CANADIAN ACCREDITATION

NURSES KNOWLEDGE CHCK LIST

SURGICAL AREAS

Ward - Date- Name of the staff audited by:

1 – good

2- Very good

3- excellent

10. NURSES KNOWLEDGE: 1 2 3 Remark

10.1.  What is accreditation?
 Accreditation is a process that organizations use to
evaluate and improve the quality of their services.
It involves examining everyday activities and services against standards of
excellence
10.2.  What is CCHSA stands for?
Canadian council on health service accreditation

10.3.  What is CCHSA accreditation Survey?

 It includes a Review by outside peer surveyors of quality of
services in an organization.
The survey comes after the organization has completed the” SELF-
ASSESSMENT “which was conducted by the accreditation team
10.4  What is accreditation focus on?
 Accreditation focus on Quality improvement and Risk
management.
This includes patients, care providers, support services and strategic
Directions
10.5  How will the organization benefit from accreditation?
 Powerful change management tool.
 Effective self assessment.
 Educational process that benefits all staff.
 Increase credibility and demonstrates accountability.

10.6  How accreditation assists in improving safety and quality in health

services?
 Measure organization’s compliance against standards of
excellence.
 Drive significant improvements towards safety issues.
 Provide organizations with critical path to achieve
improvements.
 Promote team work.
Promote provision of safer and higher quality health care services
10.7  What are CCHSA survey objectives?
 To evaluate our quality care / services which we provide to
our clients in creating quality culture and obtain the best

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 of practice throughout the organization.
 To continuously improve our work environment which
assures safety for hospital staff and clients within the
framework of continuous quality care?
 To enhance effective communication in our organization
among staff and patients.
 To standardize our services as per the CCHSA and other
related standards.
 To establish client’s trust and increase hospital revenue.

10.8 What are the Strategic priorities of the organization?

This strategic plan is created for three years duration. It has started from
January 2010 and end December 2012 (Muharram 1431 to Safar 1434)

1. Management & Operation:

 .Achieve Self-operation

 . Improve the administrative structure and supporting services

 . Identify and support core competencies based on national needs and

local expertise

2. Patient needs:
 . Develop a community-needs assessment mechanism

 . Make the hospitals more patient-friendly

 . Define the eligibility criteria for care in the university hospitals


3. Learning Environment
 Improve the learning environment in the university hospitals

4. Quality Enhancement:
 . Establish a high quality and patient safety environment and obtain
international accreditation for both hospitals.

5. Support & Infrastructure:
 . Improve IT, laboratory, and radiology services

 Improve training opportunities for the supporting staff

10.9 Vision mission and values of the Hospital

Vision:
To be a leading medical school and health care provider, that has a major
impact on the health of the Saudi community and contributes significantly
to the science and practice of Medicine worldwide.

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 Mission:
 To educate and train future healthcare professionals in an innovative
learning environment.

 To explore new areas of research and produce significant scientific

contributions to the world.

 To provide high quality and compassionate healthcare to the Saudi

community.

 To integrate education, research, and healthcare in an inclusive

environment.

Values:
 Creativity

 Excellence

 Teamwork

 Honesty

 Accountability

Lifelong learning.

Objectives of the nursing department:

1. Develop and implement an evidence base practice culture

through assigned projects in all clinical areas.
2. Develop and implement sound policy guidelines and
educational programs related to the prevention and
control of infection
3. Develop computerization of services such as :
 Nursing care plan
 Administrative policy and procedure and
standards.
4. Ensure a planned efficient recruitment process through
appropriate testing and interviewing of candidate.
5. Promote appropriate research awareness and activities
related to improvement in patient care.

11.0 What is your departmental vision, mission and values?

11.1. What is your job description?
11.2. How often you are evaluated? What was your strength and area of
improvement told to you during your last evaluation?
12.3. In case of patient’s arrest which number to call for code blue?

