Quality Management Office- Ongoing Survey Readiness TipsIn an effort to promote continued survey readiness, the Quality Management

Department will provide regulatory tips on a weekly basis to ensure that we are providing optimal care for our patients and their families.

Tip#1 Medication Management

Two patient identifiers must be checked prior to administering medications. Medication carts should be clean and dust free. Pill cutters/ crushers should be cleaned before and after use. Medication carts must be locked when not attended (for those areas that have

medications carts -- ancillary areas such as PACU, OR, etc...) Fluid warmers should NOT be set higher than 104 degrees F. Always check medications for expirations prior to use. Multi-dose vials must be dated and discarded after 28 days. Label with expiration

date Automated Drug Cabinets (ADC) {Omnicell} are secure. Staff should remember to

log off of the machine when they are done. Medication refrigerators connected to ADC {Omnicell} are automatically monitored.

Appropriate personnel are notified of excursions. In ancillary areas, staff from those areas monitor temperatures of medication refrigerators. Pharmacy must be contacted to access medication integrity.

Blanket orders such as “continue previous medication orders” are NEVER acceptable. PRN medication must include indications SCAN medications and patients Know which medications require double checks Reconcile medications on admission, at transfer (ICU), and at discharge Follow guidelines for RANGE orders Always ensure that medications are secure

Tip#2 FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE) & ONGOING PROFESSIONAL PRACTICE EVALUATION (OPPE)

Practitioners granted initial or new clinical privileges must undergo focused professional practice evaluation (FPPE) at that hospital to assure competency. Additionally, any triggered evaluation (issue-based) event should also cause an FPPE to be performed. In addition, the Medical Staff is required to conduct an ongoing evaluation of each practitioner’s professional performance (OPPE). The OPPE process is a summary of ongoing data collected for the purpose of assessing a practitioner’s clinical competency and professional behavior. OPPE provides each practitioner with useful feedback that will help improve the quality of performance and identify professional practice trends that may impact quality of care and patient safety.

To ensure focused & ongoing professional performance evaluations are conducted in a complete and concise manner, please contact Delinda Pendleton for more information at ext. 2660 or delinda.pendleton@fccc.edu

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Quality Management Office- Ongoing Survey Readiness Tips

Tip#3 Documentation

• When documenting on a pre-printed form, ALWAYS complete every box or line. If the element is “Not Applicable” to your patient, indicate that.

• Always sign, date and TIME every entry whether it is a pre-printed form or progress note or H&P.

• Document completely and clearly so that the next person taking care of the patient can continue the care without concern or question. Read what you wrote – do you understand it? Could you provide care based on what you wrote?

• Make sure all your chart entries are legible!

Entries: All entries signed, dated, timed, legible NO unapproved abbreviationsVerbal/telephone orders:

Write it down and then READ it back Physician to sign, time, date within 24 hours

Verbal test results : Write it down and then READ it back

Tip#4 APPROVED ABBREVIATIONS- Administrative Policy #2

Please refer to the list of approved abbreviations for your review.https://myportal.fccc.edu/portal/c/document_library/get_file?groupId=11406&uuid=68115957-c6a3-4fd0-9889-7d956520d4fb

Tip#5- Radiation Protective Equipment (RPE)

Lead aprons and thyroid collars are provided for your protection against scattered radiation. Care must be taken to prolong the life of this RPE. All aprons must be hung properly on apron racks after use to avoid creases and cracks. RPE should be cleaned regularly using a gently cleaner and a soft brush. Do not use bleach, machine wash or dry clean. All aprons are checked for integrity each year by the Radiation Safety Staff and labeled with a color coded sticker. Please assure yours was checked by looking at the sticker.  New RPE must be checked by Radiation Safety Staff and added to the inventory database. Report any aprons that are removed for repair or replacement. Make sure that your radiation badge is on the apron before you wear it.

