Joint Commission

2013 Questions and Answers

A pocket guide to making quality, safety and preparedness a permanent part of your job

& A

1IndexImportant Phone Numbers ..................................................................3About This Guidebook ........................................................................ 4You and the Survey Process ................................................................5The AAMC Mission Statement ............................................................. 9National Patient Safety Goals ............................................................ 11Ethics, Rights and Responsibilities ....................................................16Provision of Care, Treatment and Services ......................................... 24

Assessment (nutrition, pain, abuse/neglect)POCTRestraintsLearning AssessmentPatient EducationHandoff/SBARContinuum of CareBlood AdministrationFallsCode Blue/Rapid ResponseCode Carts

2Medication Management ..................................................................53 Surgical Services ..............................................................................59Surveillance, Prevention, and Control of Infection ..............................67Improving Organizational Performance ..............................................78Management of the Environment of Care............................................85Radiation Safety ...............................................................................92Emergency Management ...................................................................93Leadership .......................................................................................95 Information Management ..................................................................97Human Resources ............................................................................ 99

3Important Phone Numbers

The hospital emergency number to contact security officers (i.e. fire) is x6911

In the Sajak Pavilion, Wayson Pavilion, or Health Sciences Pavilion, dial 9-1-1 for police or fire emergency

Patient Safety/Incident Report Hotline x4787 (4PTS). Compliance Officer, Shirley Knelly, x1328/ Compliance Hotline x1338 Privacy Officer, Robin Smith, x4130 Patient Safety Officer, Shirley Knelly, x1332EnvironmentofCareSafetyOfficer,TonyKuzawinski, x4798

Emergency Repair Hotline at x4777

4About This GuidebookWhile this guidebook is meant to prepare you for a Joint Commission survey, its larger purpose is to make that level of preparation a permanent presence in the way you go about your job every day, every time. You are responsible for being familiar with the information in the guidebook, which means you share in the responsibility for making sure that quality, safety and preparedness are not the exception but the constant rule.

Check with your director/manager about your specific responsibilities in preparing for the survey, and about what specific information will assist you in responding to surveyors questions during the survey process.

5You and the Survey Process1. What is the Joint Commission?

The Joint Commission is an accrediting organization that evaluates a health care organizations performance in areas that most affect patient health and safety. These areas are defined in The Joint Commission Standards. By achieving accreditation, a health care organization has demonstrated its commitment to provide safe, quality care to its patients.

2. What is your role during the survey?

All employees should know that a surveyor must first be identified by administration as a bona fide surveyor before any hospital business is discussed. If you are the first contact a surveyor has made, smile, introduce yourself, including your title, and accompany the surveyor to your area manager to contact the Vice President of Quality and Patient Safety.

63. What is Tracer Methodology?

Tracer methodology is an evaluation method in which a surveyor selects a patient and uses that individuals record as a roadmap to assess and evaluate an organizations compliance with selected standards and the organizations system for providing care and services.

4. What is the role of the staff in the survey/during a tracer?

As surveyors move around the hospital, they will ask to speak with the staff members who have been involved in the tracer patients care, treatment and services. Assume they will want to talk with you, so have confidence in yourselfyou provide awesome care, so let them see it! Remember that you are prepared to answer their questions.

7Consider the following recommendations:

> Answer their questions directly (keepyouranswersshort and sweet) and ask the surveyor to repeat or rephrase the question if you dont understand it.

> Be polite and smiledo not let the questions make you feel defensive or angry.

> Be honestif you do not know the answer, do not make one up. If you dont know, state your resources.

> Be specific, provide examples for an answer and refer to policies or procedures whenever possible.

> Be enthusiastic about what you do.

8Examples of what will be asked:

> Your role in patient safety (i.e., NPSGs)

> What makes you competent in your role and how you were oriented in that role (i.e., licensure, yearly competencies)

> How care is coordinated and communicated with other disciplines (i.e. care planning)

> What you would do in an emergency (i.e. fire)

> How do you support patient rights

> What are your Performance Improvement Projects on your unit

> What is a Sentinel Event/Near Miss

9The Anne Arundel Medical Center Mission StatementIt is important that all employees know, understand and can speak about the mission of the hospital.

The mission of Anne Arundel Medical Center is to enhance the health of the people weserve.

AAMC enhances the health of the people we serve by recognizing its responsibilities for following the highest standards of care, treatment and services in meeting the needs of individual patients, affiliated physicians, third party payers, subcontractors, independent contractors, vendors, consultants, our community, and one another.

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1. How do you support the mission of AAMC?

Anne Arundel Medical Center staff provides patient care in a manner consistent with the mission statement.

2. Do you know what is meant by one level of care?

Yes. The care we provide is the same for all patients throughout the hospital who have similar needs. We assure that all patients receive the same level of care when we use common policies/procedures and collaborate with other departments in the provision of care. Outcomes then can be assessed and measured through performance improvement activities.

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National Patient Safety Goals Each year the Joint Commission identifies National Patient Safety Goals and surveys organizations efforts to achieve these goals, as appropriate to their settings and services. Each employee is expected to know how these safety goals are being applied in their particular area of service. Please refer to the National Patient Safety Goals flipcharts and/or posters in your departments for details.

ThecurrentNationalPatientSafetyGoalsareonthefollowingpages:

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GOAL 1: Improve the accuracy of patient identification

> Double identification of patient:

>> Name and contact serial number (CSN)

> Two person verification process for the administration of blood and blood products

GOAL 2: Improve the effectiveness of communication among caregivers - Critical value results reporting process

GOAL 3: Improve medication safety

> Labeling of meds

> Management of anticoagulation therapy

> Accurately and completely reconcile medications across the continuum of care

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GOAL 7: Reduce the risk of healthcare associated infections

>ComplywithCDCorWHOhandhygieneguidelinesand compliance monitoring

> Implementation of evidence based practices to prevent:

>> Health care associated infections due to multi-drug resistant organisms (MDRO) and Cdiff flagging and isolation, patient and healthcareworkereducation.

>> Central Line Associated Bloodstream Infections (CLABSI):centralline insertion checklist, patient education prior to insertion.

>> Surgical Site Infections (SSI): proper antibiotic prophylaxis, pa-tient education prior to surgery.

>>CatheterAssociatedUrinaryTractInfections(CAUTI):limitFoleyuse, leg securement.

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GOAL 15: Identify safety risks inherent in its patient population

> Identify patients at risk for suicide

> Provide suicide information (i.e., crisis hotline) to the patient and family members

Universal Protocol topreventwrong site, wrong procedure

> Pre-procedure verification process

> Mark procedure site

> Perform a time-out just prior to the procedure

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What are the responsibilities of the Patient Safety committee?

