Leadership

1. How do you decide on Board members?

2. How do you evaluate Board members?

3. What would I hear at the beauty shop about your facility?

4. Do you have a formal process to evaluate the Board?

5. What is your safety management process?

6. Who is responsible for safety management? Have you selected or confirmed

a safety committee?

7. Who decides how sentinel events are addressed?

8. What is your policy for how unintended adverse outcomes are addressed?

9. What have you done concerning ergonomics?

10. How do you protect the integrity of clinical decisions?

11. Tell me about your organ donation program?

12. How does the community let you know their needs?

13. How do you measure if you are meeting community needs?

14. Do you have a chaplain employed?

15. What keeps you up at night?

CBC-maternity

1. Tell me about your scope of service?

2. Are staff cross trained?

3. Asked about security with entrance/exit door in main hallway by

elevators?

4. Questioned fire hoses in cases in hall?

5. Do you have central monitoring in CBC?

6. Who has authority to shut off O2 valves?

7. Asked about integrity of sterile wraps?

8. Asked about emergency drugs in labor rooms?

9. Asked about quality control for nitrozene?

10. Asked physician what was procedure for scrubbing prior to procedures?

11. Asked what type of anesthesia is provided in CBC?

12. Who takes care of infant after delivery?

13. Asked pediatrician if there was a problem with this?

14. Are you level 1?

15. Where are your major referrals?

16. Who does circumcisions? Are there any complications?

17. Asked physicians if there are any barriers on CBC?

18. Asked about physician education?

19. Are all nurses and physicians certified in NRP/

20. What is the role QCM plays on CBC?

21. Where is the H&P on this chart. What is your policy for the H&P?

22. Questioned handwriting of physicians? Are you doing anything about this?

23. Where will I find the plan of care

SNF-skilled nursing unit

1. Tell me about your population?

2. Do you function under same policies at acute care?

3. Who cleans the whirlpool bath? May I see the written policy?

4. Where do you stand on the use of restraints?

5. Has your fall rate increased with less use of restraints?

6. What state did your survey, did you have any deficiencies?

7. What are the job requirements of the medical director?

8. Asked medical director if there areas that make his job requirements

different?

9. Asked medical director about performance improvement activities?

10. Asked what is the medication error report for SNF?

11. How often do you assess for pain?

12. What type of feedback do you get from patients?

ED

1. Asked about security in ED and entering facility after doors closed in

main lobby?

2. Where is decontamination performed?

3. In entrance to ED asked where patient is seen first?

4. Are you applying for level 3?

5. Asked to see resuscitation log?

6. Checked pediatric cart for paddle size.

7. Asked about private physician wanting to see own patient?

8. What is your on call policy?

9. How do you assess pain in the ED?

10. When does the medical record have to be complete?

11. Do you have observation care?

12. Do you have access to nutrition for patients after dietary is closed?

13. What kind of control do you have for narcotics?

14. Asked about restraint/seclusion?

15. What is the biggest complaint you have had from patients?

16. Asked about physician involvement in CQI?

17. Asked about physician coverage for urgent/non-urgent care?

18. What is the major role of the chaplain?

19. Tell me about your emergency preparedness plan?

20. What would you do for a utilities emergency?

21. What is your involvement with EMS? Are you providing any teaching?

22. Tell me about your EMS program (private/volunteer)?

23. I see you have a heliport. How is it used?

24. How does staff demonstrate age specific competency?

25. How are you responding to DNR?

26. What are you doing for PI?

27. Do you have SANE?

28. What do you use for poison control?

29. What thrombolytics do you use?

30. How about strokes? What are you doing?

31. If a patient is dropped off in the parking lot and left there, what is

your policy for treating them?

32. What is your response during the night or on weekends for ECGs, X-rays,

CAT Scan, etc.?

33. What is your turnover for MDs in the ED?

34. What is your policy for alcohol or drug abuse?

35. Asked respiratory therapist how they are involved with care in ED?

36. How do you assure O2 is coming out when you turn it on?

Diagnostic Imaging

1. Do you use conscious sedation? How often do you use it?

2. How often is your resuscitation cart checked?

3. Looked for biomedical check on equipment.

4. Do you have self-referral?

5. Tell me about your equipment?

6. Is there always someone in the "hot lab" when doors are open?

7. Asked about delivery and pick up of nuclear medicine. Asked about

documentation?

8. Asked where Cardiolyte procedures are done?

9. Asked about pediatric resuscitation cart.

10. Asked if conscious sedation is used for pediatric patients in radiology?

11. Do you have MRI? Does there staff go through HR?

12. Looked for state of Ohio report.

13. Who looks at film badges?

14. Asked about lead aprons?

15. Asked about policy for technologist that gets pregnant?

16. Do you have both lightweight and heavy aprons?

17. How do you assure aprons are hung properly?

18. Did medical staff approve the MRI contract?

19. Do you have clinical affiliates?

20. Does the film rate go up when clinical students are here?

21. Asked physician about adequate histories on requisitions?

22. Asked to see a chart with conscious sedation/What are you doing for PI

in your department?

