Standard 5

Question 1

What is Standard 5 about?

Answer 1

PATIENT CARE SERVICES

Question 2

What is standard 5-1?

Answer 2

The program MUST ensure the availability of adequate clinical patient experiences that afford all residents the opportunity to achieve the program’s written goals and objectives or competencies for resident training.

Question 3

Standard 5-1: Three examples of evidence to demonstrate compliance may include:

“The program must ensure the availability of adequate clinical patient experiences that afford all residents the opportunity to achieve the program’s written goals and objectives or competencies for resident training.”

Answer 3

1. Written goals and objectives or competencies for resident training
2. Records of resident clinical activity, including specific details on the variety and type and quantity of cases treated and procedures performed
3. Description of the method used to monitor the adequacy of patient experiences available to the residents and corrective actions taken if one or more resident is not receiving adequate patient experiences

Question 4

What is standard 5-2

Patient records MUST…

Answer 4

…be organized in a manner that facilitates ready access to essential data and be sufficiently legible and organized so that all users can readily interpret the contents.

Question 5

What is the intent of standard 5-2?

“Patient records must be organized in a manner that facilitates ready access to essential data and be sufficiently legible and organized so that all users can readily interpret the contents.”

3 Examples of evidence:

Answer 5

Intent:
Essential data is defined by the program and based on the information included in the record review process as well as that which meets the multidisciplinary educational needs of the program.
The program is expected to develop a description of the contents and organization of patient records and a system for reviewing records

Examples of evidence to demonstrate compliance may include:

1. Record review plan
2. Documentation of record review
3. Patient records

Question 6

What is standard 5-3?

Answer 6

The program MUST conduct and involve residents in a structured system of continuous quality improvement for patient care.

Question 7

What is the intent of standard 5-3?

“The program MUST conduct and involve residents in a structured system of continuous quality improvement for patient care.”

2 Examples of evidence?

Answer 7

Intent:
Programs are expected to involve residents in enough quality improvement activities to understand the process and contribute to patient care improvement.

Examples of evidence to demonstrate compliance may include:

1. Description of quality improvement process including the role of residents in that process
2. Quality improvement plan and reports

Question 8

What is standard 5-4?

All residents, faculty, and support staff involved in the direct provision of patient care MUST…

Answer 8

…be continuously recognized/certified in basic life support procedures, including cardiopulmonary resuscitation

Question 9

What is the intent of standard 5-4?

2 Examples of evidence?

” All residents, faculty, and support staff involved in the direct provision of patient care must be continuously recognized/certified in basic life support procedures, including cardiopulmonary resuscitation.”

Answer 9

Intent: ACLS and PALS are not a substitute for BLS certification.

Examples of evidence to demonstrate compliance may include:

1. Certification/recognition records demonstrating basic life support training or summary log of certification/recognition maintained by the program
2. Exemption documentation for anyone who is medically or physically unable to perform such services.

Question 10

What is standard 5-5?

The program MUST…
Polices MUST…
Additionally, policies on blood-borne and infectious diseases MUST…

Answer 10

…document its compliance with the institution’s policy and applicable regulations of local, state and federal agencies, including, but not limited to, radiation hygiene and protection, ionizing radiation, hazardous materials, and blood-borne and infectious diseases.

…must provide to all residents, faculty and appropriate support staff and continuously monitored for compliance.

… be made available to applicants for admission and patients.

Question 11

Intent and 2 examples of standard 5-5

Answer 11

Intent:
The policies on blood-borne and infectious diseases should be made available to applicants for admission and patients should a request to review the policy be made.

Examples of evidence to demonstrate compliance may include:

1. Infection and biohazard control policies
2. Radiation policy