Joint Commission International (JCI) Survey

Guidance Document

pg. 1 JCI Survey Guidance Document - 5B Pediatric Surgery

 ABLE OF CONTENTS (QPS)

19 STAFF QUALIFICATION AND EDUCATION

NO TOPIC PAGE NUMBER 20 GOVERNANCE AND LEADERSHIP

1 SIDRA HOSPITAL MISSION ,VISION AND CORE 2

VALUES
5B-Pediatric General Surgery
2 JCI SURVEY OVERVIEW 4

3 USEFUL TIPS AND ETIQUETTE 7

Sidra Medical Research Center
4 THINGS TO REMEMBER 8 11/17-21/2019
5 EMR-DOCUMENTATION 9
SIDRA MEDICINE
6 EMERGENCY CODES 11
VISION
7 INTERNATIONAL PATIENT SAFETY GOALS (IPSG) 13 Sidra Medicine will be a beacon of learning, discovery and exceptional
8 ACCESS TO CARE AND CONTINUITY (ACC) 16 care, ranked among the top academic medical centers in the world.

9 PATIENT AND FAMILT RIGHTS (PFR) 21

MISSION
10 ASSESSMENT OF PATIENT (AOP) 24 Sidra will provide patients with world class healthcare services in an
11 CARE OF PATIENT (COP) 26 innovative and ultramodern facility specially designed to promote healing. In
particular, it will initially address the growing need for more comprehensive
12 ANESTHESIA AND SURGICAL CARE (ASC) 29 patient-focused medical services for women and children in Qatar and
throughout the region.
13 MEDICATION AND MANAGEMENT OF USE 30
In collaboration with the premier medical school in Education City – Weill
(MMU)
Cornell Medical College in Qatar, leading research institutions worldwide, and
14 PATIENT AND FAMILY EDUCATION (PFE) 32 Qatar’s health sector, Sidra will provide a diversity and quality of care conducive
to training medical students and highly skilled clinicians and will be a pioneer in
15 PREVENTION AND CONTROL OF INFECTION 32 clinical and translational biomedical research of value to the population of Qatar
(PCI) and the world.
16 FACILITY MANAGEMENT AND SAFETY (FMS) 38
CORE VALUES
17 MANAGEMENT OF INFORMATION (MOI) 44 Sidra's values are core to bringing about a significant shift in how we will operate
as a premier healthcare institution. Our Values were created with consideration
18 QUALITY IMPROVEMENT AND PATIENT SAFETY 45
pg. 2 JCI Survey Guidance Document - 5B Pediatric Surgery
of feedback received from staff interviews and focus groups and input from our there will be some patients with certain congenital defects that are older than 18
leaders and board of how we achieve our vision and mission. years.
The department of Pediatrics at Sidra’s main goal is to improve the health status
Trust: Being competent; acting consistently, reliably and predictably; of children in Qatar and around the world.
acting with honesty and integrity; respecting patient, employee and The vision & mission of the Department are:
commercial confidentiality; delivering on commitments  To be the national, regional and international leader in children’s
healthcare through excellent and innovative clinical care, education,
Innovation: Freedom to innovate; welcoming ideas and encouraging research and advocacy and to
creativity; supporting talent; creating confidence; celebrating successes  Become the neonatal and pediatric tertiary and quaternary referral
center for Qatar and the region.
Teamwork: Sharing information and knowledge and learning from Our values in the department of pediatrics will consist of the following:
demonstrated expertise; being respectful, and thereby earning respect of  Customer Satisfaction
others; acting with professionalism; leading and following; collaborating  Advocacy for Children
and being accessible  Respect for Others
 Excellence in All We Do
Transparency: Frequent and honest communication; open access to  Stewardship of Resources
information for decision making; willingly acknowledge shortcomings;
speaking up about concerns; publishing performance indicators

Care: Acting with empathy, kindness and compassion; being humble; PEDIATRIC SURGERY
listening and responding; acting with cultural sensitivity; Caring for
patients and staff
The mission of the Pediatric Surgical Ward at Sidra is to provide safe
Efficiency: Providing measurable value; using data to drive decision family centered patient cares for all children and young people 0-18yrs old in a
making; having and achieving clear goals; building processes that work; holistic and evidenced based manner. Services are provided 24 hours per day, 7
continuously improving outcomes in patient and family care days per week. Our services consist of first class surgical care with highly qualified
staff from all around the world.
The Paediatric Surgical program in line with the Sidra mission and vision delivers
patient care that is:
Safe – avoiding injuries to patients from care that is intended to help
them.
CHILDRENS MEDICAL GROUP Timely – reducing waits and sometimes harmful delays.
Effective – providing services based on scientific knowledge and
refraining from services unlikely to benefit.
The pediatric service at Sidra is the largest division and will be Patient-centred –providing care this respectful or responsive to
responsible for all medical aspects of children ages 0-18 years. On occasions, individuals’ needs.
Efficient – avoiding waste.
pg. 3 JCI Survey Guidance Document - 5B Pediatric Surgery
 Equitable – providing care that does not vary regardless of personal
characteristics

pg. 4 JCI Survey Guidance Document - 5B Pediatric Surgery

JCI SURVEY OVERVIEW To follow course of care and service provided to the patients.
Assess relationships and the effectiveness of interdisciplinary communication
A JCIA survey provides an assessment of an organization’s compliance with among disciplines and important functions/services.
standards and their elements of performance. JCIA evaluates an Organization’s Evaluate performance and processes relevant to the individual.
compliance based on: More specifically the following are tracer selection criteria, i.e.,
• Patient and staff interviews via tracer methodology’ about Actual practice. Determinants of how surveyors will select processes:
• Performance improvement data/trends Clinical /service group as identified by Sidra Medicine Hospital
• Verbal information provided to JCIA. Patients who have received complex service.
• On-site observation by JCIA surveyors. Patients who cross different programs (e.g., Inpatient and outpatient)
Patients who relate to “System” tracer
Purpose of a survey Infection Control
The survey is key to accreditation. The JCI Accreditation process seeks to assist Medication Management
organization in the identification and correction of problems and improve the Patient’s in complex situations, e.g.
quality of care and services provided. In addition to evaluating compliance with ICU.
standards and their elements of performance, significant time is spent in ED.
consultation and education. JCI expects hospitals to be in compliance with ALL of
Receiving anesthesia services
the standards, ALL of the time.
.

Do we do things a certain way because “JCIA” says so “?

No, our practice is governed by the Sidra Medicine Hospital Mission, Vision and
Environmental of Care Tour
Core Values. As an organization, we have developed our own organization
The JC surveyor will tour the unit or department. During the tour, the surveyor
Standards, Polices, and Procedures to support our staff in the realization of the
will observe practice and will
Mission and Vision.
Ask different staff questions about the work environment and fire safety.

What will the surveyor observe?

TRACER METHODOLOGY
 Hand hygiene and Standard and Transmission Precautions per policy
This Survey method traces a number of patients through the organization’s entire
health care process. Tracer activity is customized to the individual organization  Protective equipment and supplies available
and surveys care across service and programs. This methodology uses multilevel  Needle boxes present and not overfilled
participation, i.e., as cases are examined, the surveyor may identify performance  Equipment correctly cleaned and disinfected between patients with
issues in one or more steps of the process or in the interfaces between hospital approved disinfectant (i.e. contact time)
processes. The surveyors determine which process to focus on using information  Clean equipment identified and properly stored
from the “Application for Surveys” submitted by Sidra Medicine Hospital.  Precaution gowns properly worn and secured
 Gowns and gloves not worn in hallways
 No expired supplies, no external shipping boxes; no supplies on floor, or
Primary objectives of tracer activities are: underneath sinks
pg. 5 JCI Survey Guidance Document - 5B Pediatric Surgery
  Clean supplies/linen on covered cart or in cabinet/container or clean  Universal protocol checklist completed for invasive procedures(includes
 supply room; those done at bedside)
 Clean and soiled utility rooms doors closed  Discharge planning
 Compliance with HIPAA regulations  No unapproved abbreviations
 Security of medications and IVs (med carts, med and IV closets locked)  Date/time, legible signature and licensure present for all documentation.
 Medication refrigerator temps logged; includes action if out of range  POCT machine cleaned between patients with hospital-approved
 Code Cart locks checked daily Disinfectant
 Fire extinguisher not blocked  Glucometer control solutions (hi/low) initialed, dated when opened; not
 Oxygen tanks secured and stored per standard expired, (within days of opening)
 Access to exit doorways not blocked  Blood transfusions verified and vital signs recorded
 Corridors kept clear (all equipment on one side of hallway)  Critical values written down and read back and action documented in
 Response to clinical alarms and call lights
 Patient food refrigerator checked; out of range actions noted; patient
food dated Tracer visits included:
 No food or drink in patient care areas, clean supply or soiled areas, or Evaluation of top 4-5 diagnoses identified by Sidra Medicine Hospital.
where specimens are collected. Observation of care areas and environment of care issues.
Review of the medical record with staff, with the nurse being the Initial
interviewee.
What will the JC surveyors look at during the general hospital survey?
(Continued)

 Problem/outcome/intervention sheets updated as problems get

resolved
Tracer visits may include:
And new problems added Observation of direct care.
 No medical interventions or diagnostic tests without an MD order Observation of medication processes.
 Progress notes reflect interdisciplinary planning and follow-through Observation of care planning process.
 Fall risk assessment (Humpy Dumpy/Morse scale on admission and as Individual/family other interview.
necessary) Review of additional medical records, as needed.
 Pain assessment and patient’s response to medications and other Staff level interaction:
interventions ● Performance measurement activity.
 Patient understanding of education ● Daily roles and responsibilities.
 Handoffs including unit-to-unit and unit-to-diagnostic and procedural ●Orientation, competency assessment/reassessment
Areas (SBAR) ● (Maintenance), and continuing education.
 Restraint orders and restraint documentation