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Quality Management Office- Ongoing Survey Readiness Tips

Tip#6 Pain Management Screen every patient for pain, regardless of whether they are being admitted as an

inpatient, visiting a clinic or diagnostic service or having ambulatory surgery.  Convey report of pain to treating clinician. When pain is present, treatment (pharmacologic and non-pharmacologic) or referral

should occur as appropriate Involve the family in the patient’s plan of care for pain. Be sure the family is adequately educated about pain and medications - particularly

upon admission and at discharge. Use language and age-appropriate pain-intensity tools consistently. Evaluate the effectiveness of every step taken to manage a patient’s pain.  If one

approach is not effective, try another. Document your evaluation, management activity and effectiveness of treatment

prominently in the medical record. Assess patients for pain on an ongoing basis, with vital signs for inpatients (while

awake) and before and after interventions used to relieve pain.Restraints—Non-Violent:

Documentation of care plan Order on chart for the appropriate restraint Physician MUST authenticate the order Reordered every 24 hours if needed Document patient monitoring every 30 min.

Restraints—Violent: Paper order & Documentation Requires close monitoring – every 15 minutes Reorder every 4 hours

For additional information, refer to link… http://www.fccc.edu/patients/support/painManagement.html

Tip#7 Material Safety Data Sheets (MSDS)

• Material Safety Data Sheets (MSDS) provide detailed health and safety information and precautions for handling hazardous substances, including emergency and first aid procedures – they are specific to each chemical.

• MSDS binders can be located on the units and in your departments. • In case of a computer and network shutdown , MSDS Binders can be found in the

Safety Office, please contact Joe Rawson at ext. 2573 or joseph.rawson@fccc.edu (R-281) during normal business hours. After hours contact security by calling the operator.

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Quality Management Office- Ongoing Survey Readiness Tips

Tip#8 Occupational Exposures

• OSHA – The Occupational Safety and Health Administration of the Federal Government prohibits eating, drinking, applying cosmetics or lip balm, and handling contact lenses in work areas where there is a likelihood of occupational exposure.

• They have clarified this to include nurses’ stations as work areas where there is a likelihood of occupational exposure.

• So be safe – keep food and drinks (covered or not) in the lounges and outside of patient areas and work areas. This is for YOUR protection.

• If you are working, save your food and drink for your breaks. Breaks are not held in work areas or patient care areas.

Tip#9 Eye Wash Station Maintenance & Testing

Weekly checks of the eyewash station must be conducted to ensure proper function, flush out stagnant water and remove sediment from the emergency equipment.

• Remove the eyepiece caps• Push the handle to the “on” position • Allow the eyewash station to run for three (3) minutes• Replace the caps• If the eyewash station does not function, immediately report the

problem to Maintenance at ext.2217 or go online and put a work ticket in. • Document this procedure on the Emergency Equipment Log weekly

Tip#10 Drying Time Sani- Wipes(Alcohol) and Sani wipes (Bleach) Wipes

Red Sani-wipes and (Gold) Bleach wipes are disposable wipes that kills germs The effectiveness of the Sani wipes depends on their dwell time Sani Wipes = remain on the surface, visibly wet before drying, do not dry with

towels as this will make the product ineffective. Bleach Sani-Wipes are used for C. Diff patients only, call CSR for this product. Questions: Contact Infection Control at 3125, or Environmental Services at 2736

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Quality Management Office- Ongoing Survey Readiness Tips

Tip#11 Expiration Dates

Product ExpirationMulti-Dose Medication Vials: Meds Insulin: 28 days *

Other’s: Manufacturer’s DatePeroxide, Alcohol, Betadine: Meds Manufacturer’s DateSaline Solution for Irrigation 24 hours **Glucose Strips: POCT 120 days from openingGlucose Controls: POCT 90 days from openingHemoccult / Gastroccult Slides: POCT Manufacturer’s DateHemoccult / Gastroccult Developer: POCT Manufacturer’s DateUrine Dip Sticks: POCT Manufacturer’s DatePDI Wipes: (example: label reads MFG 2009/11)

Expires two (2) years after manufacturer’s date (ex: expires 2011/11)

All vials & containers must be labeled with date opened, date expires, and initials. *Date expires & initials on label only**Date opened, date and time expires, and initials on label

Tip#12- SMOKING POLICY

• Fox Chase Cancer Center is a smoke-free campus • Under no circumstances will patients, families, visitors or staff be permitted to

smoke on campus- This includes contractors • Absolutely no smoking is permitted near entrances of hospital buildings,

which includes the Receiving/Loading Platform

Tip#13- ID Badges

Identification badges are a required part of your work attire.

