CBAHI common questions 2023

1. Most common
Questions of CBAHI

2. Q: How does the credentialing and privileging process work at FH ?
A:
Medical staff are credentialed by the FH Credentialing and Privileging
Committee.
(Refer to Credentialing, Privileging Policy).
Initial privileges include a 3 month probationary period, and full privileges
are
granted at the recommendation of the Department Head and endorsed by the
Hospital/Center/Director.
Privileges are reviewed every 2 years and granted at the recommendation of
the Department’s Head.
Essential Safety Requirements

3. Q: How will you access the clinical privileges of the medical staff?
A: We have it in our nursing station ; we go to station then locate folder FH" medical
staff privileges“
Q. What will you do if the physician is not privileged to do the procedure?
A: Stop the physician and inform that he or she has no privilege to do such procedure.
Refer
to the consultant
Q: How will you access the clinical privileges of the medical staff?
A: We have it in our nursing station ; we go to station then locate folder FH" medical
staff privileges“
Q. What will you do if the physician is not privileged to do the procedure?
A: Stop the physician and inform that he or she has no privilege to do such procedure.
Refer
to the consultant

4. Q: Where are medical staff responsibilities defined?
A: Medical staff structure and responsibilities are incorporated into
Medical Services Policies or By laws.
Documentation requirements are addressed in the Documentation
Policy.
Each member of the medical staff is responsible for reading,
understanding and
implementing the responsibilities outlined in these policies which are
available in
the FH Departments , Director Approved all Policies Folder.

5. Q: Do your qualifications match the requirements of the
department where you are working?
A: Yes. Screening begins during the recruitment process,
including interviews, evidence of medical education and
experience.
The credentialing and privileging process validates education,
experience, additional skills and training.
** The process of blood transfusion**
Q; who is requesting?
A: Only the physician is allowed.

6. Q: Elements of blood transfusion request ?
A: - Description of the transfusion process,
- identification of the risks and benefits of
transfusion,
- identification of alternatives including
consequences of refusing the treatment,
giving opportunity to ask questions, giving the
right to accept or refuse the transfusion,
physician is responsible in obtaining the consent

7. Q: Frequency of monitoring blood transfusion ?
A: According to FH policy,
Check the vital signs and record it accordingly:
Prior to transfusion.
Every 15 minutes during the first hour.
Every 30 minutes during the 2nd hour.
Then hourly.
At completion of the transfusion
Transfusion in operation room will be checked as above or as needed
per clinical
situation.

8. Q: Process to be followed if there is Blood transfusion reaction ?
A: According to policy,
Stop the transfusion; remove blood unit bag and administration set. Keep Intra Venous
(IV) line and run normal saline
check vital signs,
inform the physician immediately,
check for clerical error,
maintain good urine output,
for hypotension: consider administration of dopamine
Send Blood bank transfusion reaction workup samples: ABO and Rh-D type, direct
anti globulin test (DAT), antibody screening and identification and blood unit bag
with tag attached along with the administration set.
To note, blood bank may call for more samples as required,
inform blood bank immediately,
fill the blood transfusion reaction form,
initiate OVR

9. Q: When do you assess patients for Venous Thromboembolism (VTE) ?
A: According to our policy Venous Thromboembolism Prophylaxis Guideline
(VTE ),policy all
patients must be assessed and evaluated on admission or within 24 hours of
admission to FH .
Q: When do you reassess patients for Venous Thromboembolism (VTE) ?
A: According to our policy Venous Thromboembolism Prophylaxis Guideline
(VTEP), when there are changes in patient's condition we must re-assess the
patient for VTE .
Q: what tool do you use for assessing medical patient for VTE ?
A: We are using --- VTE prediction Score

10. Q: what tool do you use for assessing surgical patient for VTE ?
A: We are using VTE Risk Score .
Q: How do you start VTE treatment to your patient?
A: Follow guidelines outlined in the policy, VTEP- Venous Thromboembolism
Prophylaxis Guideline.
: As for nurses: Follow the physician order written in the patient file .
Q: What is the proper patient identification process?
A:
Refer to Patient Identification Policy ( -----)
Two patient identifiers (MRN and Patients verbalization of Full Name
composed of
four digits)

