JCIA Q & A

JCIA Survey


Specially Trained Surveyors Will Visit & Evaluate Each Health Care Organizations Compliance And Identify Strengths And Weaknesses. The Surveyors Goal Is Not Merely To Find Problems, But to score Health Care Organizations for their Improvement .

Preparation for Accreditation

Its very important that you have to be ready for the survey.  Keep up-to-date & thorough with all the standard procedures involved in your assigned job & related medical records procedures.


Seek your direct supervisors help & clarify your doubts

Tips to get educated

Education Is A Big Piece of the Puzzle:


Try to review your departmental announcements & policy / guidelines information from the intranet "hospital portal Maintain competency in all your tasks. The training manuals are readily available in your respective stations Use it as your regular reference guide.

This is the Key



Be organized (in your respective areas) And Surveyors Are Less Likely To Dig Deep. Always Have Key Information Handy Demonstrate Improvement Surveyors Will Want To See Whether Your Area is undergoing any improvement.

JCIA Questions/Answers Contd

Question What is the mission of Madinat Zayed Hospital? To provide high quality healthcare services, that is accessible to all people we serve in the Western region


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Question What is the vision of Madinat Zayed Hospital?


The vision of Madinat Zayed hospital is to be a leader in the provision of excellent, compassionate, rural healthcare

JCIA Questions/Answers


Question

What do I say if I dont know the answer to a Joint Commission surveyors question?
Inform him/her where you would go to find the answer (e.g., I would ask my supervisor, reference a specific policy manual, etc.). NEVER RESPOND, "I DONT KNOW."

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Question

What do you do in case of fire?

RACE see printed cards in all units PASS see printed cards in all units CALL 666.

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 A.

Question Where are the fire extinguishers in your work area?



(Individual to each area)

B.

List the 2 types of extinguishers and the types of fires they may be used on.


Type 1 Carbon dioxide (CO2) in black cylinder. Use on flammable liquids and electrical fires. Type 2 A multi-use dry chemical extinguisher in a red cylinder.

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Question

If there is a fire, where are patients moved?

Please review the unit map and the evacuation route and fire exits in your unit. Please locate the closest assembly point (recently placed outside the hospital building)

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Question

If there is a fire, where are patients moved?

Move patients laterally beyond one set of fire doors if the fire is in your area. If not possible to evacuate horizontally, evacuate vertically using fire safe stairwells. Do not use elevators.

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Question

When the fire alarms are ringing, how do you know if the fire is in your area? Over head address system Continuous alarm means the fire is in the area

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Question How do you report an emergency security incident such as an assault?


Activate Code White( violent person) by dialing switchboard on (0). Fill out OVR.

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Question What is the Madinat Zayed hospital smoking policy?


MZH is a smoke free zone

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Question How do you report suspected infant abductions?


Immediately activate Code Yellow (Missing Patient by dialing the switchboard.

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Question What is an MSDS sheet and where are they located?


MSDS is the acronym for Material Safety Data Sheets. They describe products, safety measures and precautions that should be considered when using products, and procedures for hazardous exposure. MSDS information can be found on each ward.

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Question

A chemical you dont know about is on the floor. What do you do?
Refer to the MSDS manual.

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Question

What is the proper method of needle disposal?

Do not recap Dispose in the sharp box

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Question What are Standard Precautions?


Precautions used for all patients and are designed to reduce the risk of transmission of microorganisms from recognized and unrecognized sources or infections in the hospital. Use personal protective equipment appropriate for the situation to avoid any exposure. See the Infection Control Manual

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Question Do we need to screen patients for HIV and hepatitis before surgery?


No We follow standard precautions which means that same precautions are taken regardless of HIV status

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Question How do you dispose of infectious waste?


Red plastic bags and refer to the Infection Control Manual.

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Question What are the infection control indicators at MZH:


1-Compliance with hand hygiene 2-Ventilator associated pneumonia (ICU) 3-Catheter related blood stream infection (ICU) 4-Urinary catheter related infection (ICU) 5- Surgical site infection

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Question What are the infection control indicators at MZH:


6-Compliance rate with Ventilator associated pneumonia and central line bundles of care 7-Compliance rate with the surgical site infection bundle of care

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Question What is the best resource for infection control issues?


The infection control manual and the infection control nurse Ext:560

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Question How do you report a Code Blue and code pink?


All Code Blues should be reported by dialing 222 followed by Overhead bagging

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Question What happens in the case of an electrical shutdown?


Emergency generator power will come on within seconds after losing power.

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Question How are communications maintained in the event of a telephone outage?


Via e-mails Mobile telephones Porters

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Question What would you do if the medical gas system were disrupted? What gases are available in your area?


Use portable oxygen tanks as necessary until the system is restored and then have tanks refilled in hospital there is oxygen in all wards/department but in some specific areas nitrous oxide is present.

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Question What would you do if the water supply were cut off?
Inform engineering department. The hospital has an alternative source of clean water in case of emergency.

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Question

How is a patients Do Not Resuscitate (DNR) order communicated to all caregivers?