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12.4. What is your role in the code procedures?
12.5. How will you maintain patient’s confidentiality and privacy?
13.6. What are patient’s rights/ responsibilities?
13.7. How will you maintain patient’s safety?
 All the patients are having ID band
 Safe medication administration following 7 rights.
 Patient’s identification with double witness.
 Prevention of patient’s fall by putting rails.
 Adequate lightings.
 Keep the toilet and floor dry at all times.
 Informed consent before sending to OR
 Call bell system in all the patient’s rooms and toilets.
 Emergency doors are functioning well at all times
 Keep a Clear hall ways always.
 Fire drill class conducted every month.
 Well maintenance of crash carts ready to use at any time.
13.8. What is the admission policy?
14.9 What is the discharge policy?
15.10 What is the policy of documentation?
15.11 What is the statistical data of the following?
 Number of patients admitted per year?
 Patient’s occupancy rate?
 SSI rate?
 Patient’s fall rate?
 Medication error rate?
16.0. What are the ongoing quality improvement activities in your
department and what are your role in these?
 Physician care plan
 physician’s pre operative notes
 physicians progress notes
 Consent forms
 discharge plan
 physician’s care plans
 stat medication
 delayed patient’s discharge
 Nurses are working in collaboration with medical team by Only for
conducting survey in all the wards of the surgical wards and general wards.
the report is presented to all multidisciplinary team during
the quality meetings. ( started 6-8 months before)
 As a result now the physician’s care plan, discharge plan and
consent forms are well recorded and maintained for all the
patients.
 The other surveys are started on October 2010 for which the
first session of the survey is on progress.

17.0. Where do you locate following manuals

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  Departmental manual 1st cabinet top
 Departmental policy manual shelf
 Departmental procedure manual
 Quality improvement manual
 Infection control manual
 Disaster manual training manual
18.0 Where do you locate the job description of all staff categories? 1st cabinet top
shelf
19.0 Where would you locate the following in your department. Bulletin board.
 Organization mission statement
 Organization chart
 Department organization chart
 Organization goals your department goals
20.0 What is the purpose of the critical incident report form what is your
response?
 To identify and to report the problems
 To prevent the problem
 Improve the quality culture and patient’s and employee’s
safety.

21.0 What is code Orange? Where do you locate the policy and procedure
of a missing patient?
 Bomb threat- 953
 Nursing manual
22.0 What is your responsibility during fire drill?
R- Rescue the person in immediate danger
A-activate 953 fire alarm
C-contain the fire
E-extinguish if possible or evacuate
23.0 What is code black?
External disaster.
24.0 How do you open the emergency door?
25.0. Is the staff schedule in your unit readily available?
Yes, 4th cabinet bottom shelf.
26.0. Tell me what the organization expect from you in terms of the
confidentiality of information?
27.0 How do you treated as an employee?
28.0 Do you have any concerns regarding working conditions?
29.0 Do you live in hospital housing?, how is it?, Are you needs looked
after?
30.0 Did you receive orientation to your department? How long was the
orientation? Tell me about this?
31.0 What would you do if you had concerns regarding your
employment ? how is your working condition?
32.0 When was this department’s last fire drill and how it went on?
33.0 If there is a fire in that Room what will you do?
34.0 When was your last evacuation exercise?

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35.0 What is the procedures for the lifting and moving the heavy patients?
36.0 What will you do if there were a violet patient or family members?
37.0 What are the emergency codes for the following?
 Medical emergency- 1234 code blue
 Missing patients - 953 code yellow
 Disruptive behavior -953 code white
 ED overcrowding – 953 green
 Fire - 953 code red
 Utility failure - 953code gray
38.0 What will you do if you had a needle stick injury?
39.0 What type of education opportunities you have in your hospital
39.2. Why the indicators used for?
 To track improvement activities
 To pin point area of improvement
 To measure day today base operations
 To provide strategic plans.
40.0 What indicators are you using in your hospital?
 Mortality rate of the hospital
 Medication error of the hospital- 23%(2010)
 Patient’s satisfaction rate of the hospital
 Staff satisfaction rate of the hospital- 56%(2010)
 SSI rate of the hospital
 Hospital Readmission
 Patients returning to operating Room
 Pressure ulcers
 Patients fall
 Thromboprophylaxis
 Day of surgery admissions

40.1  Why were they selected? (rational) :

To measure the existing day today problems
To pin point area of improvement an
To make plans for the improvement of care.
 By whom it is selected?
 How is the information from the indicators used for quality
improvement?
 How are the result shared within the organization?

39.2. What is the one of the basic tool used for the quality improvement?
PDCA ( plan, Do, check and Act
40. What do you mean by shewhart cycle?
 It is a continues process of plan, Do, Check and Act.
For example to reduce waiting time in emergency department.

