On the Day of Survey
By:
Dr. Zakaria AlAttal
Senior Consultant – Undersecretary Office
Director – Clinical Quality & Healthcare Accreditation Department
17th JAN 2015
General
•Confidence
•Introduce your self
•Refer to a policy or a document
•Clarify the question
•Don’t make up answers
What we need to do today and tomorrow?
•Complete all the fields of Wareed
•Level of triage
•Nutritional , functional and psychosocial screening
•Pain assessment and reassessment
•History and physical
•Consistency between doctors data and nurses data
•Allergy
Documentation
•Integrated care plan
•Fall risk assessment and reassessment
•Patient education
–Infant abduction
–Operation
–Medication
–Food
–Devices
Medication
•Self medication to be added to the list
•No medication samples in the clinics
•No expired medications
•Inventory of medication
•Security of medication
•Competency for ER medication
•PRN medication and indication
•TRAMAL and Perfalgan
•Reassessment after medication
•Review of medication before the administration
•High alert medication and its implication
General
•Identification
•Communication
•Safe surgery, site marking , verification, timeout
•High alert medication
•Hand hygiene
•Patient fall assessment, action and reassessment
Patient Identification
C H A L L E N G I N G S T A N D A R D S
Patients are identified using two patient identifiers which are:
1.The patient’s full name ( first, second and family name)
2.The Health Record Number.
3.Patient’s room number or bed number or location should not be used for identification.
Examples of findings:
-Two different medical record number numbers.
-Different identifiers were suggested by staff members.
Triaging
C H A L L E N G I N G S T A N D A R D S
-Objectives of this system will include: . Identification of patients requiring immediate, definitive care. . Promote patient safety. . Efficient use of resources and space. . Facilitate patient flow in the department. . Calm anxiety of patients and significant others. . Provide assessment and reassessment of patients
-The Nursing staff and ER physicians are responsible for implementing this procedure as outlined.
Examples of findings:
-There was no evidence that the patient was triaged in ER.
-Triaging level not documented.
Nutritional Screening & Referral
C H A L L E N G I N G S T A N D A R D S
-The patient (Inpatient and Outpatient) shall be assessed and the documentation will be made as appropriate to the patients age and needs in the patient’s EMR: .Pain assessment .Vital Signs .Psychosocial assessment. .Nutritional Screening, if applicable. .Functional Screening, if applicable. .Allergy history .Provisional Diagnosis, Investigations, Care plan with Measurable Goals .Discharge Plan/Follow Up.
Examples of findings: – There was no evidence that nutritional screening was done for a patient who came with vomiting with blood and who is underweight.
Functional Screening & Referral
C H A L L E N G I N G S T A N D A R D S
-The patient (Inpatient and Outpatient) shall be assessed and the documentation will be made as appropriate to the patients age and needs in the patient’s EMR: .Pain assessment .Vital Signs .Psychosocial assessment. .Nutritional Screening, if applicable. .Functional Screening, if applicable. .Allergy history .Provisional Diagnosis, Investigations, Care plan with Measurable Goals .Discharge Plan/Follow Up.
Examples of findings: – There was no evidence that Functional screening was done for a patient who came with vomiting with blood and who is underweight and the patient was unconscious
Psychosocial Screening & Referral
C H A L L E N G I N G S T A N D A R D S
-The patient (Inpatient and Outpatient) shall be assessed and the documentation will be made as appropriate to the patients age and needs in the patient’s EMR: .Pain assessment .Vital Signs .Psychosocial assessment. .Nutritional Screening, if applicable. .Functional Screening, if applicable. .Allergy history .Provisional Diagnosis, Investigations, Care plan with Measurable Goals .Discharge Plan/Follow Up.
Examples of findings: – There was no evidence that Psychosocial screening was done for a patient who came with vomiting with blood and who is underweight and the patient was unconscious on arrival.