23. Do you find problems with emergency department film readings? Are you

monitoring?

Telemetry

1. Asked to see narcotic count form.

2. How often is your resuscitation cart checked?

3. How do you know this fire extinguisher has been checked?

4. What are you doing for PI?

5. Tell me about your call system?

6. What is your scope of care?

7. How do you do nutritional screenings?

8. When does dietitian see the patient?

9. What do you do about needing to see the patient on weekends?

10. Asked about physical and speech screenings.

11. Show me the patient plan of care and goals for the patient?

12. How does the physician have access to the computerized record?

13. Are you familiar with the safety standards. What have you done?

14. If a patient had an unintended adverse outcome how would you handle it?

Is there physician involvement?

15. I see your hospital is looking at ways to prevent errors. What kind of

input are they getting from staff?

16. Tell me about your discharge planning?

17. What point of care testing are you doing?

18. How do you address advance directives?

19. If patient has an advance directive but you don't receive it, how do you

address it?

20. Asked pharmacist how they review orders/

21. Do you have self-administration of medications?

22. Tell me about staff orientation and competencies?

23. Asked physicians if they felt there is enough staff?

24. Asked physicians how they are involved in PI?

25. Tell me about use of restraints?

26. What sort of patient satisfaction do you get?

27. Tell me about your clinical pathways?

28. Tell me about patient satisfaction related to the food?

Laboratory

1. What sort of things are you performing quality checks for?

2. Who draws blood besides phlebotomists?

3. How does this work with nursing drawing blood? How do they maintain

competency if they are drawing blood very often?

4. How do you assure right person is getting right blood at right time?

5. Tell me about your RhoGAM program?

6. How quick is turnover for biopsies?

Rehab Services

1. Asked each department to tell about their services.

2. How do you work on patient goals?

3. How much is OT involved with PT services/

4. Tell me about medications used in Rehab.

5. How do you assess staff competency in each of your departments?

6. Tell me about your orientation process?

Work Pro

1. Do you see substance abuse?

2. What lab tests are you doing?

3. Do you store medications in your refrigerator? Asked to see log.

4. How do you know if electricity goes off on weekend?

5. Asked physician if she goes out to industry?

6. Assessed drug-testing area. Asked when dye is placed in container?

7. Tell me some things you have found on a plant visit?

8. Do you drug-test physicians?

9. Who cleans room where medical records are stored?

10. Reviewed chart for completeness.

HR Interview

1. How do department directors assure they have qualified staff?

2. How does the hospital support CNE?

3. How do you quantify staff education?

4. What data do you have to assure you have adequate staff?

5. PCAs are doing cleaning that was previously done by other staff. How do

you assure they are competent?

6. How do patients know they won't get their sheets changed every day?

7. Asked if annual report to Board was timely?

8. Asked about timeliness of performance appraisals?

Patient Care Interview

1. Pharmacist: What are you doing for ADRs?

2. How do you track nutritional errors?

3. Tell me about medication/food interactions?

4. How do you assess for herbal medications?

5. How do you inform patients about unintentional adverse outcomes of care?

6. Do you tie medications with pain scale?

7. Is pain and chronic conditions reassessed on an ongoing basis?

8. Do you use samples anywhere?

9. Do you serve grapefruit juice?

10. Tell me about special diets in oncology?

11. Do you have meals available when dietary is closed?

12. Using PI perspective, how do you know you are getting patient to the

next level of care? How do you know it was appropriate?

13. Do you have access to other religious sects/

14. What is available for food preferences for patients of other

cultures/religions?

15. What barriers make it difficult to obtain needed staff?

Check the following (notes form briefings)

1. Add criteria necessary for autopsy report.

2. Complete fire drill in OR.

3. Check options for improvement in completing delinquent medical records.

4. Look at timeliness of H & P (Prenatal in office to medical record).

5. Keep working on smoking policy.

6. Assure alarms are on all medication refrigerators.

7. Look at abduction policy again.

8. Use proactive risk assessment for safety standard.

9. Assign someone to clean fans brought in patient's rooms.

10. Year-end summary of EOC report to Board.

11. Provide master list of EOC projects to check off when completed.

12. Link pain management with medication protocol.

13. Educate and assure nutritional functional screening is completed.

14. Improve documentation of patient plan of care.

15. Be specific with timelines on root cause analysis.

16. Review policy for closing hospital to visitors for infection control measures.

17. Check to see if pledge for continuous care is signed.

18. Check to see if more info is needed in community education about smoking

and advance directives.

19. Include medical staff with chart review.

20. Begin working on illegible documentation.

21. Think about ordering stamp with signature and date for verbal orders.

22. Educate appropriate staff about impaired practitioner policy.

23. Evaluate leaders participation in PI.