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 When responding to a surveyor question
Surveyor activity may include:  Always make sure you understand the question before you answer. Ask
Review of closed records (if issues are found in initial tracer activity). for clarification if you are not sure.
Facility tour (areas not visited during the tracer), if applicable. For example,  Do not rush to answer. Take your time.
pharmacy, etc.  If you don’t know the answer, tell them you don’t and refer them to
someone who knows such as your supervisor/Department Head.
 Don’t give more information than what is being asked for.
Remember!
 Keep your answers focused and specific to the question they ask.
 Surveyors know the standards, but YOU know your practice and your
 If the question requires only a ‘yes/no’ answer don’t volunteer further
patients and families.
explanation.
 Relax and take your time answering the surveyor’s questions, but be
 If they ask for explanation/examples then you should respond with what
direct and to the point with your response
you know.
 If you don’t know the answer to a question, it’s okay to say “I don’t know
 Keep the conversation professional. Use appropriate language and
but I know where to find it.”
behavior.
 Tell positive stories! If the surveyor asks you a question that relates to
 Be prepared to show the surveyor documents, policies, and tools that
special project on your unit or in the hospital, tell about it!
you use in performing your work if they ask.
USEFUL TIPS AND ETIQUETTE
When responding to a surveyor question
How to Talk with Surveyor?  Do know where they are or how to locate them (e.g. policies) hard copy
Useful tips for responding to surveyor questions or in the portal.
 Remember that surveyors are highly experienced individuals: Physicians,  Be able to access the site to show them the answer.
Nurses, Pharmacists, Administrators, Social workers, Medical  Never begin an answer with the words “Usually”, “Most of the time” or
Technologists. “Sometimes “when asked questions regarding processes or procedures.
 They are here to evaluate us based on our policies and by compliance to Such questions need to be answered with “Sidra’s policy is …” or “Our
JCI Standards procedure to deal with this issue is …” By answering in this manner we
 They are seeking evidence of compliance to elements of performance show we have a uniform approach to care.
and Standards for these Accreditation Bodies... They are in search to  Remember that anytime you say “we” the surveyor will expect that you
document evidence of quality processes and to assess for Variation to are referring to all of Sidra
process and to identify system issues  Don’t discuss your personal issues with them.
 The survey process is organization specific.  This is not the time to ask questions or discuss problems.
 The surveyor focus is how you do your job in this organization. They
expects you to be knowledgeable of your job description and the policies
and procedures that pertains to your work in this organization THINGS TO REMEMBER
 The surveyors are focused on patient safety.
PORTAL (Electronic Files):
pg. 7 JCI Survey Guidance Document - 5B Pediatric Surgery
 Know how to navigate:  Patient’s Bill of Rights
 Approved Policies and Procedure  High Alert Medication
 Clinical Guidelines  Downtime Forms
 Lippincott
 E- Privilege ENVIRONMENT/EQUIPMENT:
 Infection Control Site  Location of Fire Alarm/Fire Extinguishers/Fire Blanket/Fire Hose
 Major Incident Plan  Evacuation Plan
 SDS  Waste Management
 Disaster Plan  Biohazard and Spill Kit
 Datix Reporting  Medication Room and Fridge/Omnicell
 Risk Management  Nutrition Room Fridge/Microwave and Stocks
 Isolation Room and PPE Trolley/Wall Dispensers
 Clean Supply Room
 Equipment Room
DOCUMENTS (Hard Copy):  Soiled Utility Room
Familiarize Yourself with:  Crash Cart
 Standard of Practice
 Clinitek
 Ward Manual
 Novostat
 Staff Files
 Cyracom
 Disaster Plan
 Equipment Competencies
 Hand Hygiene Compliance
 Key Performance Indicators
 How do we do escalation of care
 What to do in case of needle stick injury
PROCESSESS:  What to do in case of body fluids spillage
 How to activate emergency responses
 What to do in case of downtime

DOCUMENTATION

Electronic Medical Record –Power chart

pg. 8 JCI Survey Guidance Document - 5B Pediatric Surgery

 Admission/ Initial Assessment done within 30mins  Vital Signs
for new patient admitted/transferred  Measurement (Height; Weight) –Reassessment after
7 days if patient is still admitted
 Pain Assessment (as appropriate)
 Level of Consciousness
 Pediatric Early Warning Scores
Perform complete and fully document an  System Assessment
individualized comprehensive assessment within  Health History/Admission History
2 Hours of patient’s admission or Transfer to the  Medication Reconciliation
unit  Activities of Daily Living
 All Risk Screenings
 Fall Risk Assessment
 Multidrug Resistant Organism Screen (MDRO swab to
be repeated after 14 days from admission if patient
is still admitted in the ward
 Infection Control Risk Screen
 Psychological Screening
 Nutritional Risk Screening -
All patients identified as low and medium risk when
screened using the screening tools, will be re-
screened by nursing for nutritional risk after 7 days.
Rescreening every 7 days will continue until a patient
is discharged.(Strong Kids and MUST)
 Braden Pressure Sore Risk Screening
Existing patient will have initial assessment done  Vital Signs
within 60 mins of the shift  Measurement (Height; Weight)
 Pain Assessment (as appropriate)
 Level of Consciousness
 Pediatric Early Warning Scores
Comprehensive Holistic Assessment performed  System Assessment
and documented within 2 hours of the shift  Activities of Daily Living

Every 4 hours  Vital Signs

 PEWS
 Intake and Output

pg. 9 JCI Survey Guidance Document - 5B Pediatric Surgery

  Wound Check
Pain Management  Utilize an age, developmental and condition
appropriate pain assessment tool and include
parenteral report and opinions as part of the pain
assessment.
 Provide pharmacological and/or non-pharmacological
measures within 30 minutes if pain assessment
indicates that pain control is warranted.
 Reassess pain within 60 minutes of treatment for
pain to determine the effectiveness of any treatment.
PCA/NCA/Epidural  Pain Assessment and Management
 Appropriate Documentation (e.g. motor blocks;
hourly PCA rate)
 Ramsay Scoring
Pediatric Line  Every 1 HOUR Assessment and documentation of
Vascular Access (PICC Line, Central Line, IV Line)
 Labeled with date of insertion
Medication Administration  Countersign (Witness Nurse)
 Monitor as appropriate (e.g. Narcotic/Controlled
Drugs)
PRN Medication  Should have INDICATION and SPECIFIC Range for
fever or pain
Pre-procedure Checklist  Complete the form accordingly
 Anesthesia and Consent for procedure secured and
signed properly
 Site marking if appropriate
Post-Operative Vital Signs and PEWS  Q15 min x 4
 Q30 min x 2
 Q1 hour x 2
Nursing documentation  As Needed

Line/Drains  Labeled accordingly

Patient and Family Education  Once every shift as appropriate with the care plan

SBAR  SBAR
 Transfer of Care
pg. 10 JCI Survey Guidance Document - 5B Pediatric Surgery
 Interdisciplinary Plan of Care  Initiate upon patient’s admission and change in
condition
 Evaluate every shift
 D/C upon discharge if not needed

Key Contact Numbers Emergency Codes

Legal Hotline – 4012 6445
Main Call Center – 4003 3333 Code Pink - Infant Abduction
Ethics & compliance – 40126160
Code Silver – Criminal Activity
Immigration – 55252912
– 55957188
Code Blue – Medical Emergency
SSOC Emergency – 66
Sidra Assist – 11 and Press Code Red – Fire Emergency
1 for Facility
2 for IT Code Grey – Combative Person
3 for Telephone / Audio visual
4 for Biomedical Code Green – Internal / External Disaster

5 for CMIST
Code Orange – Hazardous Material Spill
6 for General Security
Code Black – Bomb Threat, Explosion threat

Code Pearl – Computer down Time

INTERNATIONAL PATIENT SAFETY GOALS

pg. 11 JCI Survey Guidance Document - 5B Pediatric Surgery

 IPSG 1 Identify Patients Correctly
Use two identifiers; Patient’s full Name and DOB .For unknown/comatose patient we
use Alias convention name asunknown1or2.
For multiple birth: we use Multiple birth acronym chart – Twin A, Twin B.
Eg;mother name: Al Basher Noor Huda
Al Basher Twin A Noor Huda, Al BASHER Twin B Noor Huda

IPSG 2 Improve Effective Communication

Do write and read back for verbal /telephone order and laboratory test result to
obtained on the phone and follow the process(for handover communication)
(i) Comply to handover communication policy
(ii) Critical results policy
(iii) Verbal/telephone order policy

IPSG 3 Improve the Safety of High-alert medications

Eg: Potassium Chloride at concentration greater than or equal to 2mmol/ml (2mEq/ml)
Look alike and sound alike medications are stored with proper labeling with tall man
method

IPSG 4 Ensure Correct Site, Correct-Procedure, Correct Patient Surgery

Follow pre-surgical site marking with a first name and last name initial of surgeon
performing the procedure, pre-operative checklist and time out in OT and Bedside
procedures.

IPSG 5 Reduce the Risk of Health Care Associated infections

Follow the WHO hand hygiene guidelines.

pg. 12 JCI Survey Guidance Document - 5B Pediatric Surgery

 IPSG 6 Reduce the Risk of Patient Harm Resulting from falls.
”Follow Fall Risk Management Protocol”

IPSG 1 Identify Patient Correctly  As soon as possible or within 24 hours.

What are the two Patient Identifiers that we start with in Sidra? IPSG 2.1
 Patient Full Name What is a Critical Result?
 Date of Birth  Any result that may be considered life threatening or that could result in
When do we use these identifiers? Give at least 3 situations. severe morbidity and may require urgent or emergent clinical attention.
 Carrying out any patient care What are included in the Critical Results? Give three examples.
 Giving Medications 1.) Laboratory Tests
 Giving blood and blood products 2.) Radiology Tests
 Taking blood sample 3.) Nuclear Medicines Exams
 Taking other samples for clinical testing 4.) Ultrasound Procedure
 Providing treatment 5.) MRI and Cardiac Diagnostics
 Carrying out any procedure How long a critical result should be reported upon identification of value?
What should NOT be used as a patient identifier?  30 minutes
 Patient Room Number and or location 
IPSG 2 Improve Effective Communication What information will the technician include to the LIP when reporting a critical
Give a situation when a Telephone/Verbal order is accepted? result?
 Urgent/Emergency Situation  Patient’s name
 During a sterile procedure  Patient’s date of birth
Who can give verbal/telephone order?  Patient’s Sidra Medical Record Number
 Licensed Independent Practitioner (LIP)  Critical result(s)
 Physicians
 Nurse Practitioners
What is the step followed to correctly confirm verbal/telephone order? IPSG 2.2
1. Confirm the name and role of provider giving orders You are receiving a patient from previous shift; how should the communication
2. Confirm the identity of the patient process be?
3. Write down the order in the patient’s medical record  SBAR (Situation, Background, Assessment, Recommendation)
4. Read back the order to the person providing the order. Aside from handing over of patient during end of shift, give three other
5. Ensure that the person providing the order has verified that the order is situations that we utilize SBAR.
correct.  Transferring a patient from one unit to another
How long a verbal order does needs to be signed off?  Transferring a patient to another facility