11. Q: When do you use two (2) unique identifiers of patient?
A: (2) unique patient identifier (MRN & Pt. Name) are used when:
Administering medications
Administering blood and blood products
Taking blood samples
Taking other samples for clinical testing
Providing treatment or procedure .
: Q Who are privileged to administer moderate sedation?
A: According to policy moderate and deep sedation/analgesia () only
anesthesiologist, ICU
Physicians, emergency physicians (at least assistant or associate
consultant)
certified ACLS and training sedation conscious with
people other are privileged to administer the
sedation

12. Q: What discharge criteria do you use for patients who had sedation?
A: PACU: Modified Aldrete Scoring System (12/12): Oxygen Saturation, Respiration, Color,
Circulation, Conscious Level, and Activity. The patient shall be discharge if total reached 10
or more.
Q: What is time out?
A: Also known as surgical pause, it is when everyone in the team involved in a procedure
pause to do the final verification of the patient.
Q: What are the components of time out?
A: During the time-out, the team members agree on the correct patient
identity, the correct procedure to be performed, the correct site, and when
applicable, the availability of the correct implant or equipment

13. Q: How do you ensure correct procedure to the correct patient?
A: By properly identifying the patient thru MRN and complete four
names, by rechecking the
consent, and checking the pre-op checklist and finally by doing time
out.
Q: What is your criteria for doing site marking?
A: Site marking is done when the organ/body part to be operated is
bilateral, multi-structural
like fingers or multi-level like the spine

14. Q: Who is the only allowed staff to do the site marking?
A: The performing surgeon is the only staff allowed to do the site
marking
Q: Where is site marking done?
A: Arrow like sign is drawn in the patient's skin at the inpatient unit or
the day care surgery
unit
Q: Where are your medical gases, and who turns these off in case of fire?
A: Our medical gases are wall-mounted. In case of fire, the charge nurse
or head nurse can
turn these off.

15. Q: How will you know if your negative pressure room is working?
A: According to our policy, the accepted range of pressure inside must be
less than -2.5, ACH 12
temperature is 21*C to 24*C for patient room and 18*C to 22*C for OR,
humidity is 30%- 60% ACH 20
Q: How frequent are you monitoring the airflow in the negative pressure
room? A: According to our policy, it must be daily .
Q: What is MSDS and where it is available?
A: MSDS is material safety data sheet and it is available in all areas where
chemicals are
existing.

16. Q: Where do you store your chemical spill kits and how frequent are you replacing its
contents?
A: It is stored in an easily accessible location and should be restocked following use and the
contents should be checked in monthly basis
Q: How do you promote safety of high alert medications?
A: By storing the medications in a locked storage room, proper labeling of high alert
medications, and by doing independent double checking by nurse upon administering the
medication

17. Q: Are you aware about high alert or medications?
List of approved medications is available
All high alert medications are labeled with special label in the pharmacy and
patient care areas.
High alert medications required triple check before dispensing, refer to High
Alert Medication policy.
Q: How do you ensure safety of look-alike and sound-alike medications?
A: By following the TALLman and shortMAN method of labeling, and by
independent double- checking by the nurses upon administration.

18. Q: What is a Near Miss?
A: According to Occurrence/Variance/Accident Reporting Policy describes
that Near Miss is an event or situation that could have resulted in an accident,
injury or illness, but did not, either by chance or through timely intervention.
Q: What is a Sentinel Event?
A: According to Sentinel Event and Root Cause Analysis Policy (QMD-007),
Sentinel event is
an unanticipated occurrence involving death or major permanent loss of
function unrelated
to the natural course of the patient's illness or underlying condition. They are
events that
require an immediate response from the hospital with root cause analysis and
recommendations to prevent future occurrences.

