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Nationwide Children's Hospital - CSPR > NCH Joint Commission Prep > Flashcards

NCH Joint Commission Prep Flashcards

To prepare for the Joint Commission’s on-site survey process.

1
Q

Our Promise

A

When your child needs a hospital, everything matters.

(pg. 11 of the study guide)

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2
Q

Our Mission

A

Nationwide Children’s Hospital is committed to best outcomes and health equity for all children, ensuring every child has access to the best care regardless of their ability to pay.

[best outcomes, health equity, regardless of ability to pay]

(pg. 11 of the study guide)

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3
Q

Our Vision

A

Leading the transformation of child health so children everywhere achieve best outcomes.

(pg. 11 of the study guide)

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4
Q

Our Values: “Do…”

A

“…the right thing.”

(pg. 11 of the study guide)

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5
Q

Our Values: “Prioritize…”

A

“…quality and safety.”

(pg. 12 of the study guide)

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6
Q

Our Values: “Are…”

A

“…agile and innovative.”

(pg. 12 of the study guide)

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7
Q

Our Values: “Get…”

A

“…results.”

(pg. 12 of the study guide)

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8
Q

Our Values: “Promote…”

A

“…health and well-being.”

(pg. 12 of the study guide)

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9
Q

Our Values (name all 5)

A
  • Do the right thing
  • Prioritize quality and safety
  • Promote health and well-being
  • Are agile and innovative
  • Get results

(pg. 11-12 of the study guide)

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10
Q

What are the 4 steps of our Quality Improvement methodology?

A

1) Plan
2) Do
3) Study
4) Act

(p. 12 of the study guide)

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11
Q

What are the 3 basics of the Zero Hero patient safety program?

A
  • Pause to Predict
  • STAR
  • Stop and Resolve

(pg. 14-15 of the study guide)

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12
Q

Zero Hero patient safety program: What 3 questions do we ask when we “Pause and Predict?”

A
  • What?
  • So what?
  • Now what?

(pg. 14-15 of the study guide)

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13
Q

Zero Hero patient safety program: What are the four steps of “STAR” and what is its purpose?

A
  • Stop
  • Think
  • Act
  • Review
  • A self-checking technique to prevent errors during routine tasks and safety-critical actions.

(pg. 15 of the study guide)

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14
Q

Communication: What is “SBAR?”

A

A tool used for planning and structuring communication about a situation, task, or problem.
- Situation (What is the problem, patient, or project?)
- Background (What is important to know?)
- Assessment (what is your evaluaion?)
- Recommendation (What action needs to take place?)

(pg. 15 of the study guide)

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15
Q

Communication: What are the 4 steps of SBAR?

A
  • Situation (what is the problem, patient, or project?)
  • Background (what is important to know?”
  • Assessment (what is your evaluation?)
  • Recommendation (what action needs to happen?)

(pg. 15 of the study guide)

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16
Q

Communication: What should always happen after we receive crucial communication?

A
  • Repeat back & Verify

Sender states information, receiver verifies back message, and sender acknowledges response.

(pg. 15 of the study guide)

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17
Q

Questioning Mindset: What are the 3 steps of “QVV” and what does it achieve?

A
  • A tool used to proactively prevent harm by respectfully questioning the source, content, or suggested action before moving forward.
  • Qualify the source
  • Validate the content
  • Verify with an expert source

(pg. 16 of the study guide)

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18
Q

Questioning Mindset: What are the 4 steps of “ARCC” and what does it achieve?

A

A technique that can help raise or escalate a concern

  • Ask a question
  • Request a change
  • Concern: voice a concern
  • Change: escalate along the chain of command

(pg. 16 of the study guide)

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19
Q

Questioning Mindset: what are the 4 steps of “IDEA” and what does it achieve?

A

A tool used to support communication when uncertainty exists

  • Introduce the situation or concern
  • Discuss options and ideas with team members
  • Explore benefits and potential unintended consequences of options
  • Accept questions - keep an open mind through active listening, curiosity, and flexibility

(pg. 16 of the study guide)

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20
Q

How and why should patient safety concerns be reported?

A

When a “near miss” or a “good catch” occurs (even when harm hasn’t been caused), report it using the online reporting system or call Risk Management at 722-3940.

(pg. 16 of the study guide)

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21
Q

National Patient Safety Goals: which 2 patient identifiers should be used when providing care, treatment, and services?

A

Name and Medical Record Number (MRN)

(In lab, birth date may also be used)

(pg. 21-22 in the study guide)

22
Q

National Patient Safety Goals (fill in the blank): critical results of tests and diagnostic procedures should be reported ________.

A

“…in a timely manner.”

(pg. 22 in the study guide)

23
Q

National Patient Safety Goals: (fill in the blanks) label __________, _________, and _______ on and off the sterile field.

A

“…medications, medication containers, and other solutions…”

(pg. 22 in the study guide)

24
Q

National Patient Safety Goals: (true or false) medication or solution without a label should be immediately discarded.