All FCCC staff and physicians must wear their photo identification badge whenever they are at any of the hospital or satellite

Badges must display a full-face photo of the employee, which assures patients, visitors, and colleagues that you are a part of the organization.

Lost, displaced or damaged badges must be reported immediately to Security, Human Resources and your Department Manager.

Tip#14- Five Minute Clean-up Checklist for Surveys

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UPDATUPDATEE

Quality Management Office- Ongoing Survey Readiness Tips  No food or drink in patient care

areas.   Check the clean utility room. Make

sure it is clean. Nothing should be stored on the floor or 18 inches from the ceiling.

  Make sure everything is on the same side of the hallway. All egress routes must be clear.

  Automated Drug Cabinets (ADC) {Omnicell} are secure. Staff should remember to log off of the machine when they are done.

  Make sure fire exits / doors/ fire extinguishers are not blocked.

  Remove material / papers / charts with patients’ names from the top of counters.

  Make sure any stretchers in the hallway have sheets on them and no tears in the mattress.

  Check crash carts: locked, clean, no out of date supplies in it or on top of it, defibrillator strips removed.

  All oxygen tanks are secured.   Pantry: clean, no out dated food products, refrigerator log is up to date.

  All linen carts are covered. No linen hamper is overflowing.

  Make sure staff are wearing their ID badges.

  All aspects of documentation are complete.

  Medication reconciliation is complete.

  Verbal orders are signed, dated, and timed.

  Unapproved abbreviations are written out.

  All medical record entries are signed, dated, and timed.

  IPOC is multidisciplinary and updated.

  Restraint orders are current; restraint documentation by nursing is complete.

  Patient Education form is multidisciplinary, updated, and complete.

  Pain assessments and reassessments are documented.

  All aspects of nursing assessment are complete.

  Fall assessments are complete and documented.

  White Board information is current and neat.

  Advance Directive documentation is complete.

  Ensure that Patient Health Information Protected.

  Patient Care Areas: identify patients in restraints, “fresh” post-ops, and patientsready for discharge.

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Quality Management Office- Ongoing Survey Readiness Tips

Tip#15- …Be Prepared to Respond

• How do you document the multidisciplinary assessment?• Where are the nutrition assessment and functional assessment

documented?• How is the need for dietary and rehab consults determined? • What is the timeframe for completing the initial nursing assessment?• How do you demonstrate the integration of disciplines?• Where does each discipline document patient education?• Can you tell me your policy about restraints?• How often is a patient in restraints checked?• How often does the order for restraints need to be written?• What is a Sentinel Event?• What is Root Cause Analysis? What is FMEA? • What is MSDS? Where do you find copies of MSDS?• What is the expiration date for multi-dose vials?• What are the approved POCT for RN’s and LPN’s?• Are POCT used for screening or treating purposes?• Who has the authority to turn off Medical gases?• What has been done in your area to improve patient care?• What do you do during a disaster?• What do you do during phone outages and computer downtime?• What is the policy for maintaining the food/medication refrigerators?• What is the automatic stop time for narcotics?• What is your institution’s smoking policy? • Demonstrate to me how you unlock the patient bathroom door when it is

locked and a patient is inside?• What do you do if you suspect abuse?• Have you been offered a flu shot? Is this a policy at FC?

Tip#16- Labeling Medications Labeling occurs when any medication/solution is transferred from original packaging to

another container. Label medications/ solutions that are not immediately administered Label each medication/ solution as soon as it is prepared, unless it is immediately

administered. Medication or solution labels include the following:

o Medication name, Strength, Quantity, Diluent and volume, Preparation date, Expiration date when not used within 24 hours, Expiration time when expiration occurs in less than 24 hours

Verify all medication/ solution labels both verbally and visually.

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Quality Management Office- Ongoing Survey Readiness Tips Immediately discard any medication or solution found unlabeled.

All medications/ solutions both on and off the sterile field and their labels are reviewed by entering and exiting staff responsible for the management of medications.

At the conclusion of the procedure, remove all labeled containers on the sterile field and discard their contents.