1. Plan –
a, Do base line assessment of existing problem ( survey)
b, Set target time for the expected out come.

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 d, Make a plan for the improvement, based on the problems
identified like providing extra staffs, transfer system expertise,
categorizing the patients according to the diagnosis and critical
condition etc.
1. DO : make changes on an experimental and piolet basis.
2. Check - Check the outcome
3. Act: implement and go back to the plan, make alteration if
required or add additional plans.
41. What is DEMING cycle?
 It is a focus oriented process which include
 F – Find an important project.
 O- Organize
 C - clarify correct process
 U - Understand the process ( what is the root cause,
desired outcome etc)
 S- select the best practice.
42. PATIENT’S SAFETY:
The focus of accreditation in patient’s safety. Because we cannot say
there is quality if patient’s safety is poor. 10 years ago quality was the
top priority, but now patient’s safety is the top priority in all health
care facilities. The next challenging situations will be based on
patient’s safety goals.

WHAT DO YOU MEAN BY PATIENT’S SAFETY?

It means we have good practice, achieving optimal outcome and also
avoiding risk minimizing outcome,

PATIENT’S SAFETY TERMS;

 Adverse event
 Medical errors
 Sentinel events
 Near miss
 Retro specter analysis( identify the problem and prevent the
future occurrence by setting standard)
 Prospective analysis( before the problem occur set standard
to prevent it. That means learn from daily experiences and
do something to prevent it . Here focus is on process.)
Ii there is any process in place to carry out a patient safety
prospective analysis?

43.0 WHAT DO YOU MEAN BY QUALITY?( terms used)

42.1. doing the right thing at right time.
42.2. exceeding the customer’s expectation
42.3The degree in which health services increase the
likelihood of desired health outcomes, and are current
professional knowledge.

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 42.4. Quality is about achieving optimal outcome and also
about avoiding risk minimizing harms.
44.0 THE THREE (3) PARAMETERS THE ACCREDITATION FOCUS ON THE
BASIC CONSEPT OF THE SAFETY ARE: Structure, process and
outcome.)
44.1. STRUCTURE: it includes quality of the staff,
specialization, training, experience, human resources,
physical layout, equipments etc
44.2. PROCESS: whatever we do for the patients, it include
clinical process, care delivery process and administrative
process.
44.2.1. . clinical process such as patient assessment,
interventions, treatment plan, treatment procedures, test
ordering and interpretation, administration of medication,
patient education etc.
44.2.2. . CARE DELIVERY PROCESS : which include: patient’s
registration, room cleanliness, patient’s transfer, out
patient’s laboratory services, medication dispensary etc.
44.2.3. . ADMINISTRATIVE PROCESS: which include health
information system, financial management, contract
management etc
44.3. OUTCOME : the result of the care, two types of
outcomes include clinical and functional
44.3.1. clinical outcome. Which involves short-term results
of specific treatment and procedures and also
complications, such as adverse events, mortality etc.
44.3.2. FUNCTIONAL OUTCOMES include, long term health
status, activities of daily living etc.
The concept of outcome refers to a technology of patient’s
experience.

45.0 What do you mean by Root Cause analysis?( RCA)

It is the detailed investigation of a major problem occurred. For
example over dose medication given and as a result patient died.
This involve those directly involved with the situation and ask “why “
at the each level of cause and its effect. what happened, why it
happened and how such incident can be prevented.
 To be a RCA it must involve 6 steps:
1. Good understanding of human interaction
2. Definition of potential problem
3. Analysis of cause and effect
4. Development of action steps
5. Measurement and evaluation of each steps
6. Documentation of all steps.

45.0 ROPs (required organizational practice guidelines)

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 ROPs are the required practice an organization must have to reduce
risk and improve patient’s safety.
According to the Canadian standard the organizations accredited
under them should follow the required organization practices.
According to them ,these ROPs should be in place to enhance
patient/ client safety and to minimize patient’s risk.
We have to comply 9 ROPs in KKUH. According to Canadian
accreditation standards they are requiring our organization to meet
the entire test for compliance as a proof of having the ROPs in place
as well as achieving the stated goals.

46. 0 Patient safety areas and ROPs are

ROPS 1.COMMUNICATION:
1.1. ROP- Patient verification:
implement a client verification procedure for all services and
procedures example band, photo identification etc.

1.2 ROP . Transfer of client information at transition point.

Example the team uses mechanisms such as patient transfer
forms, check lists , communication during the endorsement
etc.
1.3. ROP. Medication Reconciliation
1.4. Safe surgical practices.

2. MEDICATION USE;
2.1. Control of concentrated electrolytes

3. INFECTION CONTROL
3.1.Hand hygiene
3.2.Timely administration of prophylactic antibiotics
3.3.Safe injection practices
4.0. WORK LIFE:
4.1. training of patient safety.

Prepared by Rosily Varghese ADON Surgery.

Knowledge is power

BEST WISHES TO ALL THE NURSES IN SURGICAL AREAS.