19. Q: Why reporting incidents is important?
A: To determine unusual events which can affect the clients of FH and to help
the management levels to take appropriate decisions to prevent or minimize
risks or harms.
Q: How do you report events/incidents in the hospital?
A: We have manual OVR system, which we utilize according to policy ,
Occurrence/Variance/Accident Reporting Policy
Q: When are you supposed to report an incident?
A: According to Occurrence/Variance/Accident Reporting Policy , we must
report incidents
immediately

20. Q: What is your role in case of fire?
A: Rescue the patient, activate the alarm, confine the fire, extinguish the
fire and evacuate the patient (RACE) .
Q: How do you extinguish the fire?
A: Pull the pin, Aim at the base of the fire, Squeeze the handle/lever, sweep
from side to side (PASS) .
Q: What are the types of fire extinguishers that you have in the hospital?
A: We have ABC powder, Carbon Dioxide and FM200

21. Q: What are the two types of evacuation?
A: We have vertical and horizontal evacuation. In horizontal evacuation command is coming
from the charge nurse, head nurse or the safety office while the vertical evacuation,
command is coming from the office HD in center Command
Q: Where is the nearest: Emergency Exit? Fire extinguisher? Eyewash station? Evacuation
Map?
Inform the surveyor about the locations of at least two Emergency Exits, show the
evacuation maps or the eyewash station if available in the unit.
If you do not know, ask your FH SAFETY OFFICE (Mr. ---------------

22. Q: What procedures do you follow in case of a chemical spill?
A: According to our Hazardous Materials and Waste Management Plan ,
Identify the chemical before attempting to clean up any hazardous chemical
spill or splash.
Obtain MSDS on chemical. Follow the directions according to the established
procedures for cleaning up that kind of chemical spill or leak.
Notify people in the immediate area, supervisor and Safety Officer.
Activate CODE ORANGE + Location of the spill by dialing -------.Mr Officer
Hazmat
Evacuate all personnel from the area and close all doors.
Ensure adequate ventilation. fire occurs, set off the fire alarm and extinguish
flames.
Wait by the spill area, well out of danger, until help arrives. Avoid tracking
through the spill.
Obtain appropriate personal protective equipment. (See MSDS)
Complete incidents report on spill or leak.

23. Q: codes Emergency For FH call emergency call ------------
Q: From where can you obtain information about safe handling and
chemicals used in your area?
A: Information can be obtained through Material Safety Data Sheet
(MSDS), which explains
the safe handling and storage of chemical used in the unit or department.
Q: What is your role during an Internal / External Emergency/Disaster?
A: According to FH Internal and External Disaster Plans,
My role being a physician/nurse/technician/support service staff is
...........
(Kindly refer to the plan and identify your role in FH External Disaster
Plan and FH Internal Disaster Plan ACTION CARDS)

24. Race Pass

25. Hospital
Codes

26. Q: What do you do in case a patient locked bathroom's door and fainted
inside?
A: There is a mechanism by which bathroom doors can be opened from
outside (you might be asked to show how).
Q: Where should you keep flammable materials?
A: Inside Safety Cabinets
Q: What is the voltage rating for FH ?
A: 220 volts
Q: What are the types of isolation precautions do you know?
A: Types of isolation are
Droplet Precautions
Airborne Precautions
Contact Precautions
Q: When will you change the sharp box/container?
A: When the sharp container is ¾ or spoiled or bad smile
according to our policy

27. Q: What are the components of standard precautions?
A: According to Standards precautions policy , components of standard precautions
include:
Hand hygiene
Personal protective equipment as per need
Equipment disinfection/sterilization.
Proper sharps disposal
Safe injection practices
Proper disposal linen and wastes.
Patient Placement
Healthcare workers immunization.
Environmental Control
Cough etiquette and Respiratory Hygiene
Q: When do you implement standard precautions?
A: According to standard Precaution Policy , all healthcare workers will practice
standard precautions in any setting where healthcare is delivered regardless of patients’
health condition

