May 28, 2024

Tips and Tools for a Successful Accreditation Survey

Who are you going to call…..? Take the quiz

Match the correct officer with the correct incident.

-Privacy officer (Alycea Lakin ext. 5029)

-Compliance officer (Lorraine Meyer ext. 5014)

-Safety officer (Michael Bomberger ext. 4180)

1. Who do you call with a concern about a staff member giving protected patient information to an unauthorized person?

2. Who do you call if you would like to know what to do for patients and staff in case of a tornado?

3. Who do you call regarding concerns with fraud, waste, and abuse?

Answer: 1. Privacy officer, 2. Safety officer, 3. Compliance officer

PATIENT SAFETY

As an employee of CHCS, we have a responsibility to provide high quality, uninterrupted patient care, and maintain the highest degree of patient confidentiality. Some highlights of our “Safety and Security –EOP Functional Annex E” Safety policy. What I need to do…

Wear my ID badge while at work. If you do not have one have a name sticker on to help patients and staff know who you are.

Make sure all patients in the hospital have an ID bands and alert bands on their wrist. Check and identify your patient prior to giving ANY care or treatment.

“See something, Say something” – report incidents or concerns accordingly to the correct officer. Examples (including but not limited to):

Building security/safety, Parking lot safety issues,Vehicle accidents
Disputes/loud noises, Suspicious circumstances/packages, Threats to organization/staff
Fire/safety hazards
Lost, theft, or vandalism of property

“Safety starts with me” – the goal is for all CHCS associates to report and promote workplace safety and health through reporting near missing, following safety guidelines and keeping staff and patients safe from identified risk.

Watch for Slips, trips, and falls.
Mark faulty equipment properly.
Watch this short video: https://www.youtube.com/watch?v=RWKqUkNBEVE

Medication Safety- Review the 5 rights

Right Patient
Right Time
Right Medication
Right Dose
Right Route

Incident Reports for patients (falls, medication errors, injury)

Why? - improve our patient safety for our staff and our patients
Fix broken equipment or items.
How? – go to the computer click on Quality Data Check icon, then click on “submit an incident report”

Emergency Codes

Why do healthcare facilities have Emergency Codes?

· Emergency codes are used to communicate promptly with associates when an organized response is necessary for a medical emergency, fire, bomb threat, active shooter, missing or abducted child, or an external or internal disaster.

What is my responsibility with Emergency Codes?

· Associates are responsible for knowing their role in emergency situations.

· It is common for a surveyor to ask any associate “Tell me what you would do in the event to a fire? Or “What is your responsibility in the event of a disaster?”

· Participate in drills to improve and review your responsibility during these times.

What is your hospitals response to a Code Red? – RACE

Rescue persons directly threatened by the fire.

Activate Alarms

Contain the fire by closing doors and windows

Evacuate the zone or area

How do you use a Fire Extinguisher? –Stand 6-8 feet from the fire, PASS procedure.

Pull the safety pin at the top of the extinguisher.

Aim the nozzle/hose at the base of the flames. Hold extinguisher vertically.

Squeeze or press the handle to release the pressurized extinguishing agent.

Sweep from side to side at the base of the fire.

Inclement Weather Alerts and Tornado Warnings

What do I do during a Tornado Warning or inclement weather (severe thunderstorm warning)?

· Close windows and blinds

· Ensure patients have blankets to cover up with.

· Move to small interior rooms and hallways, patients in the hospital will be moved to the Severe Weather Shelter, located in the PACU/Surgery area.

· Stay away from glass enclosed places or where there are skylights.

· Once Sheltered protect your head with your arms and crouch down.

· Ask your manager/supervisor regarding any additional directions for your specific area such as helping other departments assisting other patients.

What do I do if my patient does not speak English?

CHCS uses the Propio Language Services.
Call 888-804-2044
Select a language
State the department name, your name, and the name of the patient or visitor needing the service.
Propio ONE – on the IPad

INFECTION CONTROL

According to the CDC, "Studies show that some healthcare providers practice hand hygiene less than half of the times they should. Healthcare providers might need to clean their hands as many as 100 times per 12-hour shift, depending on the number of patients and intensity of care. Know what it could take to keep your patients safe."

WHEN TO PERFORM HAND HYGIENE?

Use an Alcohol-Based Hand Sanitizer

Wash with Soap and Water

Immediately before touching a patient
When hands are visibly soiled
Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices
After caring for a person with known or suspected infectious diarrhea
Before moving from work on a soiled body site to a clean body site on the same patient
After known or suspected exposure to spores (e.g. B. anthracis, C difficile outbreaks)
After touching a patient or the patient’s immediate environment
After contact with blood, body fluids or contaminated surfaces
Immediately after glove removal

Wash your hands- save a life!

Questions? Send them to mandathompson@chcsks.org

May 28, 2024﻿

Tips and Tools for a Successful Accreditation Survey

Emergency Codes

May 28, 2024