‫ادارة اﻟﺠﻮدة واﻻداء‬

Quality and Performance

AdministraƟon

Common QuesƟons
 Saudi Central Board for Accreditation of
Healthcare Institutions

The logo

CBAHI Development Process

2012: Health Services Council Decree No. 8/58: CBAHI
Accreditation is Mandatory for all healthcare facilities in the kingdom
2014: The Ministerial Cabinet’s decree about the new mandate and
structure of CBAHI No. 371 dated 24/11/1434 H concerning
change in the organizational restructuring of CBAHI, a new
name was conferred

“Saudi Central Board for Accreditation of Healthcare Institutions”

‫المجلس السعودي العتماد المنشآت الصحية‬

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 CBAHI Mission and Vision
‫رسالتنا‬
‫نعمل على رفع مستوى الجودة والسالمة من خالل مساندة المنشآت الصحية على االلتزام المستمر بتطبيق معايير‬
.‫االعتماد‬

Mission
“To promote quality and safety by supporting healthcare facilities to continuously comply
with accreditation standards.”

‫رؤيتنا‬
.‫أن نكون رواد تحسين جودة وسالمة الخدمات الصحية على مستوى المنطقة‬

Vision
“To become the regional leader in improving healthcare quality and safety.”

CBAHI Values
Professionalism

‫االحترافية‬

Integrity

‫النزاهة‬

Commitment to Excellence

‫االلتزام بالتميز‬

Team Spirit

‫العمل الجماعي‬

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 CBAHI Standards

Chapter Total Standards Total Sub-Standards Total ESR Standards

Leadership 31 157 0
Human Resources 16 66 1
Medical Services 19 86 1
Provision of Care 43 212 2
Nursing Care 12 48 0
Quality Management
25 108 2
& Patient Safety
Patient & Family
18 74 0
Rights
Patient & Family
7 34 0
Education
Anesthesia Care 19 52 2
Operation Room 14 61 0
Adult Intensive Care
13 48 0
Unit
Coronary Care Unit 14 49 0
Neonatal Intensive
13 43 0
Care Unit

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 Pediatric Intensive
14 48 0
Care Unit
Labor & Delivery 9 23 0
Hemodialysis 10 45 0
Emergency Care 15 51 0
Radiology Services 10 28 0
Burn Care 11 22 0
Oncology &
10 20 0
Radiotherapy
5 15 0
Social Care Services 5 18 0
Dietary Services 6 29 0
Physiotherapy
4 16 0
Services
Dental Care 7 21 0
Management of
12 48 0
Information
Medical Records 17 61 0
Infection Prevention
44 188 2
and Control
Medication
41 266 3
Management
Laboratory 76 209 1
Facility Management
39 171 6
and Safety
Total 579 2317 20

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 What is the mission and vision of KAMC?
Mission: King Abdullah Medical City, Ministry of Health, is a nonprofit tertiary and
quaternary healthcare organization that provides the highest standards
of integrated patient care, education and research in an innovative work
environment for caregivers

KAMC is the place of choice for patient and guests of the Holy Capital who seek a
safe and healing experience

Vision: To set a world-class model in global healthcare, education and research by

2030.

DO’s and DON’Ts when answering the Surveyors:

 When responding to a surveyor question, make sure you stay relaxed, maintain eye
contact, and demonstrate confidence and pride.
 Seek clarification if the question is not clear.
 Do not rush to answer. Take your time.
 Remember, the survey process is organization specific.
 The surveyors focus is how you do your job at this organization. He expects you to
be knowledgeable of your JOB DESCRIPTION and the POLICIES and PROCEDURES
that pertains to your work in KAMC.
 Always make sure you understand the question before you answer. Ask for
clarification if you are not sure.
 If you do not know the answer, tell them you do not and refer them to someone
who knows such as your supervisor/Department Head.
o I have an answer to your enquiry but to make sure, I can refer you to my
Supervisor/Department Head.
 Keep your answers focused and specific to the question they ask.
 Do not give more information than what is being asked for.
 If the question requires only a ‘yes/no’ answer, do not volunteer further
explanation.
 If they ask for explanation/examples, then you should respond with what you know
according to our CEO approved policies and plans.
 Keep the conversation professional. Use appropriate language and behavior.
 Be prepared to show the surveyor documents, policies, and tools that you use in
performing your work if they ask.