28. Q: What are the transmission- based precautions?
A: These are precautions applied based on method of transmissions of the
organisms and can be classified as follows:
Contact precautions organisms transmitted by contact such as MRSA.
Droplets precautions for droplets transmitted diseases like influenza
Air-born precautions for air-born transmitted diseases like Pulmonary
tuberculosis
Q: What do you mean by Contact Precautions?
A: Contact precautions means to prevent organisms and infection transmitted by
touch including:
Keeping patient in single room or cohort with other patients with same
organism
Keeping contact precautions signage outside on the room door
Wearing gown and gloves when contacting patients
Posting “Contact Precaution” signage in the patients room door/entrance.
Examples:

29. Q: What do you mean by Droplets Precautions?
A: Droplet precautions means precautions taken to prevent infections transmitted by droplets
within three (3) feet distance, including;
Keeping patient in single room or cohort with other patients with same organism
Keeping droplets precautions signage outside on the room door
Wearing surgical mask if close to the patient within three feet (1 meter) distance.
Applying the above with standard precautions
Examples:
Influenza, Meningococcal meningitis .
Q: What do you mean by Air-borne precautions?
A: Air-borne precautions means a precaution to prevent infection transmitted by air
including;
Keeping patient in Negative pressure room
Keeping Air-born precautions signage outside on the room door
Wearing N95 mask before entering the room
Applying the above with standard precautions
Examples:
Open pulmonary TB, Chicken pox, Measls ,MERS CoV

30. Q: What will you do if you get needle stick injury?
I will wash the injury site with soap and water
Stop the bleeding by covering the injury site
I will write stick Needle Report and submit to my supervisor.
I will go to infection control department for recommendations.
I will go after that to staff clinic during working hour or ER outside the
working hours, receive any necessary medications, and have serology tests
done.
Q: Can you tell me how to prevent needle stick injury?
I should be very careful during use of sharp.
I will keep the sharp box close to me during procedures.
I will dispose the sharp needle along with the attached syringe immediately
as one
piece in the sharps box and will not recap or give it to somebody to dispose
it.
I will keep the sharp box within the reach of my hand.
I will not walk with the sharps in my hand

31. : How are patients accepted for admission or outpatient care at FH ? What
are the eligibility criteria?
A: Based on patients identified needs and BCH mission and resources.
Acceptance for care at FH is criteria based. Refer to Patient Eligibility
Criteria , Admission, Discharge, Transfer Policy , Patient Registration
Q: Is there a type of patient that you would not admit to FH ?
A: Patients whose identified needs cannot be met at FH are not accepted for
admissions at FH based on FH mission and resources. Refer to Patient
Eligibility
Criteria ,

32. Q: What are the assessments and tests required before admitting patients
to FH ?
A: Assessments and tests required before admitting patients are based on
the patient's
identified medical and nursing needs and the service specific requirement
(Refer to Interdisciplinary Assessment and Re-Assessment Policy and
Admission, Discharge and Transfer Policy ).
Q: How are patients prioritized for care at ED FH ?
A: Patients with emergent, urgent and immediate needs are given priority
for
assessment, treatment and admission.
Refer to ED Triage Policy ( --), the triage process is evidence based.
Patients are
prioritized based on urgency of their needs and managed accordingly
Other standards

33. Q: What information is provided to patients and families upon admission to
FH?
A: Patients and families are provided information on the proposed care,
expected outcome of that care and any expected cost to the patient for
care. Refer to Admission, Discharge and Transfer Policy , patient
information booklet and Rights and Responsibilities of Patients and Family
Policy.
Q: What are the barriers to access to care and delivery of services at FH?
How are those barriers managed and overcome?
A: Language barrier is the most common barrier occurring in terms of
access to care and delivery of services. However, FH - Patient Services
Management provides social services and translation for patients with
language barriers according to Communications with Patients-Visitor with
Special Needs Policy .

34. Q: What criteria are used to admit and transfer patients to and from
Intensive and Special Care Units?
A: Intensive and special care units have admission, transfer and
discharge criteria as per Admission and Discharge in ICU and Criteria are
physiologically based. (Refer to individual unit criteria) .
Q: How do you find out who is the attending consultant responsible for
the care of the patient?
A: All patients admitted FH to are admitted under the care of an
attending consultant. The attending consultant is responsible for the
care of the patient. The patient is
informed of his attending consultant. This can also be checked through
our medical plus system and the patient medical records.