pg. 13 JCI Survey Guidance Document - 5B Pediatric Surgery

  Transferring a patient to another department for a diagnostic test or  Nope, it depends on the procedure.
procedure Do we have site marking pen?
 Change in clinical lead  Yes we do, and it’s always readily available
 Between all members of the multidisciplinary team Sidra Medicine’s protocol for site marking is
 Reporting a deteriorating patient ● Surgeons first and last initial. No additional marks such as X, checks, arrows, or
IPSG 3 Ensure the Safety of High Alert Medications words should be used.
What is a high alert medication?
 Medications involved in a high percentage of errors and serious harm IPSG 5 Reduce the Risk of Health – Care Associated Infection
events to patients. What are the 5 moments of handwashing?
Name at least 3 medications that are considered as High Alert  Before touching a patient
 Anesthetic Agents  Before clean/aseptic technique
 Neuromuscular blocker/paralytic agents  After touching a patient
 Controlled Medications (Narcotics)  After body fluid exposure
 Look Alike and Sound Alike Medications  After touching a patient’s surrounding
 Concentrated Electrolytes.
 Anticoagulant, Antiplatelet and Thrombolytic agents IPSG 6 Reduce the Risk of Patient’s Harm Resulting from fall
 All insulins, including U-500 insulin What is the tool used in Sidra for Fall Assessment?
 Intrathecal and epidural medications, including PCEA (patient-controlled  Humpty Dumpty Fall Risk Tool age 17 years old and below and
epidural analgesia) Assessment and Morse Fall Risk for fall
 Chemotherapeutic agents (including oral, parenteral and investigational  Modified Morse Fall tool for adult age 18 years old and above
agents) What are the fall prevention measures are we doing for patients that are at risk
Do we have high alert medications in the 5B ward? for fall?
 Yes, we have the Narcotics and Psychotropic (Controlled Medications) A score of 12 and above is considered high risk for fall for pediatric
Where and how they are stored? A score of 45 and more is considered high risk for adult
 We are keeping them in the Medication Room, locked in the Omni cell  Fall Education to the family
and only CNLs can access.  A falling leaf sign will be put on the door
 Red sticker is used to label all high alert medications.(medication store in  A yellow dot sticker will be put on the ID band of patients.
the shelves should have HIGH ALERT Label on shelve, medication  High risk patients will always be noted during handover
dispense by pharmacy and stored in patient bin will have HIGH ALERT  Monitor every 4h for risk for fall
Label on the product itself)
Are we allowed to have concentrated electrolytes in the unit? The re-assessment of inpatients for Low/medium risk for falls will
take place as follows;
 Yes, but we only have concentrated electrolytes in the crash cart.
● once per shift
IPSG 4 Ensure Correct Site, Correct Procedure, Correct Patient- Surgery
● upon transfer from one unit to another
As a surgical unit, what is the verification tool that we use before ● Post-operatively/post procedure
surgical/invasive procedure? ● Following sedation or anesthesia
 Pre-procedure Checklist ● Any change in medication regime that can affect level of consciousness
Is site marking required to all patient? (e.g. narcotics, anti- hypertensive, hypoglycemic, chemotherapy, diuretics)
pg. 14 JCI Survey Guidance Document - 5B Pediatric Surgery
 ● any change in the patient’s condition

The re-assessment of inpatients for HIGH Risk for falls will take place
as follows
● At least every four hours or less
Patient Screening
● any change in the patient’s condition
Purpose:
● Upon transfer from one inpatient
Canunit
the topatients’
another health care needs be met by Sidra Medicine.
● Upon ambulation following initiation or discontinuation of epidurals
At the first point of entry, are we providing the highest quality care
When the patient is transferred off the unit or will have procedure, how do
staff receiving the patient know the patient is on fall precautions?
 A yellow dot is placed on patient Identification band and SBAR is given
that patient is Risk for fall

Where do we document these interventions?

 Power chart – Patient Education – Fall Education
 IPOC

What do we do when a patient falls?

 Take the vital signs and do your post fall assessment (Power chart –
AdHoc – Post Fall Assessment)
 Inform the physician and CNL on duty Process:
 Notify the family if not around • Visual assessment of a patient prior to triage. – What do we
 Report a Datix
see?
(Male/female, adult/child, pain, bleeding, stable/unsteady
etc.)
• Over the phone through discussion with a referring source
(Patients for transfer into Sidra Medicine).
• Review of physical, psychological, clinical lab or diagnostic
imaging evaluations.

ACCESS to CARE and CONTINUITY of CARE (ACC)

Who are ESI

the LEVEL At least
4 being admitted
patients one
in Sidra resource is required to stabilize the patient
Hospital?
 Women and Children that needs tertiary healthcare services.
pg. 15 JCI Survey Guidance Document - 5B Pediatric Surgery
 ESI LEVEL 5
Patient Triage
The patient does not require any resources to be stabilized

Sidra Medicine utilizes the Emergency Severity Index (ESI)

To triage patients

ESI LEVEL 1 Patient requires immediate lifesaving intervention.

ESI LEVEL 2
Patient is in a high risk situation is disorientated, in pain or
vitals are in danger zone

ESI LEVEL 3
Multiple resources are required to stabilize the patient but the
patients vital signs are not in the danger zone
What is the process of admitting a patient in the Unit?
 Physicians assess the patient, explains the treatment plan and need for
admission, if the patient/family agrees, General Consent for treatment is
obtained.
 A biometric procedure is done to confirm the identity of the patient. If
not registered, patient is asked for Qatar Identification Card (Residence
Permit) or Passport for biometric enrollment. If registered, a biometric
pg. 16 JCI Survey Guidance Document - 5B Pediatric Surgery
 scanning is performed, ensuring a correct match to each patient’s  Education about the Home medication.
electronically accessible for life (PEARL) record.  Appointment and home instruction depending on the case of the patient
What type of Patients is admitted in 5B? with printed literature given to the family.
 All patients that fall under the care of General Surgery, Urology, ENT, If the patient or family requested to be discharge without the physician or the
Ophthalmology and Dental Care. healthcare team’s advice, what is the process?
Upon admission, how do we give orientation to the patient?  Once confirmed that the patient wants to leave against medical advice,
 During the process of admission information to the inpatient ward such the physician who is aware of the incident will document and will order
as specific unit orientation and hospital appropriate policies are given, in the patient’s chart.
Staff nurse who will handle each patient are introduced, Patient’s Bill of
Rights and Responsibilities are discussed.
 For expected cost referral to social workers for any financial concerns or
hospital’s financial councilors are to inform them of daily charges. If the patient suddenly left the unit without notifying the staffs, what will you
How will you know if a patient should be admitted in the ESM Beds or other do?
intensive/specialized departments?  After confirming patient who leave the hospital without notifying the
 Patient for admission on intensive or specialized departments needed to staff, a detailed report of the incidence is written in patient medical
meet the criteria to utilize it when possible. There is a policy on the record as well as notifying staff’s CNL and attending physician.
Admission/Discharge and Transfer of patient in the ESM bed that is  A separate incident report is filed on the Datix system.
available in the portal and ESM Trolley.  In case patient left the hospital and haven’t settled with the finance
 Criteria are decided by the attending physician and will be the one to department; the finance counselors will be the one to have contact with
facilitate the admission/transfer/discharge to appropriate services. the patient.
Physician will write down the order. Capacity management and
responsible department/unit will be informed. What is the process of transferring patient outside of Sidra?
If a patient needs a referral from other care team, how do we communicate  After assessing the patient’s appropriateness for transfer, sending
this? Physician contacts Sidra Transfer staff or Capacity Management
 Physician responsible for the patient will input an order of Consult with  Capacity management connects sending physician with receiving
other services needs to be provided either on inpatient and outpatient physician
settings or on discharge. Information regarding referrals can be seen on  Receiving Physician accepts patient
patient’s record under Order tab – Consult & Referral tab.
 STS connects sending and receiving physician to Hamad Medical
How are patients informed when there is a delay in treatment?
Corporation Ambulance Service Healthcare Coordination Centre
 Whenever a delay in treatment or procedure, patients and relatives will
(HMCAS).
be informed by the healthcare team responsible in the care of the
patient. Documentation in patient’s EMR to be facilitated to show record  Level of transport and team composition will be determined by HMCAS.
that patient and relative was informed and that they verbalized HMCAS dispatches ambulance to agreed location and at agreed time.
understanding of the information provided by them.  Clinical Nurse Leader (CNL)/Physician will assess if there is a need for a
What is included in our discharge instruction? pt. chaperone and or licensed healthcare professional to accompany the
 Patient discharge summary is given
pg. 17 JCI Survey Guidance Document - 5B Pediatric Surgery
 patient, this will be done based on the healthcare professionals QCPH Identification (QID) number. QID number may be replaced with HMC
scope of professional practice. number.

How are we receiving patient from other facilities?

 Capacity management will notify admitting unit of estimated time of Discharge Planning
arrival.
 Assigned Nurse will prepare room to receive patient Discharge planning is done at the time of admission so that the patient needs
 HMCAS will provide verbal handover to receiving nurse and/or even on discharged can be planned well ahead of time.
physician.
Mandatory elements of the discharge summary include:
 A copy of the electronic patient care record will be accessible on the
● Reason for admission, diagnoses, and comorbidities
Language
● Significant physical and other findings
A list of interpreters is available on all nursing ● Diagnostic and therapeutic procedures performed
stations. ● Medications administered during hospitalization with the potential for residual
Cyracom is used for any language barrier effects after the medication has been ● discontinued and all medications to be
Physical Wheelchairs/Stretchers are readily available taken at home
●The patient’s condition/status at the time of discharge
● Follow-up instructions including when to return to the emergency department
Religious Prayer Places, are available within the hospital. ● The patient will be advised regarding safe transportation
● Rehabilitation when appropriate/needed
Spiritual Services are provided when asked for. ● The patient and family will also receive education and instruction related to:
Cultural Different types of food choices are available. and in a form of language patient/family can understand
* All discharge medications, including their potential side effects and
Patients’ needs to observe auspicious time for any potential interactions with over the counter medications or food.
procedures are considered. * The safe and effective use of medical equipment when appropriate
Learning
*The correct diet and nutrition
Patient education leaflets, using krames as a
*Pain management when appropriate
resource for education materials