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  You must know where they are or how to locate them (e.g. policies) through
DROP-BOX.
 Be able to access the Policies/Plans to show them the answer of their enquiry, if
needed.
 Never begin an answer with the words “Usually”, “Most of the time” or
“Sometimes” when asked questions regarding processes or procedures.
 Such questions need to be answered with “ACCORDING TO OUR POLICY……”. By
answering in this manner, we will show the surveyors that we have a unified
approach to care.
 They are here to evaluate us based on our policies abiding to CBAHI Standards.
 Remember that anytime you say “WE” the surveyor will expect that you are
referring to all of KAMC.
 Do not discuss your personal issues with them. This is not the time to ask answers
to your personal issues or discuss problems.

Useful tips for responding to surveyor questions:

 Remember that surveyors are HIGHLY EXPERIENCED individuals: Physicians,

Nurses, Pharmacists, Administrators, Social workers, Medical Technologists, etc.
 They are WELL TRAINED across the continuum of health care delivery systems. DO
NOT TRY TO OUTSMART THE SURVEYOR.
 Surveyors are NOT out to catch you.
 They are not on a mission to find something wrong.
 They are SEEKING EVIDENCE OF COMPLIANCE to elements of performance and
standards.
 They are in search to document evidence of quality processes and to assess for
variation to process and to identify system issues.

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 CBAHI Questions

Essential Safety Requirements

Q: How does the credentialing and privileging process work at KAMC?
A:
 Medical staff are credentialed by the KAMC Credentialing and Privileging Committee.
(Refer to Credentialing, Privileging and Promotions Policy [CPP-001]).
 Initial privileges include a 3 month probationary period, and full privileges are
granted at the recommendation of the Department Head and endorsed by the
Hospital/Center/Director.
 Privileges are reviewed every 2 years and granted at the recommendation of the
Department’s Head.

Q: How will you access the clinical privileges of the medical staff?

A: We have it in our electronic system; we go to dropbox then locate folder "KAMC medical
staff privileges"

Q. What will you do if the physician is not privileged to do the procedure?

A: Stop the physician and inform that he or she has no privilege to do such procedure. Refer
to the consultant.

Q: Where are medical staff responsibilities defined?

A:
 Medical staff structure and responsibilities are incorporated into Medical
Services Policies or Bylaws.
 Documentation requirements are addressed in the Documentation Policy.
 Each member of the medical staff is responsible for reading, understanding and
implementing the responsibilities outlined in these policies which are available in
the KAMC drop-box, CEO Approved Policies Folder.

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Q: Do your qualifications match the requirements of the department where you are
working?
A:
 Yes. Screening begins during the recruitment process, including interviews, evidence
of medical education and experience.
 The credentialing and privileging process validates education, experience,
additional skills and training.
** The process of blood transfusion**

Q; who is requesting?

A: Only the physician is allowed.

Q: Elements of blood transfusion request

A: Description of the transfusion process, identification of the risks and benefits of

transfusion, identification of alternatives including consequences of refusing the treatment,
giving opportunity to ask questions, giving the right to accept or refuse the transfusion,
physician is responsible in obtaining the consent

Q: Frequency of monitoring

A: According to policy HTC-001,

 Check the vital signs and record it accordingly:
 Prior to transfusion.
 Every 15 minutes during the first hour.
 Every 30 minutes during the 2nd hour.
 Then hourly.
 At completion of the transfusion
 Transfusion in operation room will be checked as above or as needed per clinical
situation.