Tip#17- Infection Prevention and Control~ Hand hygiene Wash in and Wash out Every patient every time. Use appropriate transmission based precautions when providing patient care. No food or drink in work areas. Prevent central line infections:o Hand hygieneo Use catheter checklisto Use standardized supply kito Sterile barrier precautions for insertiono Daily review of line necessityo Disinfect hubs before accessingo Educate patient and family about prevention

Prevent ventilator associated pneumonia:o Daily sedation vacationo DVT prophylaxiso Elevate head of bed (30-45 degrees)o Oral care

Prevent surgical site infections. o Antimicrobial agents for prophylaxis according to evidence-based best practices. o When hair removal is necessary, use clippers or depilatories. Shaving is an inappropriate

hair removal method. Prevent foley catheter associated urinary tract infectionso Daily review of catheter necessity.o Do not use component systems.o Use securement device to prevent tension and possible dislodgement.o Do not routinely send cultures post removal

Isolation:o Know which patients are screened for MRSAo Know criteria for which patients to isolateo Know the types of isolation & associated precautionso Treat all blood and body fluids as if they are infectious (Standard Precautions)

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Quality Management Office- Ongoing Survey Readiness Tips

Tip#18- Safety and Security

At all times please consider the following: Wear your I.D. badge at all times. Complete emergency equipment and code cart checklists. Do not use hallways for equipment or furniture storage Report strangers or unauthorized personnel in your area to security Ext. 41 Keep hallways and exits clear of obstructions (no blocked exits, fire extinguishers or

utility/gas panels). Do not prop doors open. Do not store items less than 18 inches from the ceiling. Know medical gas emergency shutoff valves’ location, operation and shutoff

procedures. Do not store patient care items on the floor or under sinks

Know what FCCC disaster and emergency codes mean and what to do: Code Red = Fire Code Blue= Cardiac or respiratory Code Gray= Security/Threat Code Black= Security Alert- Issued by Security personnel relating to a threatening

situation that staff should be aware of. Code Brown= Campus lock down Code Pink= Infant/Pedi Abduction Code White= Internal/External Disaster Code Orange = Biomedical/Hazardous Materials

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Quality Management Office- Ongoing Survey Readiness Tips

Tip#19- SCRIBES- Do the Joint Commission standards allow organizations to utilize scribes?

Q. What is a scribe and how are they used?

A. A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant). It is the Joint Commission’s stand that the scribe does not and may not act independently but can document the previously determined physician’s or practitioner’s dictation and/or activities.

Scribes also assist the practitioners listed above in navigating the EMR and in locating information such as test results and lab results. They can support work flow and documentation for medical record coding.Scribes are used most frequently, but not exclusively, in emergency departments where they accompany the physician or practitioner and record information into the medical record, with the goal of allowing the physician or practitioner to spend more time with the patient and have accurate documentation. Scribes are sometimes used in other areas of the hospital or ambulatory facility. They can be employed by the healthcare organization, the physician or practitioner or be a contracted service.

Q. Do the Joint Commission standards allow organizations to utilize scribes?

A. The Joint Commission does not endorse nor prohibit the use of scribes. However, if your organization chooses to allow the use of scribes the surveyors will expect to see:

Compliance with all of the Human Resources, Information Management, Leadership (contracted services standard) and Rights and Responsibilities of the Individual standards including but not limited to:

A job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities (HR.01.02.01, HR.01.02.05)

Orientation and training specific to the organization and role (HR.01.04.01, HR.01.05.03)

Competency assessment and performance evaluations (HR.01.06.01, HR.01.07.01)

If the scribe is employed by the physician all non-employee HR standards also apply (HR.01.02.05 EP 7, HR.01.07.01 EP 5)

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Quality Management Office- Ongoing Survey Readiness Tips If the scribe is provided through a contract then the contract standard

also applies (LD.04.03.09) Scribes must meet all information management, HIPAA, HITECH, confidentiality

and patient rights standards as do other hospital personnel (IM.02.01.01,IM.02.01.03, IM.02.02.01, RI.01.01.01)

Compliance with the Record of Care and Provision of Care standards also apply and include but are not limited to:

Signing (including name and title), dating of all entries into the medical record—electronic or manual (RC.01.01.01and RC.01.02.01). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff.

o Example: “Scribed for Dr. X by name of the scribe and title” with the date and time of the entry

The physician or practitioner must then authenticate the entry by signing, dating and timing (for deemed status purposes) it. The scribe cannot enter the date and time for the physician or practitioner. (RC.01.01.01 and RC.01.02.01)

Although allowed in other situations, a physician or practitioner signature stamp is not permitted for use in the authentication of “scribed” entries-- the physician or practitioner must actually sign or authenticate through the clinical information system. (RC.01.02.01).