Hamad Cerner.
 Clinical teams that do not have access to Hamad Cerner should email
[email protected] to obtain a copy. Follow the Sidra medical PATIENT AND FAMILY RIGHTS (PFT)
record exchange system procedure.
 Mandatory details to obtain the record include transport unit number, How Sidra does ensures that patients and families are aware of their rights and
responsibilities?
date, handover time, facility name, patient name and patient Qatar
 Part of the orientation for every patient admission is giving information
regarding the patient’s bill of rights and responsibilities that is wall
pg. 18 JCI Survey Guidance Document - 5B Pediatric Surgery
 mounted in the unit and written in both Arabic and English or anytime  Sidra Staff must safeguard passwords and any other codes to access
during the hospitalization process. computer systems and programs and to assume full responsibility for the
 Also, we have on each station readily printed bill of rights that can be activity undertaken using their security codes/passwords.
utilize as well.  Privacy curtains pulled, doors are shut during treatment, and family
How do you identify the common barriers for patients receiving care? members are always notified before entering the rooms.
 Upon admission, in the Admission History, there is a section asking for How are patients/family involved in decision making for their treatment
the possible barriers for the patient and or family members. process?
How do you encourage patient’s active involvement in their care?  Patient and family are given information regarding their medical
 Teach the patient and family how to report concerns about their care, condition, diagnosis and the treatment plan in a language that they can
educate importance of hand hygiene, and respiratory hygiene. We understand. Before any procedure or treatment, benefits and risks are
evaluate their understanding and document it in the record. explained and the patient and family are given an option before signing a
consent.
What do you consider when you are teaching the patient and family ? How do you deal with patient/family complaints and dissatisfaction?
 Their ability to learn, preferences, desire, motivation, and readiness. We  When conflicts arises and clinical nurses cannot resolve the issue, it will
also consider cultural and religious practices and emotional, physical, be escalated to the Clinical Nurse Leader, if the family is still unsatisfied,
cognitive, or language barriers Clinical Nurse Manager will step in and physician may be called as well is
unresolved. The Patient Experience Department can be called anytime as
How do you know that your patient/ family understand the Information they well to report the complaints and for any feedbacks, they can be called
have received? thru email [email protected] or the number 40030022.
• Asking them to repeat what was taught  For documentation, there is a section in the ADHOC –
• Watching them perform. Assessment/Txt/Monitoring – Family Initiated Escalation of Care.
When and how are consents obtained for patients?
Consents are being secured in the following situations:
If the patient or family cannot understand English nor Arabic, what will you do? 1.) General Consent for Treatment - when patient is being admitted in the
 We have medical interpreters 24/7 available that can be contacted via a hospital.
mobile number or thru Vocera. – means the authorization given by the patient or his/her legal guardian for
 Also, we have a language line called CYRACOM that can be contacted via day to day care or treatment as Sidra Medicine. Also informs the patients
phone or the computer anytime. (Kindly ask them to show how to use of their rights and responsibilities as patients of Sidra Medicine as well as
the Cyracom Hotline) notice of Sidra’s policies regarding privacy of the patient’s health
How do you exercise the right of the patient to confidentiality? information.
 It is the responsibility of all Sidra Staff to protect the privacy and 2.) Informed Consent for Surgery or Special Procedure – any surgical or
confidentiality of any information they receive from and about patients, special procedure (surgery, diagnostic tests, interventional radiology)
whether written, verbal, electronic, photographic or stored on any other 3.) Consent for Anesthesia – when patient are going for sedation
medium. 4.) Consent for Transfusion – when patient are going for blood and blood
 Sidra Staff only divulge, copy, transmit or release or access patient products transfusion.
information only as authorized and needed to provide care or perform  Consents are secured by physicians after explaining the risks and benefits
their duties. of the procedure, and is valid for 90 days.

pg. 19 JCI Survey Guidance Document - 5B Pediatric Surgery

  ABBREVIATIONS are not allowed in the consent form and an 18 year old
and above should sign the consent to consider it Valid.
Document in the EMR:
Do Not Attempt to Resuscitate Go to Adhoc-click Restrain
DNAR order be activated between the decision of the three physicians
involved and the patient/legal guardian. Restraints do NOT Include the Following:
The three physician signatories include: ● Age or developmentally appropriate protective safety interventions
● Treating Attending physician, (cribs, stroller safety belts, high chair belts)
● Other Attending physician ● surgical dressings or bandages
● licensed physician, all of whom have knowledge and understanding of the ● Bed rails (up to 3) on trollies or treatment beds to keep patients in bed
patient’s clinical condition. for safety reasons
The following list identifies some examples of types of situations ● Seizure precaution interventions
where DNAR might be considered. ● Post anesthesia immobilization while under effects of anesthesia or to
● Advanced stage, incurable cancer protect pediatric surgical sites
● Irreversible multi-organ failure ● Sedation administration for mechanically ventilated patients
● severe brain damage, and/or brain death Therapeutic or comfort holding by parents, caregivers, or staff to support
● Inoperable congenital malformations that are incompatible with life ● Non-bulky, mobile hand mitts that permit use of hands
● Life-limiting chromosomal anomalies ● the use of protective equipment such as helmets or other adaptive
● Irreversible or untreatable life-limiting neuromuscular disease support in response to the individual’s assessed physical needs (for
The DNAR order can be reversed at any time example, postural support, orthopedic appliances)
●Patient or the legal guardian withdraws their verbal agreement. ● Where child is separated from the parent/caregiver for providing
● Reversal is based on change in the patient’s clinical condition and/or medical treatment e.g. when a child is in an operating theatre
altered opportunities for therapy
The signed DNAR form will be valid for six months. ● Staff should have training and Competency assessment for
Restraint/Seclusion Use:
Restraint
The use of a physical, mechanical and chemical device to involuntarily restrain When to use restrictive interventions as a last resort:
the movement of the whole or portion of a patient’s body, as a means of ●High risk of injury to others (actions such as biting, scratching, hitting,
controlling physical activity, to protect the patient or others from injury. and kicking).
● High risk of injury to self
Different kinds of Restrain ● Interference with/or removal of medical devices that are vital for the
Mechanical Restraint - Any mechanical method, device or equipment attached to care being provided
● Intentional or uncontrolled movements or actions that place the patient
or adjacent to a patient that restricts freedom of movement or access to one's
at risk for fall or other injuries
body.
● A telephone or verbal order is accepted for restrain
Chemical Restraint - A drug used to control or manage behavior or restrict
freedom of movement and not considered standard treatment for a medical or ASSESSMENT OFPATIENT (AOP)
psychiatric condition. How do you perform assessment for patients?
Physical Hold - Physically holding a person by a competent staff member.

pg. 20 JCI Survey Guidance Document - 5B Pediatric Surgery

  Assessment includes Physical, Psychological, Social, Spiritual and Health  We had a training in the laboratory upon joining Sidra and after that, it is
History. renewed yearly with an LMS and the POCT competency sign off by the
 Nutritional Screening and Functional Needs is also assessed for each link person in our unit.
patient and appropriate referral is made if necessary. Novostat (Glucometer) strip expiry:
When do you do your assessment for patients? ● check the manufacturer expiry
 An initial assessment is performed and documented for newly admitted Glucometer solution expiry
patients within 30 minutes of arrival in the unit. ● six months from the time it is open
 All existing patients will have an initial assessment completed within the Clinitek (urine analysis test) strip expiry:
first 60 minutes of the shift and comprehensive holistic system ●
assessment and documentation within 2 hours. Clinitek (urine test) solution expiry:
 Patients going for anesthesia or surgery is assessed before procedure. ● 20 dips or 1 month
When is re-assessment necessary?
● the start of each shift How do you ensure effectivity and accuracy of your POCT?
 Re-assessment at a minimum of every 12 hours for every patient.  Quality control is performed in the POCT machine and results are
 Anytime a patient change in condition occurs, reassessment should be documented to ensure that the machines will provide reliable results.
done.  Reagents are checked for their expiry date as well.
 Anytime there is pain How will you know if your laboratory result is within the normal range?
When do you initially assess patients for pain ?  Every laboratory result has a normal range than can be viewed in the
● on admission or transfer to the unit, EMR.
●after a procedure requiring sedation,  The system will also automatically show if the result is low, high or in
● when the patient's condition changes. critical value.
How do you assess for pain? What pain scale do you use? What you will do if POCT is out of range?
Describe which pain scale you used based on your patient population.  The staff will contacted the ordering Physician and record in the cerner
 Faces pain scale ( critical result notification)
 Numeric pain scale  Record the POCT in critical results logbook in the unit
 FLACC
 N-Pass pain scale

A patient’s discharge planning is done when?

 As soon as the patient is admitted in the hospital, discharge planning
should start.
Do you perform Point of Care Testing in your unit? CARE OFPATIENT (COP)
 Yes, we have the POCT for urine (Clinitek) and for blood sugar (Novostat) How do we deliver our care in Sidra?
How are you qualified to perform the POCT?  Uniform care of all patients is provided and classification of health care
service levels. They are divided by the kind of care given, the number of
people served, and the people providing the care. The main levels of care
pg. 21 JCI Survey Guidance Document - 5B Pediatric Surgery
 are primary, secondary, and tertiary. Levels of care classified by the  All Staff are empowered to activate a Code Blue or Rapid Response when
acuity of the patient or intensity of the services provided are emergency, they have any doubts about the status of a patient, visitor, or staff
intensive, and general. member.
How is care planning for each patient integrated and coordinated among  All Clinical Staff are trained at a minimum of Basic Life Support.
departments and services in Sidra? During critical or life threatening situation such cardiac or respiratory arrest,
 Care of planning and delivery is integrated and coordinated among who are the responders?
departments and services by discussing or informing other health care
members and documentation in the EMR.  All Staff are empowered to activate a Code Blue or Rapid Response when
 The results or conclusions of any patient care team meetings or other
they have any doubts about the status of a patient, visitor, or staff
collaborative discussions are documented in the patient’s medical
member.
record.
How is and individualized plan of care is developed and documented for each  There is a Medical Emergency Response Team (MERT) - Group of
patient? individuals who are assigned the responsibility to respond and provide
 The care for each patient is planned by the responsible physician, nurse resuscitation and stabilization measures for an individual who presents
and other health care practitioners within 24 hours of admission as an with a cardiac and/or respiratory arrest and/or other unexpected
inpatient and individualized based on the patient’s initial assessment medical emergency. Consists of Code Blue Team members and Rapid
data and identified needs. Response Team members that are available 24/7 in the hospital.
 The plan of care for each patient is reviewed when initially developed
and when revised based on changes in the patient’s condition by the
multidisciplinary team. Describe the process of handling and administration of blood and blood
 The planning process is collaboratively done by physician, nurses and products.
other health care practitioners. There is a policy and a standard of practice that describes the handling
 Pharmacists and Dietician for example participates in the morning rounds and administration of blood and blood products that states:
and communicate with the Nurses and Physicians and does discussion 1.) Informed consent must be obtained
with the plan of care for the patient. 2.) Cross matching should be done
 The plan of care is provided to each patient is documented in the EMR 3.) Procurement of blood from the blood bank through PTS or manually
What is the process of prescribing patient orders? picking up from the blood bank with printed pickup slip.
 All orders given by the qualified physicians or Licensed Independent 4.) Correct patient identification at all times
Practitioners are electronically entered in the patients’ medical records. 5.) Administration of blood by a competent staff and monitoring.
How will you know if a clinical and diagnostic procedures treatments have been 6.) Assessment of patient pre, during and post transfusion
carried out and where can you obtain the results?
7.) Identification and response to signs of potential transfusion reaction.
 Orders and reports can be seen in the patient Electronic Record
How do you do your nutritional assessment for every patient?
How do you recognize and respond to changes in patient’s condition?
 During admission, patient is screened for nutritional risk in the AdHoc
 We use standardized and systematic approach for usage of age
(STRONG Kids) section and depending on the score, referral to dietician
appropriate and condition specific Pediatric Early Warning Score (PEWS)
or necessary reassessment may be done.
Tool and Vital Signs monitoring.
 MUST nutrition screening tool for adult
pg. 22 JCI Survey Guidance Document - 5B Pediatric Surgery
Is there a process that guide patient participation in planning and food ● Emergency patients
selection?
● comatose patients
 Diet orders are made by the physician and it changes as per patient’s
status/condition. ● Patients on life support
 Food servers deliver foods and take timely orders and if family
● Patients with a communicable disease
requested; it is being communicated in the kitchen/diet office
How are patients approaching end of life cared for in Sidra? ● Immunosuppressed patients
 There is a policy on end of life or palliative care and there is a palliative
● Patients receiving dialysis
care team that provides consult and care for the family alongside the
primary team. Palliative care services can be contacted thru vocera, ● Patients needing restraints
phone or email.