DNR is not accepted by UAE law Conflicts related to that can be referred to the hospital Ethics committee

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Question How are patients and families involved in planning care?


The patients plan of care is discussed with the patient and family upon admission and periodically throughout the hospital stay or ambulatory visit.

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Question How should patient complaints be handled?


All the complaints will be handled as per the compliant policy and the flow process. verbal complaints are handled by the staff/HODs in the units /ward or by the patient affairs office. Written complaints are handled by QMD And patient affairs department.

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Question How are patients rights to privacy protected?


Privacy is maintained by drawing curtains or closing doors when appropriate, refraining from conversations regarding patients in any public area, knocking on closed doors, announcing yourself prior to entering, and placing any census listing or appointment schedule where it is not readily viewed by those not engaged in patient service activity.

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Question
Confidentiality of patient information is maintained by storing patient records only in restricted access areas of all patient care areas and offices. The MEDICOM system required authorized users to log on for each session. Media requests for information are referred to the hospital Director office. Encourage a patients family and friends to designate a spokesperson to relay information. Health care workers should exercise extreme discretion when asked for patient information via telephone.

How are the patients rights to confidentiality protected?

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Question What is meant by "informed consent?


Patient are entitled to information concerning the medical necessity, possible risks, and known alternatives prior to the initiation of care, unless emergent in nature. IN some instances, MZH consent policies require this process be documented by a written consent form. (refer to consent policies)

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Question

How do you address ethical issues of patient care or clinical practice if you have questions or concerns?
First discuss your concerns with your immediate supervisor. Refer to other Administrative channels for your department as needed. MZH has an ethics committee chaired by medical director and activated when needed. For example, we had 2 ethics committee meetings this year to discuss patient requests for cord blood collection.

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Question How are patients informed of their rights as a patient?


MZH provides a pamphlet titled "Patient Rights and Responsibilities" to all admitted patients and outpatients. This document outlines the individual rights as a patient. Posters of the same will be found in key areas in the hospital, also the patient information Handbook includes them.

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Question How did you receive training to operate the equipment in your area?


Training should be received at initial orientation and through in-services. The operating manual should be accessible. Staff are also trained on new technology and equipment when they are introduced to their units. Biomedical engineering department arranges training when requested

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Question How does MZH assure that equipment is safe for use?
Equipment are checked regularly by biomedical engineering department as per their specification and stickers are maintained on the equipments to indicate the date of last preventive maintenance and date of next maintenance.

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Question What is "restraint?


A physical or mechanical device or medication used to involuntarily restrict the movement of the whole or a portion of a patients body as a means of controlling his/her physical activities in order to protect him/her or others from injury.

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Question

Are handcuffs used for prisoners considered restraints?

Devices used by corrections officers do not fall under the MZH policy on the use of restraints.

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Question

Who may initiate the use of restraints on medical/surgical areas?

Restraints may be initiated by competent staff after an order is obtained.

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Question Can a physician write a PRN order for restraints?


No. PRN orders cannot be written for restraints. Each order must be based on the assessed needs of the patient and include the reason for restraint, and the type of restraint. Length of restraint time allowed depends on the circumstances and the results of patient reassessment. Restraint orders are valid for a maximum for 24 hours only according to MZH policy.

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Question How are patient rights, dignity and well-being protected during an episode of restraint?


The patient is assessed for hygiene, elimination, hydration, nutrition and comfort needs including neurological checks and skin integrity checks depending on the reason for restraint, as per the approved policy .

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Question

How are staff trained in the proper use of restraints?

Orientation is provided to all concerned staff and the restraints' policy is accessible to all in the hospital portal.

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Question What is the governing body at Madinat Zayed hospital?


Senior management Committee which is chaired by Mr. Salem Al Mazroei and include the senior leaders from the WMR and MZH

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Question Who established the hospitals` mission statement?


The Senior management committee.

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Question What do you do if a sentinel event occurs?


Sentinel event is unexpected occurrence involving death or serious injury. Serious injury specifically include loss of limb or function. Examples: wrong site surgery, infant abduction. -Follow MZH sentinel event policy: inform head of department, manager or nursing supervisor who will inform immediately other senior leaders.

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Question Who should fill out Occurrence of Variance Reports (OVR) ?


Any MZH staff member who witnesses an accident or unusual incident involving a patients or visitor . Any staff member who is injured or involved in a work related accident.

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Question To whom do you report incidents?


The immediate supervisor on duty.

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Question Where do you find out information about hazardous materials?


Ask supervisors. Look at MSDS information sheet available in your department.

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Question What do you do if a Disaster is announced?


Refer to the hospital Disaster Plan. Check your department and unit responsibilities and the action card .

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Question

As you answer a telephone call, a news media representative asks questions about a patient receiving care at MZH. What should you do?
The caller should be asked to contact the Hospital director office.

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Question How do you report a blood exposure (via needlestick, splash, etc.)?


Fill an OVR See Infection control manual (Employee health policies)

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Question

What is the major infection control measure that you can use to decrease the transmission of organisms?
Hand washing.
When

should you wash your hands?