35. : How are patients managed in the ED when there is no bed available on the
desired service or unit or elsewhere at FH ?
A: If there is no vacant bed in the hospital for the emergency case, patients
are held for observation and treatment in ED until a bed is available or
stabilized for transfer to another institution. (Refer to Observation of Patient
held in Emergency Department- ACC 009)
Q: How are patients informed of delays or waiting periods for diagnostic or
treatment services?
A: Patients are informed when there are long waiting periods for diagnostic
and/or treatment services and the process of placement in waiting lists.
Patients are informed of the reasons for delays and are provided with
information on
available alternative CONSISTENT with the clinical needs and this is
documented in the
patient's record. Refer to Admission, Discharge, Transfer Policy (---)

36. Q: How is continuity of care ensured after discharge/transfer?
A: Discharge planning starts soon after admission to fH , Discharge planning
begins early in the care process and involves the family. Patients are referred
and/or discharged based on their health status and needs for continuity of
care. The patient's readiness for discharge is determined by the use of relevant
criteria to ensure patient safety. Discharge/transfer planning process considers
the patient's need for social,
nutritional, financial, psychological and other support upon discharge/transfer.
Refer to Multidisciplinary Discharge Planning

37. Q: What are the follow up instructions given to the patient/family upon discharge to ensure
safety and continuity of care?
A: Patients and their families or caregivers are provided with understandable FOLLOW UP
Instructions. The instructions include any return for follow up care, when to obtain
urgent care, instructions for care as necessary to the patient's condition. (Refer to
Discharge Summary)
Q: How do you manage and follow up patients who leave against medical advice?
A: When inpatients or outpatients choose to leave the hospital against medical advice, the
risks related to inadequate treatment that may result in harm on death are fully explained
to the patient and family. The primary consultant, the primary care or referring physician,
and the patient relation personnel are involved in the process of discussing further of the
risks and benefits of patient well-being. In addition, discharge medications and discharge
summary is given to the patient (Refer to Discharge Against Medical Advice Policy

38. Q: When and how are patients transferred to other institutions?
A: Patients are transferred to other institutions based on status and the need to meet their
continuing care needs. The staff, equipment and supplies needed for safe transfer are
identified. To ensure that the receiving institution can meet the patient's continuing care
needs. The patient clinical information or a clinical summary is transferred with the
patient. The summary includes patient status procedures and other interventions
provided and the patient's continuing care needs. Refer to Admission, Discharge and
Transfer policy .
Q: Tell me about the process of patient's transfer and transport?
A: During transfer, a qualified staff member monitors the patient's condition.
Depending on patient condition, patient may need continuous nursing or medical
oversight. The patient condition and status determines the appropriate qualification of
the staff monitoring the patient during transfer. The transfer process is documented in
the patient's record (Refer Admission, Discharge and Transfer Policy and Refer
to workflow and Ambulance Transport Procedure .

39. Q: What is the timeframe for initial assessment?
A: The initial medical assessments are completed within 24hours and nursing i n i t i a l
a s s e s s m e n t a r e c o m p l e t e d w i t h i n 12 hours after the patient's
admissions as inpatients or earlier as indicated by the patient condition and policy.
The initial medical assessment is documented before anesthesia or surgical treatment.
The medical assessment of surgical patients is documented before surgery. Medical,
Nursing, Nutritional and functional assessments are completed as part of the initial
assessment. All inpatients and outpatients are screened for pain and assessed when pain
is presented. When pain is identified from the initial screening, the patient is
referred for a comprehensive assessment. Additional, specialized assessments are
performed for specified needs patient population. Reassessments are conducted and
documented in the patient's records:
At regular intervals, during the care of patients.
Daily for acute care patients
In response to significant change in patient's condition.