The authentication must take place before the physician or practitioner and scribe leave the patient care area since other practitioners may be using the documentation to inform their decisions regarding care, treatment and services. (RC.01.02.01 and RC.01.03.01)

Authentication cannot be delegated to another physician or practitioner. The organization implements a performance improvement process to ensure that

the scribe is not acting outside of his/her job description, that authentication is occurring as required and that no orders are being entered into the medical record by scribes. (RC.01.04.01) 

Q. Can scribes enter orders for physicians and practitioners?

A.  The Joint Commission does not support scribes being utilized to enter orders for physicians or practitioners due to the additional risk added to the process.

Tip#20- Radiation Protective Equipment (RPE)

Lead aprons and thyroid collars are provided for your protection against scattered radiation. Care must be taken to prolong the life of this RPE. All aprons must be hung properly on apron racks after use to avoid creases and cracks. RPE should be cleaned regularly using a gently cleaner and a soft brush. Do not use bleach, machine wash or dry clean. All aprons are checked for integrity each year by the Radiation Safety Staff and

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Quality Management Office- Ongoing Survey Readiness Tipslabeled with a color coded sticker. Please assure yours was checked by looking

at the sticker.  New RPE must be checked by Radiation Safety Staff and added to the inventory database. Report any aprons that are removed for repair or replacement. Make sure that your radiation badge is on the apron before you wear it.

UNANNOUNCED SURVEYS:

ARE YOU READY?

10 tips for a successful survey

1. You may ask to see a surveyor’s identification if you are unsure about who he or she is.

2. If you are the first person the surveyors meet as they enter the building, have the surveyor(s) take a seat and contact Delinda Pendleton’s office (x2660, x2637), or Kathy Gilman’s office (x2591).

3. Never provide an impromptu hospital tour. A member or the Administrative team (see #2) will escort them to their meeting location.

4. Patient care comes first. Once the survey begins, if you need to leave a surveyor to check on a patient, be polite and offer to meet the surveyor again as soon as possible.

5. Be flexible. You may be interviewed once, multiple times, or not at all. Regardless, be

ready.

6. Be polite when answering questions. Offer truthful answers and stick to the three-second rule.

7. Answer questions with a yes or no, when appropriate. Don’t offer specifics unless asked.

8. Use open body language. Stand facing the surveyor in a comfortable, confident manner. Make eye contact and do not cross your arms.

9. Surveyors may observe you – sometimes without warning. Focus on providing quality patient care and following proper procedures and you’ll have nothing to worry about.

10. Relax! Surveyors are your opportunity to shine and show off the exceptional job you do every day.

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Quality Management Office- Ongoing Survey Readiness Tips

Follow the three-second rule

Try to answer surveyor questions within three seconds. Here are tips to help you answer surveyor questions effectively (even if you don’t know the answer):

Ask the surveyor to repeat or clarify a question.

Use the buddy system: Ask a coworker for help answering a question or offer to help someone stumped by a question.

If you don’t know the answer to a question, be able to show the surveyor where you could find it (e.g., a policy).

Other Tips- Things that should occur at all times

Doors should not be propped open...this includes clean and soiled utility rooms.

Staff food and patient food should not be stored in the same refrigerator. All patient food brought from home must be labeled and discarded after 72 hours.

Hospital supplies (even in boxes) should not be stored on the floor, even in the utility room.

Medications and syringes must be stored in secure areas (i.e. locked cabinets and drawers).

Code carts are to be checked daily when department/unit has patients.

Patient medication and food refrigerator temperatures must be checked daily when department/unit has patients. This information must also be logged.

Follow the National Patient Safety Goals 100% of the time. (Refer to your pocket card.)

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