>> Integration and coordination of all components of the Patient Safety Program.

>> Oversight and implementation and monitoring of the National Patient Safety Goals.

>>Reviewing and recommending actions related to patterns/trends identified in occurrences reports.

>> Promoting a non-punitive culture of safety.

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Ethics, Rights and Responsibilities The hospital has an ethical responsibility to the patients and community it serves. To fulfill this responsibility, ethical care, treatment, services and business practices must go hand-in-hand. The hospitals system of ethics supports honest and appropriate interactions with patients. The system of ethics also includes patients whenever possible in decisions about their care, treatment, and services, including ethical issues. Refer to policy ERR3.1.03

1. What is an ethics consult and how do you initiate it?

A patient, family member, physician, caregiver, other party or an employee may request an Ethics Consult. An ethic consult can be initiated through a clinical consultation in Epic or can be initiated through the hospital operator. This consult accesses an ethics representative who is on call 24 hours a day, seven days a week. The on-call person will ensure all supports

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are in place to facilitate the decision making at hand, this may include ensuring family conferences have taken place to convening a patient care advisory committee to provide clarification or assistance in facilitating care decisions as needed. A Patient Care Advisory Committee must include an administrator, a physician, a social worker and a nurse that are uninvolved in the care of the patient or issue in order to give an objective view and facilitation. Refer to policies ERR3.1.10/ERR3.1.09

2. How are patients informed of their rights?

Patients are given an Advance Directive pamphlet, Patient Guide and brochures during the admitting process. Information is also located in patient rooms. Volunteers visit with new patients and provide additional information if needed. Interpreters are available to assist when needed. Refer to policy ERR3.1.03

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3. What is an Advanced Directive?

An Advance Directive is either a living will or a durable power of attorney for health care. It allows patients to indicate their wish for health care in case they become involved in an end of life situation or are unable to speak for themselves. Refer to policy ERR3.1.02

4. What is the hospital policy on Do Not Resuscitate orders?

It is the policy of AAMC to honor the wishes of patients and their families who express a desire to withhold or withdraw life-sustaining treatment when specific criteria can be met. Refer to policy ERR3.1.08

5. How does a patient, family member or visitor initiate a complaint?

Any patient, family member, visitor, or nurse/caregiver can initiate a complaint to any hospital employee. Hospital employees should do as much

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as they can for the patient at the time. Access Patient Advocacy at x4820. During off shifts, the administrative coordinator or clatanoff pavilion administrative coordinator would handle such issues. Refer to policy ERR3.1.04

6. How do you ensure patient privacy?

> Only access a patients medical record when you have a need to know, for example, you are involved in the direct treatment, payment, or other healthcare operations related to that specific patient.

> Never discuss patients in public areas (i.e. elevators, cafeteria).

> Maintain confidentiality of patient information when talking on the telephone or at the computer.

> Sign off the computer when finished.

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patient privacy cont.

> Maintain security of the patients physical medical record

> Knock before entering the patients room

> Be sure a patients body is adequately covered

Refer to policy ERR3.1.05

7. How would you address the care and learning needs of patients with religious, cultural or language barriers?

> Consult with Patient Advocacy, Social Services and Spiritual Care

> Involve hospital in-person Spanish interpreters for all language barriers, including hearing and sight impairments, and they will facilitate support and interpretation for you through the Martti units or Pacific Interpretation audio interpretation services.

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> For hearing and/or sight impaired patients, refer to policy ERR3.1.01

> A patients learning needs are assessed with each hospitalization by all professionals who interact with the patient, the information is documented in patient education tab assessment.

8. Why must we document a patients primary language and where do we document this information?

Language barriers can have a significant impact on safe patient care and patient care outcomes. As the diversity of our region continues to grow, Anne Arundel Medical Center is encountering more patients with language barriers. To communicate effectively with our patients, we must provide patient care that is linguistically appropriate to all patients. The first step in providing this care is to identify and to document the patients primary language.

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> The following are the steps to document on the Adult Profile Flow Sheet:

>> Language AssistanceAnswer Yes or No

>> Language NeededOpen pull down menu and select language

>> Order an interpreter consult (x3801)

9. What are the components of an Informed Consent?

The goal of the informed consent process is to establish a mutual understanding and agreement between the patient or surrogate and the individual who provides the care or procedure that the patient received. The process allows each patient or surrogate to fully participate in decisions about his/her care, treatment and services. Obtaining consent to treatment ensures that any patient receiving surgery or medical procedures will be fully informed by the individual performing the procedure as to all the material risk, benefits and alternatives prior to giving consent.

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The consent form, Record of Consent for Procedure is required for all surgical procedures and certain categories of invasive and a several types of non-invasive procedures, such as radiological procedures, administration of blood/blood products, refusal of blood transfusions, radiation therapy. A properly executed informed consent contains documentation by the individual performing the procedure of the patients understanding of the information pertaining to the nature of the proposed care, treatment, services, medications, interventions or procedures, material risks, benefits and side effects of the proposed care, therapy or procedures. It also contains documentation of the likelihood of achieving care goals, the reasonable alternatives to the proposed care or procedure, the material risk, benefits and side effects related to alternatives, including the possible results of not receiving care, treatment and services,andwhetherotherhealthcareprofessionalswillbeperformingtasksrelated to the proposed care or procedures.

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Provision of Care, Treatment and Services The provision of care, treatment, and services to patients is composed of four core processes or elements:

Assessing patient needs.

Planning care, treatment, and services.

Providing the care, treatment, and services the patient needs.

Coordinating care, treatment, and services.

1. Who can make a referral to Nutrition Services?

Any direct caregiver for the patient may request a nutrition consult. Nutritional needs are initially assessed within the first 24 hours as part of the admission screening.

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2. When and how often is pain assessment done?

Pain assessments are done by a professional nurse on admission, after each intervention and as-needed, at least once per shift. Interventions are made based on the reassessment and in evaluation of the pain management. Patients are assessed for their risk of pain upon entering AAMC by a professional nurse.

Factors that increase a patients risk for pain include being developmentally or medically non-verbal, English is not the patients primary language, extremes of age, cultural and religious beliefs. If pain is present upon entering AAMC, a comprehensive pain assessment is completed. See NAP12.1.18 for components of a comprehensive pain assessment. Pain is subsequently assessed every shift, each report of pain, within one hour of administering a PRN opioid, any new or changed pain; prior to and following a procedure, per PCA policy and at discharge.

