Dr. Mohammad IrfanTQM coordinator

ESR1&2.CREDENTIAL & PREVILIGES

QUESTIONS ANSWERS

1. How the credentials are verified?

2. Whom credentials are verified?

3. What are the types of privileges?

4. Process of requesting privileges?

1.Through telephone or email-to the references and documenting in the CV.2.Through a third party like data flow and asking for the verification report.

2. For part time, full time, visitor and locum.

3.Temporary( for 90 days-NON renewable), Emergency( on case to case basis)Disaster ( in case of code Black-for OR)and Full privileges ( for 2 years)

From HOD – Medical Director—C&P committee

INTERVIEW: Members of Credential & Privileges Committee

ESR 3. BLOOD TRANSFUSION

Questions ANSWERS

1. Do you have the POLICY ? (Blood products handling, use & Administration)

2. Who can give orders for transfusion?

3. When you verify pt identification?

4.When consent is needed with the request for transfusion??

5.Are you reporting transfusion RXN?

1.Yes.Its in the master index

2. Only Physician Orders

3. Identification verification Before withdrawing blood, and before administering blood

4.When requesting for Non-NAT screened blood

5.Yes. If there is. To physicians and blood Bank. Transfusion reaction forms and process, from the policy in master Index

ESR4.VTE (VENOUS THROMBO-EMBOLISM)

DOCUMENTS OBSERVATION/INTERVIEW

1. VTE assessment form IN EVERY Patient file. INCLUDING BMI

2. Correct scoring of the form

3. Physician orders are written as per VTE form

4. Countersigned by Consultant/MRP

5. VTE policy In the Master Index

OBSERVATION:None

INTERVIEW:None

ESR5. IDENTIFICATION OF PATIENTS (IPSG:1)

QUESTIONS ANSWERS

1. How you identify the pt?

2. When it is must to identify ??

1. At Least 2 identifiers are written/& used.

2. PARTICULARLY: In carrying out Medication orders & Blood transfusion orders

INTERVIEW: Nursing staff.Staff of blood bankStaff of pharmacy

ESR 6.PREVENT WRONG SITE,WRONG PT AND WRONG SURGERY (IPSG:4)

QUESTIONS ANSWERS

1. How you prepare the pt for OR to prevent wrong site, wrong procedure and wrong pt??

2. Where do you do site marking??

3. When Time out is conducted?

1. By verification , site marking and Time out.

2. CORRECT and STNDARDIZED Site marking on the patients(NOT ON THE BANDAGES Particularly for orthopedic patients and use “ “ sign.(surveyor will check the day surgery cases for it, Mainly Dr.Khalid Kandeel and Dr.Adnan pts)

3.Time out’ IN OR before the induction of anesthesia and start of procedure

INTERVIEW: PhysiciansNursing staff of Wards and OR(day surgery cases)

When Required???? Where Required???

1. It is not required for single organ, tonsillectomy, hemorrhoidectomy, endoscopy, and where skin integrity is lost or may cause irritation.

2. It is required in following cases:

FOR OR.(Marking to be done in wards)

OUTSIDE OR:

ESR 7.QUALIFICATION OF ANESTHESIA STAFF

ESR 8. SEDATION POLICY

QUESTION ANSWERS

1. Who can give conscious sedation ? 1.By policy, only anesthetist are allowed to give conscious sedation.

Interview: Endoscopy unitDental unit

Policy : For sedation

ESR 9.INFECTION PREVENTION & CONTROL COMMITTEE

ESR10.ISOLATION ROOMS & POLICY

QUESTIONS ANSWERS

1. Are you keeping record of visitors to isolation room??

1.THERE SHOULD BE NO VISITORS TO ISOLATION ROOMS. THEY ARE NOT ALLOWED TO GO IN.WE ARE KEEPING THE RECORD OF NURSJING STAFF ONLY , WHO IS GOING TO ISOLATION ROOM.

INTERVIEW: 1.IPC department regarding

1.1Enough availability of isolation rooms1.2 Isolation rooms are under negative pressure1.3 HEPA filters availability1.4 Air exchange (12/hour) monitoring.