40. Q: How is multidisciplinary care integrated and coordinated at FH?
A: MRP shall overview the plan of care of all healthcare providers including
physician, nurses and others. MRP shall review this initial and ongoing plan
of care and document the review
on (MRP –CONSULTANT PLAN OF CARE REVIEW FORM) .
Q: When does patient's pain must be re-assessed
A: Refer to Pain assessment and management policy ------
Q: How are patients approaching the end of life cared for at FH?
A: Palliative care is provided, appropriate treatment of symptom according to
the wishes of the patient and family. The patient and family are involved in
all aspects of care.
(Refer to End of Life Care Policy )

41. Q: Are patients with emergency or immediate needs given priority for
assessment and treatment?
A: Yes.
The Emergency Department uses the Triage System (Canadian Triage and
Acuity Scale) which Categorizes physiological symptoms the patient presents
with on 1-5 triage score.
Prioritization of patient care in these areas is based on these established
criteria.
(Refer to Triage Policy )
Q: Are assessments from outside facilities accepted in FH ?
A: !!
Refer to Interdisciplinary Assessment and Reassessment Policy

42. Q: Have all patients been assessed for skin integrity and how can this be
identified?
A:
Refer to Pressure Ulcer Prevention and Management Policy
All patients shall be assesses as to their risk of developing pressure ulcers
using the
Braden risk assessment tool on admission, transfer in, and with any
deterioration of
condition.
Q: When you go on vacation, how do you hand over your patients?
A: I inform my patients of the name of the clinician who will be caring for
them when I am on vacation.
I also write a summary in the record of the patient’s condition, what care
the patient has received, the responses to the care received and what the
plan of care currently entails.
I also document the transfer of care to the named clinician in the
record. (Refer to Patient Care Responsibility Assignment and Transfer Policy

43. Q: How is patient care integrated and coordinated in FH ?
A:
All staff members involved with the delivery of patient care use the patient’s
record to document and review the patient’s current treatment, assessments, test
results coordinating care with other health care workers.
The I nterdisciplinary Progress Notes i s one of the tools used t o coordinate
patient care delivery. (Refer to Patient Care Planning Policy , Patient Health Documentation
Policy.
Q: Are patients at risk identified and competent staff assigned to provide their care? Give
examples.
A: Yes.
Staff providing care to patients receiving conscious sedation, chemotherapy,
intensive care and other specialized care such as the operating room receive
specialized training and maintain competencies based on the needs of the area
where they are assigned.
Additionally, all inpatients are assessed for falls risk, and appropriate
interventions are applied based on that risk. (Refer to policy)

44. Q: How do you deal with patients deteriorated in the wards?
A: Refer to Policy – Rapid Response Team
Q: How do you ensure the patient's right to confidentiality?
A:
Expect that information, communication and other records pertaining to care
including the source of payment for treatment are to be treated as confidential.
Discussions or consultations involving the patient’s case conducted discreetly.
Discussing and performing care only in the presence of the patient or in the
presence of others only after permission by the patient.
Never discuss with a patient what treatment another patient is receiving.
Patients should never be discussed in hallways, the cafeteria, on elevators or in
other public areas.
Restricted Access to Patient’s File and Ensuring all patient-related information is
safeguarded.
Refraining from discussing patient information publicly or at home.
Keeping electronic and paper medical records and patient data secure at all times.
All patient information should be accessed on a need to know basis, whether
the information is accessed by computer, paper or spoken word.
Knocking before entering the room.
To be transported to their scheduled procedure in a proper and respectful way
(Covering our patients during transport).
Privacy curtains pulled, doors shut during treatment and care
(Refer to Rights and Responsibilities of Patients and Family Policy)

45. Q: What is your Role in providing Patient/Family Education?
A: There is comprehensive patient and family education provided by care
givers (giving appropriate information about illness and possible
complications, hand washing technique, treatment and possible surgical
procedures, use of equipment, pre- operative preparations and post-
operative care, proper use of post-operative medications, x-ray
procedures, dietary restrictions, when to seek medical assistance, and
follow up appointment).
(Refer to Interdisciplinary Patient and Family Education)
Q: When are your patients' learning needs assessed?
A: Learning needs are assessed as part of the admission assessment and
each time the patient’s condition or needs change.