Fall Risk Assessment & Actions
C H A L L E N G I N G S T A N D A R D S
-Any patient determined to be at risk for fall and identified with one or more fall risk factors on the integrated initial assessment upon admission will be placed on Fall Risk Assessment Tool. [Refer to Electronic Medical Record (Wareed) the Modified Mores Risk Assessment, Score (0-24 Low Risk) (25-50 Moderate Risk). (>50 High Risk). – Attachment (1)]
Examples of findings: – Patient was identified as “High Risk”. However, appropriate interventions were not taken.
Pain assessment & Management
C H A L L E N G I N G S T A N D A R D S
-It is the policy of MOH hospitals/Centers to utilize an interdisciplinary approach to the management of pain in order to eliminate or minimize pain.
-Pain management is based upon standards of care from a variety of sources recognized as leading experts including the American Society of Anesthesia, etc.
-Assessment and reassessment of pain is done using the comprehensive pain tool except for comatose patients who will be assessed by changes in hemodynamic status.
Examples of findings: – Discrepancy between nurses pain assessment “Patient unable to report” and doctors description “Abdominal Pain”.
Most Responsible Physician (MRP)
C H A L L E N G I N G S T A N D A R D S
All MOH hospitals or centers (when appropriate) at shall define a Most Responsible Physician to coordinate care to patient throughout their stay in the facility. The MRP shall be privileged to be responsible for providing care to the patients. MOH hospitals and centers ( when appropriate) shall follow the Transfer of patient between the services/ units, when the responsibilities of one health Care provider (MRP) is transferred to another ( MRP) in MOH facilities.
Examples of findings:
-The MRP was not defined.
-The name of MRP not mention in the admission order.
Reporting Critical Results
C H A L L E N G I N G S T A N D A R D S
-The laboratory technicians shall report all critical values for inpatients, outpatients and Emergency units’ patients, as per attached process map (Attachment 1).
-All laboratory critical values as applicable in the attached list shall be reported within 30 minutes from the completion of the test (Attachment 2).
-Any telephonic test results including critical values to be taken, the following steps need to be followed: Listen; Write it down; Read back; Confirm.
Examples of findings: – Lab staff were not aware about the process of reporting critical results and the timeline associated with the process.
Multidisciplinary Care Plan
C H A L L E N G I N G S T A N D A R D S
-The initial plan of care is documented in the medical record in realistic goals and reviewed by the multidisciplinary team.
Examples of findings: – There was no evidence that all healthcare providers were involved in the care plan of the patients. (No main plan of care by the MRP and no other plan of care by others). The Multidisciplinary sheet in wareed is not used.
Medication Order
C H A L L E N G I N G S T A N D A R D S
-Medicines’ name (generic), formulation, dose, frequency and duration of therapy, route of administration for parenterals, body weight and indication for PRN orders.
-Provide special tools or precautions to alert doctors while prescribing Look – Alike / Sound – Alike medications. (In Wareed system it is defined as a change in the font of the medication)
Examples of findings:
-A PRN medication order was ordered without specifying the duration.
-LASA was ordered by the system did not change the font.
Transfer Process
C H A L L E N G I N G S T A N D A R D S
-Communicate with the receiving hospital
-Approval of the receiving hospital
-Monitoring the patient during transfer
Examples of findings:
-There was no evidence that the hospital has a strong transfer process for patients who are not within their scopes.
Consultation Process
C H A L L E N G I N G S T A N D A R D S
-The MRP may ask the input of another medical specialty for specific patient need.
Examples of findings:
-Not assesed…
Hand-off Communication
C H A L L E N G I N G S T A N D A R D S
-Moving patient from one level of care to another (Example: from the ICU to general medical unit). This shall take place by using face to face communication and following patient transfer policy through completing the transfer summary as specified in section 4 of this policy..
Examples of findings: – There was no evidence hand-off communication was done during change of level of care.
Other Important Points
C H A L L E N G I N G S T A N D A R D S
•Informed Consent
•Time-out
•Operation Notes
Other Important Points
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•Quality Programs in your departments
Other Important Points
C H A L L E N G I N G S T A N D A R D S
•Important Facility Management Issues.
-What should you do in relation to the following in emergency situations?
Medical Gases
Clearance of Exits
Patients
Assembly Point
Think Loudly…
Department of Surgery 