL RECORDS ACCESS © GE Medical Systems Healthcare Services PHYSICIAN INTERVIEW © GE Medical Systems Healthcare Services 35 © GE Medical Systems Healthcare Services
  • 35. Hazardous Materials Management Points to Remember: • Response for toxic spill and/or exposure • Describe departmental hazardous materials protection plan • Location and storage of hazardous materials • Disposal process for hazardous and/or radioactive materials © GE Medical Systems Healthcare Services Infection Control Guidelines to Remember: • Use of Standard Precautions • Use of Personnel Protective Equipment when necessary • Categories of Isolation • Departmental Infection Control issues • Management of infectious patients © GE Medical Systems Healthcare Services PHYSICIAN DIRECTOR INTERVIEW © GE Medical Systems Healthcare Services 36 © GE Medical Systems Healthcare Services
  • 36. INTERVIEW QUESTION TOPICS • Policy and procedure development • Patient/family education process • How continuity of care is maintained • Patient rights and advance directives • Ethical dilemmas © GE Medical Systems Healthcare Services Conscious Sedation: • Defined as: ! Sedation, with or without analgesia, which results in the loss of protective reflexes (see workbook for complete JCAHO definition) • Same level of care provided throughout facility, wherever conscious sedation is administered © GE Medical Systems Healthcare Services Conscious Sedation: • Must perform pre-anesthesia assessment • Must obtain patient’s informed consent • Must monitor patient’s physiological responses to sedation during procedure • Physician directed, may be registered nurse performed • Physician and registered nurse must have demonstrated competency • Proctored for assurance of competency on new procedures & techniques © GE Medical Systems Healthcare Services 37 © GE Medical Systems Healthcare Services
  • 37. PERFORMANCE IMPROVEMENT © GE Medical Systems Healthcare Services Performance Improvement Expectations: • Interdepartmental performance improvement activity (CQI teams, etc.) • Intradepartmental performance improvement activity • Quality control activity • Peer review and competency (quality assessment and improvement) © GE Medical Systems Healthcare Services DEMONSTRATED PERFORMANCE IMPROVEMENT SUCCESS © GE Medical Systems Healthcare Services 38 © GE Medical Systems Healthcare Services
  • 38. QUALITY CONTROL ACTIVITY © GE Medical Systems Healthcare Services 39 © GE Medical Systems Healthcare Services