Care of Deceased Patient: ● Patients receiving chemotherapy or radiation therapy

● as per unit checklist ● Patients at risk for suicide
● SSOC- co-ordinate the communication between each service (security, patient
transport) Care of Vulnerable includes but not limited to the following:
● Social Work-determine family wishes, provide support and grief counselling 1. Frail, elderly
● Government Relations- liaise and arrange for collection by Baladiya ambulance
from Sidra to appropriate facility 2. Patients at risk for abuse and/or neglect
● Anatomical Pathology and Morgue staff-Contact HMC mortuary to ascertain 3. Patient with Terminally illness
where deceased is to be transferred (HMC/Al Wakra), if required
● Complete Morgue registration and release of the deceased patient 4. Patients with intense or chronic pain
● Other- child life , legal if required 5. Patients with emotional or mental illness
● If the death is determined to be a forensic case then the police are informed.
6. Patient suspected of drug and/or alcohol dependency
Care of High risk and Vulnerable Patient
7. Adults patients in need of critical care
High Risk Patients:, a “High Risk Patient” means a patient who is more
likely than others to get a particular disease, condition, complication or
injury due a high risk procedure being performed in the health care Plan of Care for high risk/vulnerable patient
environment as suggested by population studies.
1. Health care providers will ensure that high risk and vulnerable patients
Vulnerable Patients: A Vulnerable patient can be defined as someone are admitted to the right unit and service/department following the policy,
who by the reason of age, mental or other disability, or an illness is or may procedures or guidelines.
be unable to take care of him/herself and protect him/herself against
significant harm or exploitation and those who are ill or dependent upon 2. Should a patient become a high risk patient after admission to a particular
another for any of the aids to daily living. patient care area, the patient will be transferred to the appropriate location.

High Risk patient includes but not limited to the following:

pg. 23 JCI Survey Guidance Document - 5B Pediatric Surgery
 3. Health care providers will be appropriately trained to demonstrate Patient who is receiving parenteral/ neuroaxialopiods will do and have ff at bed
understanding in their responsibilities for care delivery, side
4. A plan of care and scheduling of intervention and treatment will be  Resuscitation bag with appropriate sized mask
tailored to the patient's needs supporting the patient’s highest level of  Standard oxygen set up
functioning and decision making appropriate to patient’s mental status.  Suction set up with Yankauer suction catheter (or appropriate
5. All unanticipated or unintentional hospital occurrences shall be alternative)
documented using the Datix reporting system and reported to the Quality  monitored by continuous pulse oximetry and cardio- respiratory
and Safety Committee by the latter’s requirements. monitoring
ANESTHESIA AND SURGICAL CARE (ASC)  obtain baseline vital signs (heart rate , respiratory rate , blood pressure,
oxygen saturation and
How you will know if a practitioner is qualified to administer sedation to a 
level of consciousness , vital signs will be monitored and recorded every
patient? 15 minutes for 1 hour after each initial dose
 There is a policy in the portal - Medical Staff Credentialing and Privileging .
that states the qualification of a practitioner.
 We can find the clinical privileges of physicians or nurse practitioners in
MEDICATION MANAGEMENT ANDUSE (MMU)
the Portal (Application Software– Clinical– E-Privilege)
Is Procedural Sedation allowed in the Ward?
 No, we are not performing procedural sedation in the Ward
Who discusses the risks, benefits, and alternatives related to procedural
■ Sample Medications are not allowed in the hospital
sedation with the patient, his or her family, or those who make decisions■ Home for medications are not allowed in the hospital premises
the patient? ■ Nurses are authorized to administer the medication–no self-medication is allowed
 Anesthesiologists ■ All medications, which are re –called needs to be returned to pharmacy immediately
What document should be secured before a procedural sedation?
 Consent for Anesthesia Medication Process
In the EMR, which document states the medications used and the monitoringA. We of have a medication management policy for effective medication management & to reduce
the patient during a procedural sedation? medication errors.
 Anesthesia Printed Record
In the EMR where can we find information about the surgical procedure
performed to the patient? Storage of Medication and Nutritional Product:
 Operative Note ● All medicine sand Nutritional products are kept in Safe and
What is included in the Education for Planned Surgical Procedure? Clean, Humidity free Environment
● Room and Refrigerator Temperature to be monitored
 The risks, benefits, potential complications and alternatives related to
● Drugs shall be kept under lock in Floor Stock, and emergency
the planned surgical procedure.
crash trolley
 The education includes the need for, risks and benefits of, and ● checking once in a month in crash cart
alternatives to blood and blood products use.

pg. 24 JCI Survey Guidance Document - 5B Pediatric Surgery

 ● REFRIGERATOR temperature: 2◦ to 8◦C
What is your process in safe handling of medications? How is temperature for refrigerators monitored at Sidra?
 The unit has a Medication Room that can only be accessed by the staffs. ● Refrigerators are connected to hospital temperature monitoring system and
Medications that are readily available are stored in the Omnicell and therefore do not require manual temperature monitoring unless refrigerator
others are delivered by pharmacy. contains a vaccine.
 Narcotics and Controlled Drugs are only accessed by the Clinical Nurse What is near-miss?
Leaders and Manager accordingly. ● an event with the potential to result in harm but did not reach the patient.
 High Alert Medication is not allowed in the unit except for the It should be reported via Datix
Emergency Medications that are stocked in the Crash Cart only and Are you qualified to order medication?
always kept locked when not in use.  No.
What is the process of obtaining and delivering medication orders in your unit? Are you qualified to administer medication?
 All orders will be placed via computer by a physician order entry (CPOE). ● Yes, except intrathecal medication and sedation.
The prescriber will determine the urgency of the medication i.e.;"STAT" 1.1. After preparation, medications not immediately administered are
or “Routine”. Medication will be reviewed by Nurses and Verified by labeled with the name of the medication, the strength/concentration,
Pharmacy. Depending on the availability, it may be taken from the the dose, the date prepared, the expiration date, and two patient
Omnicell or will be delivered by the pharmacy in the unit.
identifiers.
What is considered as a COMPLETE Medication order?
 A medication should ALWAYS include the following: 1.2. If administration of IV medications prepared in the patient care unit has
1.) Patient's name not begun within one hour following the preparation of the IV
2.) Date and time the order is written admixture, the preparation shall immediately be discarded in a proper
3.) Drug, dose, route, and frequency of administration and safe way.
4.) Signature of the prescriber Waste of used medications
 PRN or As Needed medication should always have an indication ● Dispose of all used containers to avoid any mix up. 
How do you ensure that you are giving a patient the correct medication that ● All narcotic and controlled (Narcotic Drugs and Dangerous Psychotropic
they needed?
Substance) medication containers (e.g. ampoules, syringes, bags) whether empty
 By following the SEVEN Rights of Medication:
or partially used must be returned to pharmacy as required by Ministry of Public
1.) Right Patient
2.) Right Medication Health (MoPH).
3.) Right Dose ● If Narcotic Drugs and Dangerous Psychotropic Substance medication has
4.) Right Time/Frequency been obtained from Omnicell return to the Omnicell Return Bin.
5.) Right Route ● If Narcotic Drugs and Dangerous Psychotropic Substance medication has
6.) Right to Refuse been obtained from Pharmacy return to Pharmacy.
7.) Right to Educate Return of unused Medication
What are the standard drug references at Sidra and how they can be accessed? ● If medication is obtained from Omnicell: Return in the Omnicell Return Bin.
● Lexicom, BNF and Neofax found in Sidra Portal
● if medication is obtained from Pharmacy: Return the patient specific medication
What are the appropriate temperature ranges for storage of medications?
in the medication return bin (available in medication room).
● ROOM temperature: > 8◦ to ≤ 25◦ C
pg. 25 JCI Survey Guidance Document - 5B Pediatric Surgery
● Return unused medications in the same day or upon discharge. Refrigerated
medications that are discontinued must be labelled as such and kept there until What are the recommended concentrated electrolytes at Sidra?
picked up by pharmacy Concentrate DEXTROSE at concentrations greater than 20% (20g per
Patient’s self-administration of medications d 100ml)
● Patients are not allowed to self-administer medications while admitted to the electrolytes MAGNESIUM at concentrations greater than or equal to 20%
hospital. A nurse or healthcare provider must administer medications to the patient or solutions (20g per 100ml)
to ensure correct and safe use. POTASSIUM (all salts) at concentrations greater than or equal
In what situation is in-hospital use of patient’s own medication allowed at to 2mmol/ml (2 mEq/ml)
Sidra? SODIUM (PHOSPHATE or ACETATE at concentration greater
●only allowed if medication is not available in stock, cannot be readily obtained than 4mmol/ml
and no formulary substitution is available. SODIUM CHLORIDE at concentrations greater than 0.9% (0.9g
Describe your process for medication reconciliation per 100ml)
● upon admission to the hospital-obtain medication history - to be done by
nurses
And choose which medication to continue-to be done by Doctor Where can the high alert and LASA list be found?
Before/after procedure-deciding which medications to discontinue before ● there can be found in the medication reference binder in the medication
procedure, and which ones to resume after procedure) rooms and as appendix of the relevant procedures (PRO-O-High Alert Medication
● At different level of care-. patient transfer from medical/surgical floor to (including concentrated electrolytes) and (PRO-O- Look alike and sound alike
critical care unit, and vice-versa) medication)
●Upon discharge- which inpatient medications to continue at home, new What is Look alike and sound alike medication?
medications to start, ones to stop taking.) ● Medications with drug names that look similar (in print) or sound similar (when
spoken) to other drugs and /or other drug products (ex:packaging)
What is your practice regarding Antibiotic Stewardship?
 All patients that are admitted are screened for MDRO Medications with drug names that look
What do you do when a patient has been taking a home medication and needs similar (in print) or sound similar (when
to continue upon hospital admission? spoken) to other drugs and/or products that
 Obtain a complete and accurate list of the patient’s medication at home, physically look similar to other drug products
ensure that Medication Reconciliation is in place. (ex: packaging)
What is an adverse drug reaction? PATIENT AND FAMILY EDUCATION (PFE)
● any unexpected, unintended, undesired or excessive response to a medication How do you assess your patient and family’s learning needs?
that occurs at therapeutic dose  Upon admission, patient and family are screened for their learning needs
GOWN
Where are adverse drug reactions documented? Fully and
cover torso and
barriers from neck to knees,
documented in thearms
EMRto end of–wrist,
(ADHOC and History –
Admission
● In allergies section wrap Learning
around the back.
Needs Assessment)
What will you do when your patient develops an Adverse Drug Reaction? Fasten in back at neckand waist
How do you provide education for the family and patient?
The medication will be stopped, Adverse Drug Reactions will be reported to the  Depending
MASK OR RESPIRATOR
on the case of patient, education is provided every admission
patient’s physician and pharmacist immediately, documented in the patient’s Secure andties or elasticthe
throughout band at middle ofprocess.
hospitalization head and neck.
EMR and report a Datix. Fit flexible band to Nose Bridge
pg. 26 FitPediatric
JCI Survey Guidance Document - 5B snug toSurgery
face and below chin
Fit-check respirator
GOGGLES/FACE SHIELD
Put over face and eyes
  By getting the appropriate and specific topic by accessing the Patient
Education in Cerner or using of KRAMES
 Print out materials explained and demonstrated to the patient and
guardian as well.
How do you ensure that the patient or family understood the provided
education?
 After thorough explanation and demonstration teaching, the parents,
patient or guardian are requested to re-demonstrate the procedure for
evaluation.
 Giving of printed materials requires signature acknowledging they What is PPE?
received and understand patient education. Personal Protective Equipment consisting of the following:
 All Patient/family education is documented in the Cerner.  Gloves. • Gowns. •Mask. • Goggles or face shields
 If the family cannot understand English, Medical Interpreter is utilized or Donning PPE
the language line cyracom.
Who provides education for the patient and family?
All healthcare practitioners caring for the patient.