46. Q: Where do you document patient teaching?
A:
Interdisciplinary Patient and Family Education Policy (PFE-001) describes a process
that will provide accurate and complete information with regard to patient
assessment, barriers to learning, specific interventions and continued educational
needs.
Educational documentation is documented in Interdisciplinary Patient and Family
Education Record Form
Q: What tools can be used for patient education?
A:
One‐to‐one individual sessions with a health care provider through verbal and/or
written information, and demonstrations based on the assessment.
Lectures and/or seminars and group therapy designed to increase the knowledge‐
base of Patient/family and the general population.
The Patient and Family Education department provides pamphlets, and other
printed materials along with direct patient educational sessions.
(Refer to Interdisciplinary Patient and Family Education Policy (PFE- ) Policy)

47. Q: What is the proper patient identification process?
A:
Refer to Patient Identification Policy
Two patient identifiers (MRN and Patients verbalization of Full Name
composed of four digits) .
Q: When do you STRICTLY use two (2) unique identifiers of patient?
A: Use two (2) unique patient identifier (MRN & Pt. Name) is used when:
Administering medications
Administering blood and blood products
Taking blood samples
Taking other samples for clinical testing
Providing treatment or procedure

48. Q: How are patients at risk of falls identified?
A:
Refer to Falls Prevention and Management
All patients are to be assessed as to their risk of falling on admission, transfer in,
with
change in condition and post a fall using the approve age appropriate risk
assessment tool (e.g. Morse Fall Scale) and every shift.
Adult patients identified as at risk are to wear a PURPLE patient identification band
having and fall stickers on patient's chart.
Take action to decrease or eliminate any identified risks.
Q: Quality Improvement and Patient Safety (QPS)
A:
QPS processes provide the framework for the organization and its leaders to
achieve a commitment to provide quality patient care in a safe, well-managed
environment and reduce risk to patients, staff and visitors.
(Refer to Quality Management and Patient Safety Plan; FH Risk
Management Plan; Occurrence Variance Accident Report Policy)

49. Q: What are indicators used for?
A:
To track improvement activities
To measure day-to-day operation
To provide strategic directions
To compare performance to an established norm (e.g. benchmarking)
To reflect achievement of positive outcomes.
Q: How do you receive communication about changes in the organization?
A: Depending on the type of change in the organization, communication can be
provided through:
The Communications from HD and Management through the chain of command
Committee minutes and reports
Electronic e-mail notices
Posters
Presentations
Direct verbal communications

50. Q: How do you access your departmental KPIs?
A: QM reports for the list your key performance indicators.
Q: What are the hospital wide quality and patient safety priority in FH ?
A: Refer to patient safety committee portfolio (PSC-003) and Quality
Management and Patient Safety Program (QPA-011).
Q: Do you know what model FH uses for Quality Improvement?
using the FOCUS-PDCA improvement model.
F : find an opportunity for improvement
O : organize a team work
C : clarify the current process
U : understand the problem
S : select the desired outcome
This focus requires the chosen process to go through the (Plan – Do –
Check – Act) cycle
in order to bring about an improvement

51. Q: How are FH staff involves in Quality Improvement?
A:
All FH staff are involved in quality improvement through various activities
such as:
FH Quality Workshops and Lectures, FH Standing Committees in each
chapter, education awareness lecture, FH grand round lectures, IPSG
campaign.
Q: How are clinicians involved in Quality Improvement?
A:
Clinicians perform peer review activities and audits.
Each department monitors important aspects of care, analyzes the data
and reports
findings on a quarterly basis to the FH QM Department where they are
aggregated and shared with Medical Management.
Members of key committees also participate in QI activities by their
ongoing analysis of data provided to the committee for action.