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3. How is pain assessed and managed for our patients?

Pain management goals are set with the patient and family. All professionals who interact with the patient assess pain. Interventions are initiated as appropriate through an interdisciplinary process. Pain is assessed using developmental/age and cognitively appropriate pain assessment tools.

** Know which pain assessment tools available in Alec are appropriate for your patient **

Pain management is included in the patients individualized plan of care and supported by Clinical Practice Guidelines (CPGs) that address both acute and chronic pain. AAMC provides multi-modal and interdisciplinary pain management.

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4. Who would you notify if you suspect abuse and/or neglect of a patient?

Notify the supervisor/designee and the social worker. There is also a domestic violence coordinator at x1209 who can assist. A consult can also be entered into Alec based on the admission screenings.

5. What are some specific reportable criteria for suspected abuse of a patient?

Physical signs: cigarette burns, scalding burns, certain types of fractures or internal injuries

Personality: overly shy or aggressive, cries easily

Coping skills: inappropriate low tolerance, expresses desire to die

Personal appearance: unkempt, poor hygiene, malnourished

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6. What is Point of Care Testing (POCT)?

Point of Care tests are laboratory tests done outside of the lab by non-lab personnel. Because an accredited laboratory has many quality controls built into its processes, as well as highly trained lab personnel, any lab tests done outside the walls of the lab must be done with the same level of quality control.

7. What POCT is performed in your patient care area?

EachpatientcareareaatAAMChasdefinedPOCT.InordertoknowwhatPOCTisauthorized(permitted)inyourarea,refertothePOCTgridunder Lab Administration on the intranet. All POCT performed at AAMC is for screening purposes and should not be used as a sole source of patient diagnosis.

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8. What is the organizations policy on restraints?

AAMCs philosophy is to strive toward a restraint free-environment by continuously improving our practice to protect patients and respect their right and dignity.

9. How do you monitor use of restraints?

AAMC is committed to preserving a patients rights and dignity. AAMC utilizes retrospective chart review to monitor use of restraints to identify opportunities to introduce preventive strategies, alternative use, and process improvements that reduce the risk associated with use of restraints on an ongoing basis.

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10. What are the two types of restraints that are used at AAMC?

Medical-Surgical: Used to promote medical-surgical healing. These restraints are used for patients climbing out of bed or pulling at tubes or lines.

Behavioral Restraints: Used in an emergency to protect the patient against injury to self or others because of violent or abhorrent behavior.

11. What procedures are required for each type of restraint?

The revised Restraint Policy and the Physician Order Sets list all the requirements for each type of restraint.

Key Medical/Surgical Restraint Requirements:

> A physician order within 12 hours of application.

> When a verbal order is given to restrain, the physician must evaluate the patient within 24 hours.

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> Physician must renew the order, based on reevaluation, at least every calendar day

> Care and assessment every two hours

Key Behavioral Restraint Requirements:

> A physician order and face-to-face assessment within one hour of application

> The care and assessment is done every 15 minutes

> A time-limited order based upon age (four hours for adults, two hours for ages 9 to 17, one hour for under age nine).

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12. Do you utilize seclusion (the involuntary confinement of a person in a locked room) at AAMC?

No, we do not use seclusion at AAMC.

13. How do we determine the educational needs of patients, families and significant others?

Patient, family and significant others learning needs are assessed on admission and then reassessed on an ongoing basis. This information is documented in the patient education tab. The answers to the learning assessment questions can be viewed in the SBAR handoff report.

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14. What are considerations in a learning assessment?

> Literacy, educational level and language

> Emotional barriers and motivations

> Physical and cognitive limitations

> Learning needs preferences and readiness to learn

> The specific questions to be answered in Alec regarding learning assessment are the following:

1. Does the patient/guardian have any barriers to learning?

2. What is the primary language of the patient/guardian?

3. How does the patient/guardian prefer to learn new content?

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15. Based on the needs identified in the learning assessment, patients/families should receive education on:

> Disease processes and treatment plan

> Safe and effective use of medication and medical equipment

> Potential drug-food interaction

> Nutrition and dietary needs

> Rehabilitative techniques

> Community resources

> When and how to obtain further treatment

These items are teaching points on the General Teaching Title in Patient Education.

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16. Where do you find the hospitals guidelines on patient education?

The policy for patient education is EDU 17.1.01 and handouts are available in Alec via Clinical References, we use software from ExitCare.

17. What are you required to document regarding patient education?

> Preferred language, barriers to learning, preferred learning style(s)

> The reassessment of learning needs and challenges

> Ongoing teaching, including informal sessions and structured classes

> Patient/caregiver responses

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18. How do you involve patients in education and how do you know they have learned what you have taught?

Encouraging questions and involving patients and families in decisions about their care promotes an interactive approach to patient education. Asking patients questions such as What would you do if your catheter falls out after you go home? is a good way to evaluate teaching effectiveness. Having patients perform demonstrations of a self-care measure is another method of evaluation. Your evaluation of the patients learning must be documented in the medical record.

19. How do you make patient education collaborative andinterdisciplinary when more than one discipline is involved in teaching?

When more than one discipline is involved in the care of the patient, those same disciplines participate in the various aspects of patient and family

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teaching. Each discipline has access to all documentation in the patient medical record.

20. What is meant by continuum of care?

One of our goals in providing patient care is to maximize the coordination of services among health care providers across a variety of settings. Continuum of care refers to our process for coordinating care and services to:

> Meet the ongoing needs of individuals before, during and after hospitalization

> Assess that appropriate information is provided, not only to the patient and family, but to subsequent caregivers as well.

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Examples of services provided within the acute care setting include pharmacy, dietary, physical medicine and rehabilitation, care management, social services and pastoral care. Examples of services which extend beyond the hospital include sub-acute care, extended nursing facility care, home care, hospice and other community based healthcare services (i.e., a clinic, community education).

21. How do we ensure that patients who come to AAMC have access to care?

Our goal is to ensure access to appropriate care. Admission to each patient care unit is guided by criteria. Prior to, during, and after admission, we assess the patients status to determine if we can provide the needed care. If not, we facilitate transfer to a more appropriate unit or to another health care facility. When patients are admitted, referred, transferred or discharged, we make sure the appropriate patient care information is communicated to subsequent health care providers.

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22. What do we do to ensure that the patient and/or family receive information concerning the care to be given during the patients hospitalization?

Dissemination of information regarding procedures and/or treatment options are initiated by the physician and reinforced by all disciplines involved in the patients care.