PREVENTION and CONTROL OFINFECTION (PCI)

How do you learn about Infection Control?
 At the orientation program for new employees and. When there are
question about patients or staff with infections, you are encouraged to
call Infection Control office
Where is your orientation and annual Infection Control training documented?
 In the employee file.
What is the contact time for disinfectants?
 Disinfectant solution used for patient care equipment and the hospital
environment is supplied through the store/housekeeping section.
Disinfectant solution will kill common organism in 30 seconds. More
resistant organism is completely destroyed in 60 seconds and see specific
bacteria/virus as contact time

pg. 27 JCI Survey Guidance Document - 5B Pediatric Surgery

 What are we using for Air Borne Isolation precautions?
 N95 Particulate Respirator (for Airborne Precautions) and Negative
pressure isolation room.
Can you reuse a Respirator N95 mask? How to do a particulate Respirator N95
fit test?
 NO, we cannot reuse it. Select a fit tested respirator
 Place over nose, mouth and chin
 Fit flexible nose piece over nose bridge
REMOVING/DOFFING PPE  Secure on head with elastic
 Adjust to fit
Gloves
 Perform a fit check –
Outside of gloves are contaminated!
 Inhale – respirator should collapse
Grasp the outside of glove with opposite gloved hand; peel off
 Exhale – check for leakage around face
Hold removed glove in gloved hand
How do you educate the patient/family regarding Infection Control
Slide fingers of ungloved hand under remaining glove at wrist Precautions?
 The clinical staff informed and educate the patient and family regarding
Gown proper infection precautions and reason behind
Gown front and sleeves are contaminated!
Unfasten neck, the waist ties What do you do if you get a needle stick/splash injury?
Remove gown using a peeling motion; pull gown from each shoulder  Encourage bleeding of wound under running water
toward the same hand, gown will turn inside out. Hold removed
pg. 28
gown away from body, roll into a bundle and discardJCI Survey Guidance Document - 5B Pediatric Surgery
into waste or
linen receptacle.
  Wash the site or area IMMEDIATELY with copious amount of water. For inpatient admissions, patients eligible for MDRO admission swabbing
 Notify your /Manager/CNL will have swabs taken within 12 hours of admission to the unit and explain to
 Seek Treatment from Occupational health or Emergency Physician onsite. the family/patient to gain informed consent.
 Contact / report to Occupational Health Department between the hours 1. Swabs needed are: Anterior nares (use one swab for both nostrils), throat,
of 07.30am – 15.30pm p.m. week days- [email protected] or Vocera groin and VRE and CPO (only one swab needed for both tests) Rectal (fecal
Call ‘Occupational Health’ stain) or ostomy site. Stool swab or perianal swab is acceptable if rectal
 Manager/ area physician commences - Initial Assessment Form for swab contraindicated.
Inoculation Injuries Appendix I- print and use paper copy
MRSA Decolonization (Suppression) therapy
 Report incident on Datix
 Attend Occupational Health next working day with form. 1. Decolonization is treatment of persons colonized with a specific MDRO,
usually MRSA to try and eradicate and eradicate carriage of that
 Appropriate counselling referral and follow up by the Occupational
organism. This is also referred to as suppression therapy as the
Health Department
decolonization regimen only manages to suppress these organisms and
 Reassurance to staff member
patients tend to become recolonized by the organism.
 Determine extent of injury
 Further blood testing if indicated/ schedule same. 2. MRSA Decolonization therapy will not be given to patients routinely
 Start prophylaxis treatment as soon as possible after exposure if except where deemed necessary in high risk patients to prevent them
indicated from developing an infection.
What will you do in case of blood or body fluid spillage on your body?
● Take clothes off without contaminating eyes, mouth, nose etc. 3.Patients may be prescribed topical Decolonization therapy for MRSA
 Shower and change clothes following a risk assessment by the IPAC team and the patient’s Attending
Physician.
●Send clothes to hospital laundry, secure and place in appropriate bin
Re-Screening
What is MDRO screening-? A patient screening for multi drug resistant
organisms ● For MRSA positive patients who receive the topical MRSA Decolonization
therapy, follow up swabs can be taken no sooner than one week after completion
Colonization is defined as the presence of bacteria on a body surface (for of treatment. Patients will be screened at one week intervals.
e.g. the skin, mouth, intestines or airway) without causing disease in the
person. ● MRSA positive patients will not be rescreened in the following situations:
MDRO screened for: ● while they are receiving topical Decolonization therapy
MRSA, VRE, CPO, Candida Auris ● during treatment, and for 2 days after completing treatment with antibiotics to
which the MRSA is sensitive. (Except for PICU/CICU/NICU routine swabbing)
The Physician or Nurse are to notify
the IPAC team when a patient has three MRSA negative screening results to determining the need to discontinue isolation precautions.

General Infection Control Precautions for the Management of MDRO Positive Patient

pg. 29 JCI Survey Guidance Document - 5B Pediatric Surgery

 ● Only essential staff must enter the patient’s room and the door must be kept closed at all times.
● Strict hand hygiene must be observed and wear appropriate personal protective equipment
● whenever possible, equipment must be single patient use or dedicated to that patient. Every attempt must be made not to share equipment between
infected/ colonized patients and non-infected patients.
● Equipment must be decontaminated before it leaves the room.
● Housekeeping staff, portering staff and Facilities staff visiting the unit must be informed of the necessary infection control and isolation precautions
● Catering staff will not enter rooms occupied by patients with an MDRO. Nursing staff are responsible for taking food trays into the patient’s room.
● where patients known to be CPO and Candida auris positive are discharged from an inpatient unit, the room must undergo a Special Clean + Bioquell. The
Clinical Nurse Leader must complete a Bioquell Decontamination Request Form and email it to the Bioquell Facilities team via SSOC.

How to handle spillage on the floor?

Cleaning Body Fluid Spillage Using Spill Wipe

● WearPPE and place a warning sign on the floor, if spill contains glass
or sharps it should be pick up first.

● Absorbfor30seconds,pushdownonplasticbackedsideuntil spill is

• absorbed
●carefully pickupthewipeandplaceinspillwipebag

Wipe surfaceofabsorbedspillwithdisinfectantwipesfromkit and

discard

aaaceabsorb
● Dispose of PPE and wipes on biohazardous waste and wash
hands. Call HK to clean the area.

pg. 30
entsideofspil
JCI Survey Guidance Document - 5B Pediatric Surgery
 lwipeoverspi
What type of surveillance is being done in your departments?
 Catheter-associated UTI`s (CAUTI).
 Hand washing
 Surgical Site Infections
● Sepsis Bundle Compliance
llage,andlea
veto

Hands must be washed with liquid soap and water if:

Hands are visibly soiled or dirty;
pg. 31Exposure to spore forming organisms such as Clostridium
JCI Surveydifficle
Guidanceor aDocument
gastro –intestinal infection
- 5B Pediatric Surgerye.g.
norvovirus, is suspected or known.
 Alcohol Based Hand Rubs should be used for hand hygiene which is available to staff as near to point
of care as possible

pg. 32 JCI Survey Guidance Document - 5B Pediatric Surgery

FACILITY MANAGEMENT ANDSAFETY (FMS)
How does the hospital keep its occupants safe from fire and smoke?
According to Sidra Medicine Fire safety management plan; the hospital implements
 Strict No Smoking Policy,
 No obstructions to exits, fire extinguishers, fire alarm boxes, emergency blankets, safety showers and eye wash stations.
 Emergency lighting is adequate for safe evacuation of the Hospital occupants.
 Storage areas are properly and safely organized; items are a minimum of 50 cm( 18 inches) from ceiling levels, not blocking
 Sprinklers or come into contact with overhead lights.  If medical equipment- remove from patient room
What safety training have you received?  Put a label of Defective do not use
 Safety orientation during general hospital orientation, department  Send an email to SSOC
meetings and during safety rounds.  Damaged furnishings or equipment are removed from service and a
work order completed for repair or replacement.
Who is responsible for safety? Who is responsible for enforcing the smoking policy?
 Everyone.  All employees and staff.
What types of security incidents do you report? How often does the Hospital conduct Disaster drill?
 Any injury or potentially dangerous or threatening situation involving  Disaster Drills are held at least once in a year. One must include
staff, patients, or visitors. For example, threatening behavior, weapons, community, involvement.
fighting, or theft, bomb threat and suspected item found. How often does the Hospital conduct internal evacuation drill?
What is SDS?  Internal Evacuation Drills are held at least once in a year
 SDS is a l Safety Data Sheet and provides information about hazardous What would you do if you see a fire or detect smoke?
materials Follow the RACE protocol.
How do you handle a spill or exposure to a hazardous material? • Rescue - Remove people in immediate danger from the fire.
1.) Blood/Body Fluids: • Alarm - Pull the fire alarm closest to your location or call out Code Red (have
 Contain spill. Use personal protection equipment (PPE). someone dial 66 and report Code Red) give your name, location of the fire and
 Decontaminate with appropriate disinfectant. the type of fire..
 Dispose of contaminated supplies as per Exposure Control Plan. • Confine - Close all doors and windows to help prevent smoke and fire from
2.) Chemical spreading.
 Contain spill. • Extinguish /Evacuate- Only attempt to put out small fires only if you have been
 Evacuate all non-essential personnel from the spill area. trained to do so and have a clean escape route. Otherwise follow evacuation
 Locate SDS and follow clean-up instructions. Use PPE. procedures.
 Call Housekeeping Services for assistance if needed Announce code Where is the nearest fire extinguisher and how do you activate it?
Orange. Know location within your work area. Activate a fire extinguisher
How do you report an unsafe condition? using P-A-S-S:
pg. 33 JCI Survey Guidance Document - 5B Pediatric Surgery
• Pull - Pull the pin. Who can turn off the oxygen/Medical gas valve in your area?
• Aim - Aim the extinguisher at the base of the fire.  Nurse in charge or CNL/Physician in the area at the point and time of fire.
• Squeeze - Squeeze the handle while holding the extinguisher upright. Facility management department will assess the situation before turning
• Sweep - Sweep from side to side at the base of the fire. the valve on again.
Fire Warden Role in case of fire? OXYGEN CYLINDER SAFETY
 Direct people to the nearest available exit and Muster Point. Safety tips for handling oxygen cylinder:
 Assist any impaired mobility staff or patient by directing them to the fire • When moving oxygen cylinders, even for short distances, use a cart or carrier
lift lobby. designed for their transport.
 Ensure evacuation is carried out in an orderly manner, • If transporting via hospital bed or stretcher, ensure the cylinder is safely
 Close doors that may have been left open providing that it is safe to do secured.
so. • Never position an oxygen cylinder between a mattress and bedrail.
 Once outside, report the situation in their areas directly to the Building • Cylinders should be stored in the vertical position and properly secured by a
Warden, including details of any person(s) who have become trapped or chain or similar device.
who may not want to leave the building for whatever reason. Oxygen cylinders should never be left in any area unsecured, even for a short
 Assist staff and patient(s) to return to the building once “All Clear” code period of time.
is announced May I please see your units fire Plan?
Do you know the emergency exit path from your area in case of fire? We have a Red Binder that is kept in the Nurse’s station.
My assembly point is # .......................................................................................  Our Red Binder is kept in the CNL office
and is located
How do you know equipment is working properly?
The user checks equipment before it is used. What is the role of the fire response team in the event of a fire?
 Biomedical Engineering does an installation inspection of equipment and  To respond to the fire area, identify the fire or smoke condition and put
it is tagged when it is functioning according to manufacturer immediate corrective action in place.
specifications, calibrated, has functional and audible alarms as  Priorities are:
appropriate and is safe. The equipment tag indicates the date when it 1. Life Safety- Patients, Guests and Staff
was checked. 2. Incident stabilization- control the situation
 The operator notifies Biomedical Engineering if there is a problem with 3. Property Conservation- Protect the house from further damage
equipment functions. Any equipment not functioning properly should be What is the Sidra approach to a fire response?
immediately removed from service.  Sidra has a zero tolerance for fire.
 Equipment included in the Equipment Management Program is given a Who do you contact when there is a fire?
preventive maintenance inspection at regular intervals.  SSOC by Dialing 66, Call Out CODE RED
 All equipment must be disinfected by the department prior to being  Activate the Manual Call Point- Pull Station
serviced by engineering / Biomedical Engineering. Dial 66- Give the following:
When do you turn off the oxygen for your area? Building
 In the event of a fire in your immediate area, follow RACE protocol for a Tower- if applicable
fire, assess your patients, provide alternate life support (e.g., portable Floor
oxygen), shut off area oxygen, and evacuate the area if directed to do so. Unit
pg. 34 JCI Survey Guidance Document - 5B Pediatric Surgery
 Condition- Fire, smoke, water leak, specific codes  OPC / CSB 6 past the tram station
Hello SSOC-Hospital Building, Tower A, 7th floor, Child Dialysis Unit- we have What does RACE mean?
smoke coming from the electrical room.  R-Rescue
When would you make the decision to evacuate?  A-Alarm
 When the situation threatens the patient wellbeing or interrupts the  C-Confine
continuity of care.  E-Evacuate or Extinguish
Examples: Fire, Smoke, Flood, electrical failure, excessive What does PASS mean?
temperatures  P-Pull the Pin
Who would make the evacuation decision?
 A-Aim the extinguisher
 The decision is made by the CNM/CNL or fire warden.
 S-Squeeze the handle
If conditions are obvious, we would initiate a self-evacuation and immediately
remove patients and visitors from harm.  S-Sweep the extinguisher across the base of the flame
Do you have evacuation Plans / Diagrams? How often is training provided?
 The specific unit evacuation plan is located in the RED Book on the  All training is annual by Sidra Policy. Mandatory refresher training is
nurse’s station. provided.
 Evacuation / Escape signs
How often is Fire Drill Conducted?
How would this unit evacuate horizontally?
● Every 3 months/quarterly
 Evacuation is to the adjacent smoke compartment. We can move to the
next tower,(tower A or tower C) via Link Bridge, back corridor.
Where can I see your specific training history?
How would this unit vertically evacuate?
 Go into LMS and look up my employee number- you will see my
1. Mechanically, via the patient lifts-designated lift in case of fire
completed training
2. Manually using floor evacuation equipment and the closest
If there was a fire in Sidra right now, what would you do?
stairs (beside Clean Supply Room) away from the threat.
 In my area follow RACE
Do you have evacuation Tools?
 Yes in each Unit located in equipment room  In other areas await instructions.
What would you do if there was a fire on your floor?
Stair Sled, Evacuation chair, Baby slings
Have you been trained to use them?  Follow RACE.
 Yes, Training is mandatory and conducted annually, in the Red Binder  Get patients away from the fire & smoke
there are printed instructions on how to use the equipment.  Call out CODE RED
Where is your exterior Muster Point?  Pull the Fire Alarm
It depends on where you are in the building:  Notify SSOC by calling 66
 HB- 1 in front by traffic circle  Close the doors to the fire room and corridor
 HB- 2 by ED  Evacuate patients to a safe area, beyond the BLUE DOT to a neutral
 HB- 4 Rear of HB going towards CSB smoke compartment.
 CSB-3 Rear of CSB 4 in front of CSB What would you do if there was fire in a different part of the building?
 OPC-5 Near the A stair & Parking area Different Tower?

