JCIA QA.ppt

JCIA Survey
 Specially Trained Surveyors Will Visit & Evaluate
Each Health Care Organization’s Compliance
And Identify Strengths And Weaknesses. The
Surveyor’s Goal Is Not Merely To Find
Problems, But to score Health Care
Organizations for their Improvement .

Preparation for Accreditation
It’s very important that you have to be ready for the
survey.
 Keep up-to-date & thorough with all the
standard procedures involved in your assigned
job & related medical records procedures.
 Seek your direct supervisors help & clarify your
doubts

Tips to get educated
Education Is A Big Piece of the Puzzle:
 Try to review your departmental announcements
& policy / guidelines information from the intranet
"hospital portal”
 Maintain competency in all your tasks.
 The training manuals are readily available in
your respective stations –
Use it as your regular reference guide.

This is the Key
 Be organized (in your respective areas) And
Surveyors Are Less Likely To Dig Deep.
 Always Have Key Information Handy
 Demonstrate Improvement – Surveyors Will
Want To See Whether Your Area is undergoing
any improvement.

 Question
What is the mission of Madinat Zayed
Hospital?
To provide high quality healthcare services,
that is accessible to all people we serve in
the Western region
JCIA Questions/Answers Cont’d …

 Question
What is the vision of Madinat Zayed
Hospital?
The vision of Madinat Zayed hospital is to
be a leader in the provision of excellent,
compassionate, rural healthcare

JCIA Questions/Answers
 Question
What do I say if I don’t know the answer to a Joint
Commission surveyor’s question?
 Inform him/her where you would go to find the
answer (e.g., I would ask my supervisor,
reference a specific policy manual, etc.).
 NEVER RESPOND, "I DON’T KNOW."

 Question
What do you do in case of fire?
 RACE see printed cards in all units
 PASS see printed cards in all units
 CALL 666.

 Question
A. Where are the fire extinguishers in your work area?
 (Individual to each area)
B. List the 2 types of extinguishers and the types of fires
they may be used on.
 Type 1 – Carbon dioxide (CO2) in black cylinder.
Use on flammable liquids and
electrical fires.
Type 2 – A multi-use dry chemical extinguisher
in a red cylinder.

 Question
If there is a fire, where are patients moved?
Please review the unit map and the evacuation route
and fire exits in your unit. Please locate the
closest assembly point (recently placed outside
the hospital building)

 Question
If there is a fire, where are patients moved?
 Move patients laterally beyond one set of fire
doors if the fire is in your area. If not possible to
evacuate horizontally, evacuate vertically using
fire safe stairwells. Do not use elevators.

 Question
When the fire alarms are ringing, how do you know
if the fire is in your area?
Over head address system
Continuous alarm means the fire is in the area

 Question
How do you report an emergency
security incident such as an assault?
 Activate Code White( violent person) by
dialing switchboard on (0).
 Fill out OVR.

 Question
What is the Madinat Zayed hospital
smoking policy?
MZH is a smoke free zone

 Question
How do you report suspected infant
abductions?
Immediately activate Code Yellow (Missing
Patient by dialing the switchboard.

 Question
What is an MSDS sheet and where are they
located?
MSDS is the acronym for Material Safety Data
Sheets. They describe products, safety
measures and precautions that should be
considered when using products, and
procedures for hazardous exposure. MSDS
information can be found on each ward.

Question
A chemical you don’t know about is on the
floor. What do you do?
 Refer to the MSDS manual.

Question
What is the proper method of needle
disposal?
 Do not recap
 Dispose in the sharp box

 Question
What are Standard Precautions?
 Precautions used for all patients and are designed
to reduce the risk of transmission of
microorganisms from recognized and
unrecognized sources or infections in the hospital.
Use personal protective equipment appropriate for
the situation to avoid any exposure. See the
Infection Control Manual

 Question
How do you dispose of infectious waste?
Red plastic bags and refer to the Infection
Control Manual.