23. Describe some of the ways you communicate information to other healthcare professionals?

We communicate with each other by written forms, telephone, fax, computerized documentation and/or in person to be certain information is relayed from one health care provider to the next. We document assessments, plans and interventions on the medical record for review by all team members.

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24. What standardized tool does AAMC use in communicating hand off patient care?

SBAR

25. What does SBAR stand for? SSituation: What is happening at the present time?

BBackground: What are the circumstances leading up to this situation?

AAssessment: What do I think the problem is?

RRecommendation: What should we do to correct the problem?

26. Why do we use SBAR?

To help our healthcare team communicate in ways that improve patient safety, increase clarity, and provide a concise reporting method. This in

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turn, will lead to a reduction in harm, increased satisfaction for all providers and overall better outcomes for patients and their families.

27. How do we make referrals to the Care Management department?

Care Managers and Social Workers are easily accessible on the unit, collaborating with other members of the healthcare team to facilitate meeting patient needs. In addition, anyone can make a referral to the Care Management department by telephone at x4180, fax at x4184, or by entering a clinical consult into Alec.

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28. When does discharge planning begin?

Upon admission. It is a multidisciplinary process.

29. How are the needs of patients met after discharge if home care or hospice is necessary?

Family/patient in coordination with the care coordinator or social worker would assist in making decisions for discharge.

30. How is the Interdisciplinary Plan of Care developed?

The patients Plan of Care is determined and developed through collaboration with all disciplines involved in the patients care. Each patients plan of care in individualized based on the patients needs. Goals are identified and mutually agreed upon between the patient and the interdisciplinary team. This information is communicated and documented using the computerized interactive Plan of Care.

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31. How is the Plan of Care individualized for your patient?

> Individualization of a patients Plan of Care can be done at several levels:

> It starts on assessment when you assess your patient with the fall and skin risk tools, if the patient scores an appropriate level, the care plan topic will be recommended for you via Best Practice Alert (BPA).

> Next when you are creating your care plan by applying a template, select specific topics based on what your patient needs. For example, if your patient has had hip surgery then you select that template.

> Within the template, select the interventions that apply to your patient.

> Finally, write a patient specific goal that you anticipate the patientwillreach during the hospital stay.

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32. What are the Blood Product Administration Key Points?

> Obtain pre-transfusion vital signs

> Verification of blood product and patient must be made by two nurses before initiation

> Blood must be initiated within 30 minutes of Blood Bank release to nurse

> Monitor patient during the first 10 to 15 minutes of the transfusion and observe for reaction

> Vital signs must be taken 15 minutes after the transfusion was initiated

> Continue to monitor vital signs every hour until transfusion is complete

> PRBC must be completed within four hours

> Vital signs must be taken one hour after the transfusion completed

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> Once blood product transfusion has completed, stop the blood in the EMR and complete the section

33. What are some fall prevention measures that you can take?

> Communicate. Notify the transporter if a patient is at risk for falling. Notify the receiving department if there is a high risk for falls.

> Include the fall risk in the handoff report and charge nurse reports.

> Assess for risk of falling on admission (within 24 hours), every shift, when transferred to another unit, or after a significant condition change.

> Maintain a safe unit environment by conducting an environmental assessment of patients environment at the time of admission and at least every shift.

>> Remove clutter and tripping hazards from patients room.

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>> Place the call light and frequently used objects within reach.

> On admission, discuss patient/staff partnership in preventing falls whilehospitalizedandprovidepatientandfamilywithcopyofpatient educationonpreventingfallswhilehospitalized.

> Basicfallpreventioninterventionsforallpatientsinclude:

>> Orient patient to surroundings including bathroom location, use of bed, location of call light.

>> Useproperlyfittingnonskidfootwear

>> Keepbedinlowestpositionduringuse

>> Unless specifically indicated, avoid the use of four side rails. Patients can crawl over side rails and fall to floor.

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> In addition to basic fall prevention interventions, interventions for moderatefallriskpatientsinclude:

>> Placeyellowwristbandonpatients.

>> Postyellowfallingstaroutsidepatientsroom.

>> Assistpatienttothebathroom/commodeeverytwohours,asrequired byserviceline.Staywithpatientwhiletoileting.

>> Superviseand/orassistwithbedsidesitting,asappropriate.

>> Use bedside commode, as appropriate.

>> Monitor and assist patient in daily activities.

>> Reorient confused patients as necessary.

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> Evaluateneedfor:

>> PT and/or OT consult

>> Activation of bed/chair alarms

>> Hip Protectors

In addition to basic and moderate fall prevention interventions, the followinginterventionsforhighfallriskpatientsinclude:

> Post red falling star outside of patients room

> Remainwithpatientwhiletoiletingandperformingpersonal hygiene at sink

> Activate bed and chair alarm

> Whennecessary,transportthroughoutthehospitalwithassistance of staff. Notify receiving area of high fall risk patients.

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> Forpatientswhoarehighfallriskduetoneurologicaldeficits:

>> Usetwopersonliftuntilphysicaltherapyhasevaluateforspecific transfer recommendations

>> Followingorientationtocalllight,havepatientdemonstrateuseof call light

>> Assistpatientwithedgeofbedsitting

> Conduct post-fall assessment on all patients that have fallen and provideeitherlowriskorhighriskmonitoring.

>> LowRiskmonitoringnoapparentinjuryfromwitnessedfall

>> HighRiskMonitoringallunwitnessedfalls,fallswithactualor potential head/neck injuries, bleeding disorders, and use of anticoagulant and/or antiplatelet agent.

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34. How do you activate Emergency Response Teams Code Blue and Rapid Response?

Code Blue: Push Code Blue button in patients room and/or call x1111RapidResponse:Callx1111Who can call Rapid Response?AnyoneStaff (nurse, PCT, dietary, etc.), family members, patients, volunteers, etc.Why would you call Rapid Response? >YouareworriedaboutyourpatientCallevenifyouareunsure!! > Acute change in heart rate 130 beats/minute > Acute change in systolic BP Acute change in RR 28 breaths/minute > Acute change in saturation Acute change in LOC

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35. What areas call 9-1-1 for medical emergencies?

Wayson, Donner, Health Sciences, and Sajak Pavilions including all outpatient regulated space and campus parking areas

Exception:DonnerPavilioninpatientandoutpatientsinradiationoncologyand outpatient infusion center (Code Blue for outpatients; Code Blue and Rapid Response Team for inpatients)

36. How often do you check your emergency code carts?

The carts are checked once daily using the code cart checklist to verify that the lock identification number matches the number on the checklist, locks are intact, expiration date is valid, and appropriate items are on top of cart withvalidexpirationdates.