Before each patient contact, before and after removing gloves, after using the restroom, blowing your nose, before eating.

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Question What do you do if a patient is suspected of having TB?


See Infection Control manual We have special room with negative pressure for airborne isolation which is required for patients with Tuberculoses.

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Question How do you handle soiled linen?


It is handled minimally, placed in a bag at the point of generation and sent to the laundry.

white

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Question What is the hospitals policy on the use of drug samples?


Not permitted at MZH. Refer pharmacy policy in the portal.

to the

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Question

How do you respond to orders that permit a patients own supply of medications to be used while he/she is in the hospital?
Refer to pharmacy policy n hospital portal. It is permitted in certain situations and under certain conditions.

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Question What is the hospitals process for monitoring, detecting and reporting adverse drug reactions (ADRs)?


Fill the ADR form and send to pharmacy refer to the ADR policy.

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Question

When a patient is sedated for a procedure what elements need to be assessed and documented during the procedure?
See conscious (moderate) sedation policy

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Question

Under what circumstance and from whom may the nurse take verbal orders? What information must the nurse include when the verbal order is written and in what time frame must it be co-signed? Refer to the verbal orders policy. Verbal order is permitted during emergencies and must be signed within 24 hours

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Question

How are medications outside the Pharmacy?

stored

securely

Medications must be stored in a secure places like: locked cabinet/refrigerator; in a closed room; or within sight of a Nursing desk that is continuously staffed around the clock;

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Question How should narcotic substances be stored?


Narcotic substances must be separated from non-restricted ward stock medications behind a separate double lock cabinet.

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Question

What is the MZH structure for reporting safety issues?

Staff are required to complete an OVR

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Question What is a "Near Miss" and do we report these events?


"Near Miss" are for example category A &B medication errors which are medication error happened but not reaches the patient, yes we have to report these type of error to be used as an education tools.

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Question

What is the policy for pain assessment in Adults (inpatient settings)? All patients will be individually assessed for pain. Patients will receive interventions (pharmacological and nonpharmacological) that reduce or eliminate pain associated with their diagnosis, procedure or treatment, and will be reassessed for the effectiveness of the intervention. An explanation of the pain management assessments, interventions and outcomes will be given to the patient and family. Refer to pain management policy

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Question What pain scales should be used to assess pain?


The Faces Pain Rating Scale, in which you have the patient choose (point) to the face that represents their pain, for use in patients cannot do the Verbal Numeric Scale.

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Question

Are OPD clinics required to conduct pain assessment on all patients?

All patients need to be assessed for pain. Healthcare providers share the responsibility of assessing pain, response documented, intervention if applicable and follow-up.

PATIENT AND FAMILY EDUCATION (PFE) Q&A

Question Does the hospital have a written plan for patient/family education?
Answer: Yes, Hospital Policy (patient and family education policy) , and Hospital form (Interdisciplinary PFE Record). The hospital supports patient education by providing multiple educational brochures.

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Question: How do we educate patients concerning pain management?

Answer: Patient education about pain management
is taught by different disciplines at MZH (physicians, nurses, pharmacists, and others). Hospital (Pain Management) Policy outlines the process of pain management and considers patient education about pain.

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Question: How do you identify the patient/family need for education?

Needs are identified by performing ongoing patient assessment of educational needs which includes initial assessment, and ongoing reassessments by healthcare providers involved in the care process.

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Question: How do you identify the patient/family need for education?

Needs are identified by performing ongoing patient assessment of educational needs which includes initial assessment, and ongoing reassessments by healthcare providers involved in the care process.

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Question: Where is patient education documented?

Patient Education is documented on the Interdisciplinary Patient/Family Education form.

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Question: How do you assess readiness to learn?

Answer: The patient/family is interviewed prior to education and is reassessed throughout hospitalization. Readiness to learn is demonstrated by alert state, verbalization and ability to retain knowledge. Educators should choose the most teachable moments to educate patients. Outpatients are assessed at each clinic visit. The Interdisciplinary Patient /Family Education Record, allows the documentation of patients` readiness to learn

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Question: How the family is educated on how to assure compliance and continued care?
Answer: Written Discharge Instructions provide patient specific instructions as well as future appointments. Discharge planning teams help educating patients about continuity of care at home

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Question:

What questions can you ask your patients to determine their level of understanding regarding Patient Education?
Answer: Ask them to repeat instructions back to you, ask them for details about their medications, and ask them for return demonstrations. The IPFER helps to document patient's` understanding.

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Question: When do you start to educate the patient?


Answer: The education process begins with initial patient contact and continues throughout the continuum of care.

(PFR) Q&A


continued..

Question: How do you inform patients about complaints?

Answer: posters, handbook. visitor guidelines

(PFR) Q&A continued..

 Question

:What procedures obtaining an informed consent?

needs

Answer: mainly before surgery, anesthesia, use of blood and blood products and other high risk treatments.

(PFR) Q&A


continued..

Question: How do patients know the hospital mission?

Answer: The hospital mission, vision and values are posted in key areas, they are available in the patient booklet also.

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