2. Nurses and physicians for N95 mask re-use POLICY

QUESTIONS ANSWERS

1. What you think your infection control department has achieved??

2. N-95 mask can be re-used ???

1. Infection control plan for year 17-18 has been formulated and communicated to us . (master index)

2. N-95 guidelines

3. Fit test was done

4. Others by dr.farrukh…

2.Yes. For same pt, upto 8 hours.But w have to put in a bag, and labeled

with name and dateTo re-use , after wearing gloves, (do not

touch the front of mask), and after doing leak test.

INTERVIEW: ALL STAFF NEAR ISOLATION ROOMS.

ESR 11.HIGH ALERT MEDICATIONS

QUESTIONS ANSWERS

1.Do u know/ have you access to High alert medication policy???

2.Do you aware of the High alert medication list?

3.How you know that these medications are high alert/ where do you store??

4.How you are preparing IV medications??

1. High alert medication policy/plan in master index

2. Updated list of High alert and Hazardous medications In master index.

3. In red labels and red containers..

4. Standard Concentration for all IV administered medications(through IV manual) on master index.

INTERVIEW: Nursing staff and pharmacy staff for1.Improved Access to Information for high alert medications2.Limited access to High-alert medications3.Uniform high alert medication labels4.Standard Concentration of IV infusion administration(Staff will follow the standard concentration or UNSTANDARD CONCENTRATION ORDERS by physicians?)

ESR 12.LOOK ALIKE SOUND ALIKE MEDICATIONS (LASA)

DOCUMENTS OBSERVATION/INTERVIEW

1. What & How you know about the LASA medications???

2. Are you educated on LASA?

3. How you prescribe LASA medication?

1.Through policy and updated list of LASA in Master index.

2.Yes. At the day of orientation and through CME lectures (Last in January)

3.Through oasis which contains both 1.Generic AND Brand names.2.Writing diagnosis for LASA medications 3.Separate appearance and Storage for

LASA medications4.Minimize verbal or Telephonic orders for

LASA medications5.Checking LASA medication before 6.Dispensing and Administering

ESR 13. MEDICATION ERRORS

QUESTIONS ANSWERS

1. IS THERE A POLICY AND STANDARDIZED MEDICATION ERROR REPORING FORM???

2. Are you reporting and documenting in pt files???

1.Yes. There is. And its in master index.

2.Yes . We are reporting , if there is any, and documenting in the pt file…

KEYPOINTS:PhysiciansNursesFOR 1.Timely Notification of medication error to treating physician

2. Medication error reporting time as per policy

3. Healthcare professionals are provided feedback on reported medication error

ESR 14.BLOOD BANK

ESR15.RADIATION SAFETY

Question ANSWER

1. 1.Regular test conducted or not for valid shielding certificate??

As per Radiation safety policy

1. Annual testing record for Lead aprons and Gonadal/thyroidal shields

2. Dosimeter testing results (Every THREE months)

ESR 16.FIRE ALARM SYSTEMJUST TO INFORM U THAT ELEVATORS ARE CONNECTED TO FIRE ALARM

SYSTEM

ESR 17.FIRE SUPPRESSION SYSTEMFire suppression sprinkler system is NOT available on ground and first

floor

ESR18.FIRE EXITSThe way to fire exits SHOULD NOT be obstructed.

There should be no Cleaners trolleys, or beds or wheel chairs etc.

ESR 19.FIRE AND SMOKE SAFETYThere is NO SMOKING policy in our hospital.

PLEASE DO NOT SMOKE OUTSIDE THE DOOR, NEAR THE KITCHEN.. ON WEDNESDAY ATLEAST….

ESR 20.MEDICAL GAS SYSTEM

QUESTIONS ANSWERS

1.Is there any policy for medical gas system???

2.Who is authorized to close the oxygen valves in clinical areas???

Yes.. There is a POLICY for EFFCTIVE USE OF MEDICAL GAS SYSTEM. (Master index)

2.Nurses to know about responsibility of Closure of valves: is upon head nurse…

THAT’S ALL FOR NOW…

THANK YOU…

LOOKING FORWARD FOR YOUR COOPERATION