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37. How long must an area keep the code cart logs?

The current months log is kept with the crash cart. A department must keep prior months logs in a separate location on the unit for one year.

38. Who controls code carts?

Distribution stocks the supplies. The cart is sent to the Pharmacy for drug replacement, a final check and locked. The carts are kept in Distribution for redeployment to patient care areas.

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Medication Management1. What does AAMCs high alert acronym PPINNCH stand for?

Pitocin

Potassium concentrated IV

Insulin

Narcotics

Neuromuscular blockers

Chemotherapy

Heparin and other anticoagulants

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2. What are several ways medications are secured in your work area?

Most medications are secured in Pyxis. Individual patient medications are stored in locked drawers outside patients rooms, and in med rooms. The code carts contain medications but are secured with a tamper evident lock and checked.

3. What must you do when opening a multi-dose vial?

Check the expiration date to ensure it is not out of date. Multi-dose vials must be dated with a 28 day expiration date after opening or shorter as per manufacturers recommendations. Vials may be used until the expiration date as long as there is no evidence of contamination. Undated vials must be discarded.

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4. What is important to remember about labeling medications in OR/Procedural areas?

All medications that are removed from the original manufacturers container foruseinaprocedurearetobelabeledwiththemedicationname,concentration/strength, quantity/amount, diluents and volume of diluents (if not apparent from the container), and expiration date (24 hours or less). See SNP15.4.12 - Medication labeling and administration in the operating room/procedural areas for more detail.

5. When are Pyxis overrides permitted?

Pyxisoverridesarepermittedduringurgentpatientcaresituationswhenpatient harm could result from delay in administration of a medication. When a medication is removed via override, it becomes the responsibility of the person removing and administering the medication to perform the same

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safetyreviewthatapharmacistwouldperformbeforeadministrationtothepatient.TheoverrideorderintheeMARisthenlinkedtoaphysiciansorder by the administering nurse once the original order has been verified by the pharmacist.

6. What is the hospital definition of adverse drug reactions (ADR)?

A response to a drug that is unintended and/or unexpected and occurs at doses used for prophylaxis, diagnosis, and treatment.

7. Why is the Medications Reconciliation process important?

Patients are at high risk for harm from adverse drug events when communication about medications is not clear. The chance for communication errors increases whenever individuals involved in a patients care change.

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8. When should medication be reconciled?

At admission, transfer, and discharge.

9. Who is responsible for ensuring reconciliation occurs?

Physicians, nurses, and pharmacists.

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Medication Reconciliation Tips for Success: Ensure the medication list is accurate on admission: Enter nurse up-dates

to PTA medications via a note attached directly to the medication on the admission navigator Review PTA Meds.

Ensure all medications have been reconciled at transfer from one unit or service to another.

Ensure all medications have been reconciled at discharge:View Med Rec Status on the discharge navigator.

View the Order Reconciliation History on the Patient Summary as a quick look to see if all medications have been reconciled on admission, at transfer, and discharge.

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Surgical ServicesHow do you label medications on and off the sterile field?

1. Medication containers include syringes, medicine cups and basins.

2. Label medications and solutions that are not immediately administered. This applies even if there is only one medication being used. Note: An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers tothatpatientwithoutanybreakintheprocess.

3. Labelingoccurswhenanymedicationorsolutionistransferredfromtheoriginal packaging to another container.

4. Labelsincludethefollowing:Medicationname,strength,quantity,diluent and volume (if not apparent from the container), expiration time

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whenexpirationoccursinlessthan24hours(forexample,Propofol).Note: The date and time are not necessary for surgical and interventional procedureswhenmedicationsarediscardedattheendoftheprocedureor the end of the day.

5. Label each medication or solution as soon as it is prepared, unless it is immediately administered.

6. Label the container after the medication is prepared.

7. Verify all medication or solution labels both verbally and visually wheneverthepersonpreparingthemedicationorsolutionisnotthepersonwhowillbeadministeringit.Verificationisdonebytwoindividuals qualified to participate in the procedure.

8. All medications and solutions both on and off the sterile field and their

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labelsarereviewedbyenteringandexitingstaffresponsibleforthemanagement of medications.

9. Immediately discard any medication or solution found unlabeled.

10. Remove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure.

11. Anexpirationdateisrequiredwhenallmulti-dosevialsareopenedandnotusedwithin24hours.

When and how do you conduct a Pre-procedure verification (Universal Protocol)?

1. Pre-procedureverificationbeginswhenthepatientisscheduledfora procedure.

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2. Key elements to verify include the patients name, procedure to be performed and laterality (correct side/site).

3. A pre-anesthesia time out must be done before sedation is given to the patient so that the patient can participate in the time out and confirm the key elements. This timeout is led by the physician providing the sedation.

4. Incasesoflaterality,theincisionsitemustbemarkedwiththesurgeons or proceduralists initials.

5. Only the indelible ink marker provided by the hospital is to be used the mark the site.

6. If site marking is not possible, the alternative site marking process must beused.Inthealternativesitemarkingprocessthenurseplacesawhitealternative site marking band on the patient during the pre-procedure

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verificationandwritesthecorrectsideandsitewithanapprovedsurgical marking pen. The physician or practitioner performing the procedure must initial the band itself prior to moving the patient to the operating or procedure room to confirm the side or site. Documentation ofplacementwillfollowthesamedocumentationforallsitemarkings.Thebandwillnotberemoveduntilaftertheprocedureiscompleted. Note:InNICU,thebabiesaremarkedwithabetadineswab.

7. The site marking must be visible after the site has been cleansed and draped for the procedure

8. A surgeon/proceduralist-led time-out must occur immediately before the start of the procedure (initial incision or insertion of instrumentation).

9. During the time out, all other activities and conversations are suspended,totheextentpossiblewithoutcompromisingpatient

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safety, so that all relevant team members are focused on the active confirmation of the correct patient, procedural site and other critical elements of the procedure. If laterality is indicated, all team members must confirm that the site marking is visible.

10. Time-outs must also be conducted before anesthetic blocks (scalene, local, etc.) are done. This time out is led by the physician providing the anesthetic.

11. If a central line must be inserted before the procedure starts, the physicianinsertingthecentrallinemustperformatime-outwithmembers of the procedural team. The central line checklist is to be completed by that physician.

12. All time-outs are to be documented in the patients medical record.

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What is proper surgical attire?

1. Scrubs:Onlyscrubtopsandpantsprovidedbythishospitalareworn.Scrubsusedinrestrictedareasarenotbroughtorworninfromhome.Personnel are to change into street clothes prior to leaving the hospital.