A

TRUE

(pg. 23 in the study guide)

25
National Patient Safety Goals: (fill in the blank) reduce patient harm associated with ________ therapy use.
"...anticoagulant..." Provide education regarding anticoagulant therapy to prescribers, staff, patients, and families. (pg. 23 in the study guide)
26
Surveyor Q&A: What 4 things need to be discussed in an informed consent?
- risks - benefits - side effects - possible results of not receiving care (pg. 31 in the study guide)
27
Surveyor Q&A: How are spiritual needs of the patients addressed? (2 ways)
- documented in EPIC's patient profile under "Values/beliefs/spiritual care" - Chaplain services can provide visits, follow-up, and communication with the family's spiritual leader (pg. 31 in the study guide)
28
Surveyor Q&A: what is a "watcher?"
A patient who is at risk for clinical deterioration on an inpatient non-ICU unit. (pg. 30 in the study guide)
29
Surveyor Q&A: What is NCH's Standardized Hand-off tool? (the "5P's)
- Patient/project (the name of...) - Problem - Pertinent/ Past History - Plan/Procedure - Precautions/Potential Pitfalls (pg. 29 in the study guide)
30
Surveyor Q&A: How do we prevent patient falls?
All admitted patients/families are educated on fall prevention by many methods including in the Hospital Setting Helping Hands and they are assessed for risk for falls upon admission and at least every 24 hours. (pg. 29 in the study guide)
31
What is SDS (formerly MDS)?
"Safety Data Sheet" Information on chemical/hazardous materials used in your work area. (pg. 45 in the study guide)
32
What do you do in case of a fire?
RACE - Rescue any persons in any immediate danger - Alarm by pulling the nearest alarm and dialing ext. 23333 - Contain the fire by closing doors leading to the area - Evacuate the area if necessary. (pg. 44 in the study guide)
33
How do you you operate a fire extinguisher?
PASS - Pull the pin - Aim the nozzle at the base of the fire - Squeeze the handle - Sweep from side to side at base of fire (pg. 44 in the study guide)
34
Where is the nearest fire extinguisher?
- Coming from the research side of the floor: in the hallway on the way to John's office - Walking from consultation room hallway and toward the PAR desk: next to the farthest door from the PAR desk or in front of Fatimah's cubicle (pg. 44 in the study guide)
35
What does a red trash can mean?
Biohazardous (infectious) waste (pg. 44 in the study guide)
36
What is a CODE RED?
Fire in the hospital. Call the Emergency Communication Center at ext. 23333 (pg. 46 in the study guide)
37
What is CODE BLUE?
Respiratory and/or cardiac arrest. Call the Emergency Communication Center at ext. 23333 (pg. 46 in the study guide)
38
What is a medical assist?
Call a team for first aid for employees or visitors. (pg. 46 in the study guide)
39
What is a CODE ADAM?
Missing patient or abduction. Cover designated doors and follow your department plan. (pg. 46 in the study guide)
40
What is a CODE BLACK?
A bomb/bomb threat Call the Emergency Communication Center at ext. 23333 (pg. 46 in the study guide)
41
What is a CODE YELLOW?
Disaster. (pg. 46 in the study guide)
42
What is a CODE GREY?
Severe weather alert for Franklin County Tornado watch: conditions are favorable for a tornado Tornado warning: a tornado has been spotted (pg. 47 in the study guide)
43
What is a CODE VIOLET?
Unmanageable or combative patient, visitor, or staff member that is perceived as a threat to safety. (pg. 47 in the study guide)
44
What is a CODE SILVER?
Person with a weapon or a hostage situation. Call the Emergency Communication Center at ext. 23333 (pg. 47 in the study guide)
45
What is a CODE ORANGE?
Hazardous material spill or release. For main campus, call the Emergency Communication Center at ext. 23333 and active RIN (recognize, isolate, notify) If offsite, call 911 (pg. 47 in the study guide)
46
What is your process for screening for suicide risk?
All patients age 12 & up who are being evaluated or treated for behavioral health conditions are screened for suicide risk. Ambulatory behavioral health clinics screen all patients age 10 & up. PCD, ED, and Urgent Care will screen all patience age 8 & up (if behavioral health is primary reason for care). (pg. 47-48 in study guide)
47
How do you gain entry to a locked restroom if someone was inside and needed help?
The restroom doors are equipped with a mechanism that allows them to be unlocked by a coin/washer from the outside. Insert the coin/washer, push in, and the door will unlock. (pg. 45 in the study guide)
48
What is the time frame for completion of medical records?
30 days (pg. 34 in the study guide)
49
What is the time frame for signing verbal or telephone orders?
72 hours (pg. 34 in the study guide)
50
What is the time frame for signing patient's History and Physical (H&P) done by someone other than the Attending Physician?
24 hours (pg. 35 in the study guide)

Nationwide Children's Hospital - CSPR (2 decks)

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