 Question
What are the infection control indicators at
MZH:
1-Compliance with hand hygiene
2-Ventilator associated pneumonia (ICU)
3-Catheter related blood stream infection (ICU)
4-Urinary catheter related infection (ICU)
5- Surgical site infection

 Question
What are the infection control indicators at
MZH:
6-Compliance rate with Ventilator associated pneumonia
and central line bundles of care
7-Compliance rate with the surgical site infection bundle of
care

 Question
What is the best resource for infection
control issues?
The infection control manual and the infection
control nurse
Ext:560

 Question
How do you report a Code Blue and code
pink?
All Code Blue’s should be reported by dialing
“222“ followed by Overhead bagging

 Question
What happens in the case of an electrical
shutdown?
Emergency generator power will come on
within seconds after losing power.

 Question
How are communications maintained in the
event of a telephone outage?
Via e-mails
Mobile telephones
Porters

 Question
What would you do if the medical gas
system were disrupted? What gases are
available in your area?
Use portable oxygen tanks as necessary until
the system is restored and then have tanks
refilled
in hospital there is oxygen in all
wards/department but in some specific areas
nitrous oxide is present.

Question
What would you do if the water supply were
cut off?
Inform engineering department.
The hospital has an alternative source of
clean water in case of emergency.

 Question
How did you receive training to operate the
equipment in your area?
 Training should be received at initial orientation and
through in-services. The operating manual should be
accessible. Staff are also trained on new technology
and equipment when they are introduced to their
units.
 Biomedical engineering department arranges training
when requested

Question
How does MZH assure that equipment is
safe for use?
Equipment are checked regularly by
biomedical engineering department as per
their specification and stickers are maintained
on the equipments to indicate the date of last
preventive maintenance and date of next
maintenance.

 Question
What is "restraint?“
A physical or mechanical device or
medication used to involuntarily restrict the
movement of the whole or a portion of a
patient’s body as a means of controlling
his/her physical activities in order to protect
him/her or others from injury.

Question
Are handcuffs used for prisoners considered
restraints?
Devices used by corrections officers do not
fall under the MZH policy on the use of
restraints.

 Question
What do you do if a sentinel event occurs?
Sentinel event is unexpected occurrence involving death or
serious injury. Serious injury specifically include loss of
limb or function. Examples: wrong site surgery, infant
abduction.
-Follow MZH sentinel event policy: inform head of
department, manager or nursing supervisor who will
inform immediately other senior leaders.

 Question
Who should fill out Occurrence of
Variance Reports (OVR) ?
Any MZH staff member who witnesses an
accident or unusual incident involving a
patients or visitor .
Any staff member who is injured or involved in
a work related accident.

 Question
To whom do you report incidents?
The immediate supervisor on duty.

 Question
Where do you find out information about
hazardous materials?
Ask supervisors. Look at MSDS information
sheet available in your department.

 Question
What do you do if a Disaster is announced?
Refer to the hospital Disaster Plan. Check
your department and unit responsibilities and
the action card .

Question
As you answer a telephone call, a news
media representative asks questions about
a patient receiving care at MZH. What
should you do?
The caller should be asked to contact the
Hospital director office.

 Question
How do you report a blood exposure (via
needlestick, splash, etc.)?
Fill an OVR
See Infection control manual
(Employee health policies)

Question
What is the major infection control measure
that you can use to decrease the
transmission of organisms?
Hand washing.
When should you wash your hands?
Before each patient contact, before and after
removing gloves, after using the restroom,
blowing your nose, before eating.

 Question
What do you do if a patient is suspected of
having TB?
See Infection Control manual
We have special room with negative pressure
for airborne isolation which is required for
patients with Tuberculoses.

Question
What is the MZH structure for reporting
safety issues?
Staff are required to complete an OVR

(PFR) Q&A continued..
 Question: How do patients know the
hospital mission?
Answer: The hospital mission, vision and
values are posted in key areas, they are
available in the patient booklet also.

Cardiac Arrest Code Blue
Fire Code Red
External Disaster Code Orange
Internal Disaster Code Green
Violent Person Code White
Missing Person Code Yellow
Hazardous Spill Code Brown
Bomb Threat Code Black

JCIA QA.ppt

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JCIA QA.ppt