2. Scrub jackets: Either disposable or non-disposable, only scrub jackets providedbythehospitalaretobeworn.

3. Clean, fresh, personal scrub hatsmaybeworninrestrictedareasonly if coveredwithafresh,disposablescrubhat/bonnetpriortoentryintotheoperating rooms/sterile procedure areas.

4. Dedicated shoes for restricted areas are recommended. Shoes not dedicatedtotherestrictedareasshouldbewornwithshoecoverswhilein the restricted areas.

5. Remove shoe covers and maskswhenleavingtheoperatingroomsuite.

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6. Undergarments (e.g., undershirts, turtlenecks) are not permitted to extend beyond the necklines or sleeves of the scrubs.

7. Any jewelry(earrings,necklaces,watches,andbracelets,etc.)thatcannotbeconfinedwithinthesurgicalattireisnotpermitted.

8. Fingernail jewelry is not permitted (see policy IC5.1.04 Hand Hygiene). Fingernail polish is not permitted for scrubbed personnel.

9. Remove all personal protective equipment (gloves, masks, booties, etc.) prior to exiting the OR/CSP. Personal protective equipment (PPE) is not permittedbeyondtheareainwhichitwasused.Disposablesurgicalbonnetsareallowedoutsideoftherestrictedareasonlyifnotvisiblysoiledorwet,andmustbereplaceduponre-entryintorestrictedareas.

10. Fanny packs, backpacks, and briefcases should not be taken into the restricted area.

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Surveillance, Prevention, and Control of Infection 1. What are some measures used to prevent transmission of infectious

diseases to staff and to patients?

Isolation precautions may be instituted by the nursing staff without a physicians order. AAMCs mandatory immunization program protects both staff and patients. Environmental cleaning has become increasingly important in the fight against transmission, particularly with antibiotic-resistant organisms. Hand hygiene remains the single most important factor in preventing the spread of infectious diseases.

2. When should hand hygiene be performed?

Hand hygiene (washing hands or use of alcohol-based handrub) should be performed before and after touching a patient or any equipment that touches a patient. Wash your hands with soap and water when hands are

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visibly soiled/contaminated, before eating, after using the restroom, and whenever caring for a patient with Clostridium difficile (Cdiff). AAMC follows Centers for Disease Control and Prevention (CDC) guidelines.

3. How is hand hygiene monitored and promoted at AAMC?

Hand hygiene is monitored through audits conductedbysecretshopperson every patient unit and the Emergency Department. Compliance is compared housewide, per patient unit, and per type of healthcare worker role. AAMC is a member of the Maryland Hand Hygiene Collaborative in order to foster improved hand hygiene by healthcare workers, patients, and visitors. Alcohol-based handrub, hand wipes on food trays, hand hygiene education in the patient handbook,andhousewidesignageare only some of the examples of how hand hygiene is promoted at AAMC. Be prepared to discuss the most current data on hand hygiene compliance for the hospital andyourarea,aswellashowyourareaispromotinghandhygiene.

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Fingernails are to be short (less than inch in length); if nail polish is used, it should be clear and intact. Persons involved in patient care or handling linen,patientsupplies,food,etc.arenotallowedtowearartificialnails.

4. What are the steps to placing a patient in isolation?

> Identify the appropriate isolation and hang an isolation sign on entry to the patient room.

> Order isolation in the computer (physicians order is not required).

> Gather the correct personal protective equipment (PPE) and place at entry to patient room.

> Educate patient/family members on need for isolation and expectations of them to maintain isolation. Use handouts located on intranet to assist with education.

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> Perform hand hygiene and put on PPE prior to entry. Dispose of PPE in room upon exit and perform hand hygiene.

> With patient transfer or discharge, leave the isolation sign posted for environmental services (EVS) to remove following cleaning of room.

5. What infection control and prevention education is important to provide to your patient/patients family?

Any time a patient is diagnosed with an infectious disease or is about to undergo a procedure there is an opportunity for infection prevention education. Upon admission and throughout a patient stay, hand hygiene is emphasized. The Joint Commission emphasizes the need for education of patients and family members, and looks for documentation of education for the following conditions/situations:

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> Identification of multidrug-resistant organisms (MDROs), such as MRSA, VRE, etc., and Clostridium difficile (Cdiff)

> Placement in isolation

> Prior to insertion of a central line (central line-associated bloodstream infection (BSI) prevention)

> Prior to surgery (surgical site infection (SSI) prevention)

6. What infection prevention strategies are used during the insertion of a central line (central venous catheter)?

Remember the central line insertion checklist (make sure to document):

> Have proper hand hygiene

> Use a sterile drape to cover patient (maximum barrier precautions)

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> PPE: sterile gloves, cap, gown, mask, eye protection for inserter/assistant; maskwith eye shield for everyone else in the room

> Chlorhexidine skin prep or alternative if allergic

> Avoid femoral vein unless there are no other options.

7. How long does a disinfectant wipe or solution need to make contact in order to kill bacteria and other microorganisms?

Germicidal wipes or bleach-impregnated wipes are used to wipe down equipment, including IV pumps, stethoscopesandkeyboardsbetween patient use. Sometimes staff will also use germicidal solution (for example, Virex), used mostly by environmental service (EVS) staff for cleaning rooms, for bigger items, such as stretchers. Whatever used, you are expected to know how long the equipment needs to stay wet (contact/kill time) in minutes to be effective.

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Remember: Germicidal PDI AF3 (grey top) Wipes = 3 minutes

Bleach Wipes (for example, Dispatch) = 5 minutes

Virex Spray Solution = 10 minutes

8. How are employees exposed to bloodborne pathogens reported?

Exposures are reported by the exposed employee to their supervisor. Employees exposed to bloodborne pathogens must be evaluated in Employee Health Monday to Friday 7:30am to 4pm and in the Emergency Department at all other times. This evaluation must occur immediately as the window for giving antiviral medications, if needed, is two hours.

9. How are communicable diseases reported at AAMC?

The Infection Control Department has the responsibility for reporting communicable diseases to the local and state health departments.

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Physicians may also report as needed. The laboratory also reports any test results regarding communicable diseases.

10. How are infection control concerns reported?

Infection control concerns may be reported to Infection Control at x6446 or the 4PTS hotline at x4787. Immediate concerns can also be addressed by paging the hospital epidemiologist and/or director of Infection Control.