52. Q: How are FH staff involves in Quality Improvement?
A:
All FH staff are involved in quality improvement through various activities such as:
BCH Quality Workshops and Lectures, FH Standing Committees in each chapter,
education awareness lecture, FH grand round lectures, IPSG campaign.
Q: How are clinicians involved in Quality Improvement?
A:
Clinicians perform peer review activities and audits.
Each department monitors important aspects of care, analyzes the data and reports
findings on a quarterly basis to the FH QM Department where they are
aggregated and shared with Medical Management.
Members of key committees also participate in QI activities by their ongoing analysis
of data provided to the committee for action.
Q: What type of PI projects is your Department involved in?
A:
(Educate yourself with the Performance Improvement Projects (PI) occurring in your
Department)
Each Department and services has a PI projects identified by the related Quality
Improvement Committee. Use the FH PI form and you should be able to inform
why that project was chosen (any. 1598 or1596dept.QMcallQs
Examples: Prevention patients' falls, Prevention of pressure ulcers, Medication errors,
Triage in Emergency Department and Documentation in the Medical Records.

53. Q: What is FH policy on Informed Consent?
A: According to FH Patient Consent for Diagnosis, Treatment and Intervention
policy, it is a process in which the physician; qualified credentialed to perform the
treatment or procedure; provides adequate information for the patient or patient's legal
representatives to make an informed decision on the proposed treatment, including
medications or procedure.
Consent states patients have a moral, legal and ethical entitlement to be fully informed
regarding the risks, benefits, alternatives and options of treatment to certain types of
procedures as well as the consequences of not doing that procedure.
Consent must be obtained from a patient, legal guardian or authorized person in behalf
of the patient(should the patient be unable to give consent) for all treatments,
procedures/ interventions on one of the following consent forms:
General Consent
Blood Product Transfusion Consent
Surgical and Medical Interventional Consent
Anesthesia and Sedation Consent
Chemotherapy Administration Consent
Photography/ Videotaping Consent
Informed consent must be signed and witnessed using the appropriate consent form.
For procedures listed in the policy specifically including blood administration. (Refer to policy)

54. Q: What's the process for ordering and monitoring restraint?
A: Complete order must be written in patient's file before restraining the
patient. The order must be renewed every 12 hours. Nurses monitor the
patient every hour for any blood circulation issues related to restraint. The
restraint must be released every two hours for 15 minutes when the situation
permits. Refer to Use of Restraint Policy .
Q: What is the physician's signature time frame for verbal and telephone
order in FH ?
A: For verbal orders, it is only done through emergency and the physician
must sign the
order before leaving the unit or after the situation ends. For telephone
orders, the physician must sign the order within 24 hours. Refer to Verbal
and Telephone Order Policy

55. Q: What is the process for receiving telephone orders?
A: Write the complete order, read back to the physician, and sign with a
witness. Refer to Verbal and Telephone Order Policy .
Q: How do you deal with critical rest results reported by the laboratory
technician?
A: We utilize the critical test result form and receive the results with a
witness and verifying all the information including the technician's name
and ID and the result.
The result must be relayed to the physician in no more than five minutes
and actions must be taken as per physician's order. Refer to critical
result reporting policy

56. Q: How do you deal with critical rest results reported by the
laboratory technician?
A: We utilize the critical test result form and receive the results with
a witness and
verifying all the information including the technician's name and ID
and the result. The
result must be relayed to the physician in no more than five minutes
and actions must be
taken as per physician's order. Refer to critical result reporting
policy

57. Questions for laboratory
POCT locations and serial numbers Panic
list should have full name of patient with file number
Riqus proficiency test certificate Alborg annual visit and monthly
visit Ksh blood bank annual visit and monthly visitL.
J chart and QC for POCT Ref temp and inventory
listHow to trice the inventory expiration date
Questions for Radiology
Mostly regarding radiology programs,
KPIs Improvement plans Mri safety
Questions for admission ward
Asking about bed capacity – scope of services – Hand hygiene – and
what to do to reach to target of HH – Asking drs coverage for ward
– Medication room – LASA – IV preparation – High alert –
Patient room vacant ask if there is refrigerator inside – bathroom
patients calling bell – visit one patient in single room ask about
refragirator – food – pain killer – explaining medication .
Questions for Dental
ask staff to introduce
themselves and services given
-Consent for local anesthesia
-Fall risk for pt and how to
prevent
-WATER ANALYSIS REPORT
-See local anesthesia cabinet
and how to manage if finished (
supply chain )
- how send instruments for
cssd

58. Thank
you