pg. 35 JCI Survey Guidance Document - 5B Pediatric Surgery

  Stand by and await instructions. How many fire extinguishers do you have on your unit?
What is your role in a fire emergency on your floor? Where is the evacuation / escape sign?
 Follow procedures and instruction of supervision.  Let me show you.
 Patient safety always comes first. What does the RED arrow mean?
 You have tools and procedures that you were trained to use. Be able to  The RED arrow is the second best way out of this area.
speak about them.  This is the alternate to the quickest way. We have several ways out from
Where are the fire drill records? most locations.
Copies are posted on the Portal and hard copies are with The FSP group. What does the GREEN arrow mean?
 Let me show you the Portal posting.  The Green Arrow is the quickest way out.
Are fire drills usually announced? What is the CODE word for FIRE?
 Not always, 50% of drills are surprise drills, they are unannounced or  Code RED
with short notice, however, we respect patient needs first. What is the best way to contain a fire?
Did Sidra participate in any QCD exercises?  Close the door. RACE- C= Contain, to do this close the door, the doors are
 Yes- Jan 2018 we worked with QCD on a LPG emergency designed to contain a fire.
What happens to the elevators in your tower during a fire alarm activation? I smell gas- what do I do?
 All lifts in the Tower of alarm activation will recall to the Plaza level.  Check the location where it came from then Call 66 and report the odor.
 If the alarm is in Towers A or B the lifts in A / B will recall and lifts in C & D Close all patient room doors and make ready for an evacuation
will function normally.
 If the alarm is in C or D the C/D lifts will recall and lifts in A / B will Is oxygen a flammable gas?
function normally.  No but it highly supports combustion. SDS attached
 In OPC & CSB & MLCP all lifts will recall. How do you identify a room was successfully checked/evacuated.
What does the Blue dot over the door mean to you? The patient is removed and the door is closed. Identified with a
 The BLUE DOT indicates the different smoke zones. This is a non-verbal large X on the closed door.
visual indication of an alternate smoke zone. If you have smoke of an  This is done to indicate the room has been searched for life and is empty.
odor in your zone, you are to relocate to the far side of the BLUE DOT.
What equipment / resources do you have on this floor to fight a fire?
 Fire Extinguishers
 Small hose stations
 Stair Standpipes
 Sprinklers
 Fire Blankets Child Abduction/Code Pink- Either an attempted or actual abduction of an Infant
 Manual Call Point or a Child.
 We also have responders that will bring additional resources as needed. When Code Pink is reported:
Have you been trained to use the evacuation equipment? ● immediately notify SSOC-initiate hospital wide lockdown
 Yes- prior to the last MoPH visit, March 2108 ● Unit lockdown-where the child abduction occur
pg. 36 JCI Survey Guidance Document - 5B Pediatric Surgery
● Deployment of staff/Activation of Clean Sweep  Go to Sidra Portal- then select Approved Policies and Procedures- then
● A clinical staff member will stay with the family. search Standardized Diagnosis Codes, Procedure Codes, Symbols,
● Unit Staff will cover all possible unit level exits, fire exits, stairwells, elevators, Abbreviations and Definitions
exit path way Who is legally authorized to act on behalf of a Minor patient or a person with
● Unit staff adjacent to the locked down area will also cover all exits outside of diminished capacity?
the locked down area. Minor is:
● Security will be deployed to cover inward and outward traffic. 1. Parents
● Vehicles will be not be allowed to leave the hospital grounds until the all clear 2. Maternal / Paternal grandparents
is sounded. Person with diminished capacity is:
1. Spouse
POST ACTIVATION CLEAR SWEEP TASKS 2. Adult son (priority to the oldest son/ Adult daughter (priority to the
● The senior nurse, clinician or clinical staff member in charge will activate a oldest daughter)
verbal ‘all clear’. Security will ensure that the all clear is shared with the SSOC. Under no circumstances may a maid or nanny consent for treatment of a Minor
●The SSOC will announce an all clear over the appropriate communications without formal authorization from the parent or guardian.
medium. What is Sidra’s policy in Record Retention if the records must be maintained
The senior nurse, clinician or clinical staff member will complete a post activation permanently for historical or legal purposes?
written report  They must be stored on an electronic medium to save space and
preserve items.
What does PEARL stands for, the electronic clinical information in Sidra?
 Patient Electronically Accessible Record for Life.
What are included in the electronic Clinical Record of every patient?
 Time and date of every entry, the conclusions at termination of
treatment, and the patient’s condition at discharge, and follow up care
instructions.
Under Sidra’s medication order policy, in the event of a pediatric patient with
unknown weight, how do we ascertain the patient’s weight?
MANAGEMENT OF INFORMATION (MOI)  The estimated weight must be ascertained with the use of Broslowe‘s
What are the forms in the patient’s medical record that does not allow the use Tape.
of abbreviations? In Sidra, how do we notify the personnel who use or support the electronic
 No abbreviations are to be used on Informed Consents Forms, patient’s patient record system that downtime process is initiated?
rights documentations, discharge instructions, discharge summaries, or  Code PEARL.
SSOC responsible to activate Hospital’s call the CODE PEARL.
any other documentation that a patient that his/her family may read or
What is the severity level?
receive.
Level 1 – 0 to 1 hour downtime
Where can you find the standardized diagnosis and procedure codes that are Level 2 – 1 to 3 hours downtime
adopted by Sidra Medicine for clinical coding and data aggregation and the list Level 3 – more than 3 hours downtime
of NOT TO BE USED abbreviations symbols and APPROVED abbreviations? How do you ensure that the electronic records are secured?
pg. 37 JCI Survey Guidance Document - 5B Pediatric Surgery
  Authorized staff members are given access to the IT system by an
individual user name and password. How the staff is involve in Performance Improvement
 Do not share your passwords  All staff is responsible for performance improvement activities either
 Always log out after used of computer through ongoing data collection, analysis of results, development of
 Users will have access to the information as per their job profile and the action plans, and measurements of success or Performance
request of the respective HOD’s. Improvement.
How do you ensure that the confidentiality of patient information is
 Each Department has a Unit based council that involves staff
maintained?
participation.
 Every employee is responsible for maintaining a patient’s privacy,
whether that information is written, verbal, or electronically stored.
 Every employee whose job requires access to electronic information has What is the improvement activities carried out in last 12 months to improve
his or her own user id and password. care?
 Confidentially of patient information is the responsibility of every Surveyors often ask staff to explain their role in improving care. Plan ahead and
employee. This includes, among other things, accessing information, speak with confidence about something you or your department did to improve
discussing in the cafeteria, lifts, corridors, restrooms or with any
care or services for patients. When possible, the answer should be expressed in
person’s. All the employees sign a confidentially agreement during
measurable outcome statement,
orientation.
Patients and Legal Guardians have the right of access to review, inspect and/or Mention our KPI in the unit as our Performance activities.
receive copies of their Personal Health Information. Pain assessment
 Yes Admission Assessment
Misuse, failure to safeguard or the disclosure of Personal Health Information Hand hygiene
without compliance with policy may be cause for disciplinary action up to and Implementation of Sepsis Care Bundle
including termination-as per policy Patient Identification
Sidra may Use or Disclose Personal Health Information to family members,
friends and others?
 Yes only if the patient is present and the patient gives explicit verbal What Is Sentinel Event?
consent to the Use and Disclosure. An unanticipated occurrence involving death, permanent loss of function or
serious physical or psychological injury.

QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS) An unanticipated death, including but not limited to
Death that is unrelated to the natural course of the patient’s illness or
The Goal of Quality Improvement and Patient Safety are to continuously improve underlying condition (for
patient health outcomes. This chapter is to measure the current process and to example, death from a postoperative infection or a hospital-acquired
identify areas of improvements and implement solutions. pulmonary embolism);
The Quality and Risk Management section sets organization PI (Performance 1.1.1. Death of a full-term infant;
Improvement) priorities in coordination with Hospital leadership committee.
Section Heads set departmental PI goals to assist in addressing these priorities.
pg. 38 JCI Survey Guidance Document - 5B Pediatric Surgery
 1.1.2. Suicide of any patient receiving care, treatment and  Death that is unrelated to the natural course of the patient’s illness or
services in a staffed around the-clock care setting or within 72 underlying condition (for
hours of discharge; example, death from a postoperative infection or a hospital-acquired
1.1.3. Maternal death pulmonary embolism);
1.2. Major permanent loss of function, unrelated to the patient’s natural  Death of a full-term infant;
course of illness or underlying condition  Suicide of any patient receiving care, treatment and services in a staffed
1.3. Wrong-site, wrong-procedure, wrong-patient surgery;
around the-clock care
1.4. Artificial insemination with the wrong donor sperm or wrong egg or
setting or within 72 hours of discharge;
embryo
1.5. Retained instruments or other material after surgery requiring re-  Maternal death
operation or further surgical procedure; Transmission of a chronic  Major permanent loss of function, unrelated to the patient’s natural
or fatal disease or illness as a result of infusing blood or blood course of illness or underlying condition
products or transplanting contaminated organs or tissues;  Wrong-site, wrong-procedure, wrong-patient surgery;
1.6. Abduction of any patient receiving care, treatment, and services  Retained instruments or other material after surgery requiring re-
1.7. An infant discharged home with the wrong parents; operation or further surgical procedure;
1.8. Rape, workplace violence such as assault (leading to death or  Transmission of a chronic or fatal disease or illness as a result of infusing
permanent loss of function), or homicide (willful killing) of a patient, blood or blood products or transplanting contaminated organs or tissues;
staff member, practitioner, medical student, trainee, visitor, or  Abduction of any patient receiving care, treatment, and services
vendor while on hospital property.  An infant discharged home with the wrong parents;
1.9. Hemolytic transfusion reaction involving administration of blood or
 Rape, workplace violence such as assault (leading to death or permanent
blood products having major blood group incompatibilities (ABO,
loss of function), or homicide (willful killing) of a patient, staff member,
Rh, other blood groups)
1.10. Severe neonatal hyperbilirubinemia (bilirubin >30 practitioner, medical student, trainee, visitor, or vendor while on hospital
milligrams/deciliter) property.
1.11. Prolonged fluoroscopy with cumulative dose >1,500 rads to a  Hemolytic transfusion reaction involving administration of blood or blood
single field or any delivery of radiotherapy to the wrong body region products having major blood group incompatibilities (ABO, Rh, other
or >25% above the planned radiotherapy dose blood groups)
 Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
 Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field
Harm Event–. Any event that occurred, resulting in harm, loss or damage or any delivery of radiotherapy to the wrong body region or >25% above
No Harm Event- Any event that occurred, resulting in no harm, loss or damage. the planned radiotherapy dose.
Near Miss Events –Any event that had the potential to cause harm, loss or
damage but was detected and prevented, resulting in no harm.
What is the process for handling a potential Sentinel event?
Sidra Medicine has identified the following list of events that will be classed as Your role is recognition of a sentinel event or potential sentinel event, preserving
sentinel in line with Joint Commission International (JCI) requirements and the equipment/ supplies and environmental conditions are involved, and alerting
mandated reporting from Ministry of Public health (MOPH) : your CNL/CNM. If a sentinel event occurs, All evidence from the event must be
 An unanticipated death, including but not limited to preserved and as many statements obtained as soon as possible. A Root Cause
Analysis (RCA) is performed to determine the “Root cause” of the event, and
pg. 39 JCI Survey Guidance Document - 5B Pediatric Surgery
make necessary changes to process for identifying the basic or causal factors that  Resuscitation Program, Rapid Response and Code Blue
underlie variation in performance, including the occurrence or possible  Medical Transport Services
reoccurrence of a sentinel event.  Against Medical Advice: Informed Refusal / Withdrawal of Treatment
 Discharge Against Medical Advice
Related Policies and Procedures:  Point of Care Testing
 Patient Identification  Isolation Precautions to Prevent Infection Transmission
 Provider Order Form  Assessment and Management of Occupational Exposures to Blood Borne
 Clinical Handover Pathogens from Inoculation/ Sharp
 Communication of Critical Results  Management of Body Fluids
 High Alert Medications (Including Concentrated Electrolytes)  Medical Staff Credentialing and Privileges
 Look Alike Sound Alike Medication  Procedural Sedation
 Prevention of Wrong Site, Wrong Procedure, Wrong Person  Management of Multidrug Resistant Organisms in Colonised or Infected
 Hand Hygiene Patients
 Fall Prevention and Management  OMNICELL® Medication Automated Dispensing System
 Quality and Safety Event Reporting  Medication Administration
 Admission/Discharge/Transfer  Medication Reconciliation
 Patient and Family Rights and Responsibilities  Adverse Drug Reaction Reporting
 Patient and Family Education  No Smoking Policy
 Informed Consent  Fire and Safety Management Plan
 Confidentiality of Personal Health Information  Fire Drill
 Management of Patient, Family and Visitor Feedback (solicited and  Fire Safety
unsolicited)  Facility Safety
 Family Initiated Escalation of Care  Hazardous Material Spill Emergency
 Standardized Diagnoses Codes, Procedure Codes, Symbols, Abbreviations  Environmental Monitoring Rounds
and Definitions  Compressed Gas Cylinder Safety Procedure
 PEARL Downtime  Corrective Maintenance of Medical Equipment
 Individual Patient Access to Personal Health Information  Evacuation Procedure of Uncontrolled Fire

 Confidentiality of Non-Patient Information

 Early Warning Scores
 Record Retention Policy
 Patient Electronic Clinical Record
 Disclosures of Personal Health Information to Confidential Affiliates
 Confidentiality of Personal Health Information
pg. 40 JCI Survey Guidance Document - 5B Pediatric Surgery