11. Where does staff receive education on infection control?

All staff receive infection control education in orientation and annually on Healthstream. Also, infection control practices are integrated into competencies. Infection control programs are also offered in specific departments as issues and concerns are identified. Infection Control personnel may be contacted for questions or consultation. Resources are also found on the hospital Infection Control intranet site.

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12. What are some of the monitors in AAMCs Infection Control program?

The Infection Control program does surveillance of surgical site infections in high risk, high volume surgeries, central line-associated bloodstream infections, ventilator-associated pneumonias, urinary catheter-associated urinary tract infections, blood culture contamination rates and other high risk indicators. Surveillance also includes incidence of hospital-acquired multidrug-resistant organisms (MDROs) and Clostridium difficile (Cdiff) and other organisms. Environmental testing, such as water testing for Legionella, is coordinated through engineering and monitored by Infection Control. Infection Control Risk Assessments (ICRAs) are conducted prior to construction projects.

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13. How is selection of surveillance/monitoring determined by Infection Control?

Selection of what surveillance/monitors are conducted is dependent on the level of risk associated with patients, staff, and visitors. Periodic and as needed risk assessments are performed in order to prioritize needs for surveillance/monitoring. Annually, the risk assessments are used to determine priorities; goals for the coming year are determined based on the risk assessment and listed in the Infection Control Plan, available for review on the Infection Control section of the hospital intranet.

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14. How are data from the Infection Control activities reported?

All reports are presented at the monthly Infection Control Committee; data for specific patient populations are reported at service line and nursing quality councils, critical care committee, and shared at staff meetings. Nursing Quality indicators (NDNQI) include unit-based infections data. Be awareoftheinfectionsdatawhichrelatestoyourareaofservice.

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Improving Organizational Performance 1. What are Core Measures?

TheyaremeasuresidentifiedbytheJointCommissionthatallowforarobustassessmentofcareprovidedinfocusedareas.ThefollowingareCoreMea-sureareaswhicharecollectedandmonitored:

AcuteMyocardialInfarction(AMI)

HeartFailure(HF)

Pneumonia(PN)

SurgicalCareImprovementProject(SCIP)

ChildrenAsthmaCare(CAC)

VenousThromboembolism(VTE)

For more information on metrics, contact Carole Clarke at x1327.

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2. How do I know what is important in terms of performance?

The Board of Trustees determines strategic aims that are important to AAMC. ThefollowingarethestrategicaimsforFY14:

> Preventable death

> Harm reduction

> Patient satisfaction

> Hospital acquired infections

> Re-admissions

> Medication reconciliation

> Core measures

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These are based on organizational priorities, considered important, high volume, high-risk, and sometimes, new services. This information is communicated through our Quality unit and services line councils.

3. How can I improve performance on my unit?

Workwithyourunitleadershipand/orparticipateinunitqualitycouncilsand performance improvement projects.

4. How do I know what performance improvement projects are occurring on my unit?

Information is posted in staff areas regarding projects. Frequently, the data is displayed graphically so you can visually see how successful we are. Please ensure you know your departments performance Improvement projects, how you are doing and what actions are being taken to improve the measure.

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5. What if the data shows we are not doing as well as we hoped?

We closely analyze the data to determine what the issues and obstacles (opportunities for improvement) are. Once issues are identified we can make corrections.

6. What is the specific methodology used at AAMC for performance improvement activities?

PDCA (Plan-Do-Check-Act) is our problem solving framework:

Plan: Plan the improvement

Do: Do the improvement and data collection

Check: Check the results of the implementation

Act: Act to maintain the gain and continue improving.

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7. What is the definition of a Sentinel Event?

A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury, or the inherent risk thereof, including any process variation for which a recurrence would carry a significant chance of serious adverse outcome. (See Sentinel Event policy QI6.1.09 for criteria).

8. What is a Near Miss?

A Near Miss is an event that does not meet the definition of a Sentinel Event, but involves a process variation for which a recurrence would carry a significant chance of a serious outcome.

9. How are incidents reported at AAMC?

Incidents can be reported directly to Department Managers and in turn are reported to Administration. You may also use the 4PTS Patient Safety Hotline (443-481-4787).

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10. What is the process of Failure Modes Effects Analysis (FMEA)?

This is a process that is used for systematic, proactive approach for identifying the ways that a process or design may fail, and how it can be safer. The focus is on preventing errors before they occur, enhancing patient safety and increasing customer satisfaction.

11. What is a Root Cause Analysis (RCA)?

A Root Cause Analysis is systematic process that uses information gathered during an investigation to determine the fundamental system deficiencies that led to the incident. The goal is to analyze incidents to identify root causes and fix underlying system problems to prevent recurrence of a similar event. AAMC conducts root cause analyses for identifying the base or contributing casual factors that underlie variations in performance associated with adverse events or near-misses (See Sentinel Event QI6.1.09 policy for details).

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12. What are the terms Lean and RIE?

Lean:Thecoreideaistomaximizecustomervaluewhileminimizingwaste.

RIE:Arapid improvement event is a part of the Lean toolkit and provides a mechanism for making radical changes to current processes and activities withinaveryshorttimescale.

WhataresomeexamplesofLeanRIEsimplemented:

> Linen management > Perioperative scheduling

> Care management > Pharmacy

> Revenue cycle > Supply chain

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Management of the Environment of Care 1. What is the smoking policy of the hospital?

AAMC has a smoke-free hospital campus.

2. What are the codes to signal an emergency?

The codes are:

> Code RedMr.Firestone:Fire > Code Pink: Infant/Child Abduction > Code Blue: Cardiac Arrest > Code Gold: Bomb Threat > Code Orange: Hazardous Material Spill > Code Yellow: Emergency or Disaster > Code Silver: Active Weapon Threat

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3. What should you remember in the event of a fire?

The employee should be aware of the location of the pull stations (near the exit) and the fire extinguishers in their work area. Areas to respond to the fire should be the floor of origin, one floor below andtwo floors above the fires origin. One strip of tape should be placed on empty patient rooms to indicate the room is empty.

The acronym used is R.A.C.E.,whichstandsfor:

Remove the patient from danger

Announce (pull the alarm)

Contain the fire (shut doors)

Extinguish the fire or evacuate

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4. How frequently are fire drills conducted?

Fire drills are conducted once per shift per quarter in each area, except duringperiodsofconstructionwhenfrequenciesaretwopershiftperquarter.

5. In what ways does the hospital support a secure work environment?

The hospital provides four security officers on duty per shift. These officers do hazard surveillance rounds internally and externally.

6. What should an employee do if they see a suspicious person or activity on campus or need help restraining a violent person?

They should ask the person if they need assistance, and should keep the person in view and call Security immediately at x6911.

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7. What body within the hospital is charged with evaluating the institution in terms of general safety, utilities management, equipment management, emergency management, security interim life safety and hazardous materials/waste?

The Environment of Care Committee leads these efforts.

8. How do you identify emergency powered electrical outlets?

These outlets are red or labeled.

9. How are you notified of expected utility interruptions?

Advanced notice is given to all staff via email, or the PA system is used for immediate notification.

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10. Are extension cords prohibited for hospital use?

The use of extension cords is limited to certain situations and must be approved by Maintenance or Biomedical Engineering for medical equipment.

11. What should you do if the hospital lost access to water?

The loss should be report to the Engineering department. They will provide alternatives (i.e., bottled water for drinking).

12. Who is authorized to shut off an areas medical gas?

In an emergency situation the charge nurse shuts off oxygen as authorized by the fire marshall. When the emergency situation is identified, notify the hospital operator and the administrative coordinator. Take the necessary actions to handle the situation according to hospital policy and communicate the shut down of the gases to the appropriate people i.e., Respiratory Therapy.

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13. What should you do if there is a chemical spill?

> Remove everyone from the immediate area

> Consult the Material Safety Data Sheets (MSDS). To obtain the necessary information, call the 3E Company at 1-800-451-8346. They will respond immediately by fax or email.

> Please follow the Spill Response-Action by Category Chart (Code Orange in the Emergency Procedure Quick Reference Guide).

> If it is mercury, the spill kits are available from the Environmental Services Department.

> Notify your manager/supervisor.

> Complete a Patient Safety Report (formerlyknownasanIncident Report).

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14. How can you protect yourself, patients and the environment from exposure to hazardous chemicals?

Read and follow directions from the Material Safety Data Sheets (MSDS)

Proper storage, handling and disposal of waste.

Report any unsafe conditions to your supervisor or Security at x6911.

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Radiation SafetyIf you are identified as a worker in a radiation area, how do you protect yourself from radiation exposure at work?

After using your lead apron, hang it up.

Protective aprons have a sheet of soft lead impregnated rubber on the inside. If it is folded or creased it can fracture. When this happens, the protective nature of the apron is lost. Dont forget to hang up your lead apron properly every time you take it off.

Wear your radiation badge, store it appropriately, and turn it in every month, on time.Thatisthebestwaytoknowifyouhavebeenexposedtoradiation.

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Emergency Management1. How does the hospital prepare staff for a disaster which might

involve a large number of patients admitted to the hospital?

The Incident Commander conducts two disaster drills per year.

2. What are the six critical functions of hospitals in relation to Emergency Management?

1) Communications

2) Resources and assets

3) Safety and security

4) Staff roles and responsibilities

5) Utilities management

6) Patient clinical and support activities

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3. What are staff responsibilities during any type of a disaster?

KnowandfollowtheguidanceintheEOC4.4.01EmergencyOperationsPlan.Themainaspectsforstafftofolloware:

1. To protect the lives of your patients and families to the best of your ability

2.Toconserveproperty,suchasknowingwhattodoinafire(RACE)

3. To continue to provide and manage patient care to the best of abilities during a disaster.

4. How do you maintain patient safety when utilities fail?

Some of the ways these situations are managed is by using portable oxygen, flashlights, cell phones, bottled water, and manual respiratory equipment.

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Leadership The Leadership at AAMC is responsible for:

> The safety and quality of care, treatment, and services

> A culture that fosters safety as a priority for everyone who works in the hospital

> The planning and provision of services that meet the needs of patients

> The availability of resourceshuman, financial and physicalfor providing care, treatment and services

> The existence of competent staff and other care providers

> Ongoing evaluation of and improvement in performance

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How do we ensure that our clinical contracted services are performing high quality and safe care to our patients?

Each service line quality council is responsible to select the measures for the clinical contracted services in their area and monitor those measures on a quarterly basis to ensure that high quality and safety care are provided through the contractual agreement.

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Information Management1. Do you have the necessary computer access to do your job?

Yes. My computer access is based on my role as caregiver. If my role changes,mynewrolewillrequiredifferentaccess.Accesschangesarerequested by my supervisor.

2. How often is the computer system unavailable?

Every third Wednesday of the month at 2am the system is potentially unavailablefortwohoursmaximumforroutinemaintenanceandupgrades.Longerdowntimesarecoordinatedandcommunicateddifferently.

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3. What guidelines do you follow if the computer system is down?

IfollowtheIntegratedComputerDowntimeManagementpolicy.IS9.1.03.DependingonthescopeofthedowntimeImayhaveaccessto

> SRO(ShadowReadOnly):Thenetworkisstillavailablewhichwillallowread only access to the patient record or

> BCA (Business Continuity Access) printers:Theseallowyoutoprintapatientsummary,whichisusedwhenthereisnonetworkconnectivity.

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Human Resources1. Do you function according to your job description?

Yes. All employees sign off on their job descriptions through Performance Managerattimeofhire,ortransferintonewjob/department.Alljobdescriptions are available to any employee through the Job Descriptions tab in Performance Manager.

2. What skills are you required to maintain for competency in your department?

There are department- and job-specific competencies that are required in additiontothehospital-widecompetencies.Thesearedocumentedandkeptonfilewithyourjobdescription,annualperformanceevaluationandother educational records.

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3. What education programs are you required to attend?

All employees are required to attend AAMCs new hire orientation. All employees are expected to complete annual hospital-wide educational programs (for example, fire safety, electrical safety, infection control, hazardous materials, right to know, personal safety, TB, bloodborne pathogens [for those at risk for exposure] and cultural awareness). Nurses attend the Nursing Service Orientation during the first week on the job. Employees that use Alec are required to take Alec computer training courses appropriate for their duties. Any job-specific educational offering to address particular patient populations and unit specialty topics, or any applicable new rules or regulations may also be required. From time to time, there is a house-wide competency, such as Disruptive Behavior training.

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4. Why are specific competencies chosen?

Specific competencies are determined by your position responsibilities and are based on risk; volume; whether its a new procedure, equipment or technology; and changes in policy or procedures.

5. Are you provided with education to maintain population-specific competency?

Yes. Training is related to the population (age, bariatric, developmental challenges, etc.) served and competencies are updated and defined annually.

6. What educational programs have you attended recently?

Think about what educational program you have completed recently and write them down in the following space (for example, pain management, ethics seminars, hospital grand rounds, weekly cancer conferences, etc.).

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2001 Medical ParkwayAnnapolis, MD 21401443-481-1000TDD: 443-481-1235www.aahs.org