Q: Process to be followed if there is transfusion reaction

A: According to policy HTC-002,

 Stop the transfusion; remove blood unit bag and administration set. Keep Intra
Venous (IV) line and run normal saline
 check vital signs,
 inform the physician immediately,
 check for clerical error,
 maintain good urine output,
 for hypotension: consider administration of dopamine

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  Send Blood bank transfusion reaction workup samples: ABO and Rh-D type, direct
anti globulin test (DAT), antibody screening and identification and blood unit bag
with tag attached along with the administration set.
 To note, blood bank may call for more samples as required,
 inform blood bank immediately,
 fill the blood transfusion reaction form,
 initiate OVAR
Q: When do you assess patients for Venous Thromboembolism (VTE)

A: According to our policy Venous Thromboembolism Prophylaxis Guideline (VTEP-001), all

patients must be assessed and evaluated on admission or within 24 hours of admission to
KAMC

Q: When do you reassess patients for Venous Thromboembolism (VTE)

A: According to our policy Venous Thromboembolism Prophylaxis Guideline (VTEP-001), when

there are changes in patient's condition we must re-assess the patient for VTE

Q: what tool do you use for assessing medical patient for VTE

A: We are using Padua VTE prediction Score

Q: what tool do you use for assessing surgical patient for VTE

A: We are using CAPRINI VTE Risk Score

Q: How do you start VTE treatment to your patient?

A: Follow guidelines outlined in the policy, VTEP-001 Venous Thromboembolism Prophylaxis

Guideline.
: As for nurses: Follow the physician order written in the patient file

Q: What is the proper patient identification process?

A:
 Refer to Patient Identification Policy (PSG-001)
 Two patient identifiers (MRN and Patients verbalization of Full Name composed of
four digits)

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Q: When do you use two (2) unique identifiers of patient?

A: (2) unique patient identifier (MRN & Pt. Name) are used when:
 Administering medications
 Administering blood and blood products
 Taking blood samples
 Taking other samples for clinical testing
 Providing treatment or procedure

Q: Who are privileged to administer moderate sedation?

A: According to policy moderate and deep sedation/analgesia (AD-005) only anesthesiologist,

ICU Physicians, emergency physicians (at least assistant or associate consultant) are
privileged to administer the sedation

Q: What discharge criteria do you use for patients who had sedation?

A: PACU: Modified Aldrete Scoring System (12/12): Oxygen Saturation, Respiration, Color,
Circulation, Conscious Level, and Activity. The patient shall be discharge if total reached 10
or more.

Q: What is time out?

A: Also known as surgical pause, it is when everyone in the team involved in a procedure
pause to do the final verification of the patient.

Q: What are the components of time out?

A: During the time-out, the team members agree on the correct patient identity, the correct
procedure to be performed, the correct site, and when applicable, the availability of the
correct implant or equipment

Q: How do you ensure correct procedure to the correct patient?

A: By properly identifying the patient thru MRN and complete four names, by rechecking the
consent, and checking the pre-op checklist and finally by doing time out.

Q: What is your criteria for doing site marking?

A: Site marking is done when the organ/body part to be operated is bilateral, multi-structural
like fingers or multi-level like the spine

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Q: Who is the only allowed staff to do the site marking?

A: The performing surgeon is the only staff allowed to do the site marking

Q: Where is site marking done?

A: Arrow like sign is drawn in the patient's skin at the inpatient unit or the day care surgery
unit

Q: Where are your medical gases, and who turns these off in case of fire?

A: Our medical gases are wall-mounted. In case of fire, the charge nurse or head nurse can
turn these off.

Q: How will you know if your negative pressure room is working?

A: According to our policy, the accepted range of pressure inside must be less than -2.5,
temperature is 21*C to 24*C for patient room and 18*C to 22*C for OR, humidity is 30%-
60%

Q: How frequent are you monitoring the airflow in the negative pressure room?

A: According to our policy, it must be daily

Q: What is MSDS and where it is available?

A: MSDS is material safety data sheet and it is available in all areas where chemicals are
existing.

Q: Where do you store your chemical spill kits and how frequent are you replacing its
contents?

A: It is stored in an easily accessible location and should be restocked following use and the
contents should be checked in monthly basis

Q: How do you promote safety of high alert medications?

A: By storing the medications in a locked storage room, proper labeling of high alert
medications, and by doing independent double checking by nurse upon administering the
medication

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Q: Are you aware about high alert or medications?

 List of approved medications is available

 All high alert medications are labeled with special label in the pharmacy and patient
care areas.
 High alert medications required triple check before dispensing, refer to High Alert
Medication policy (PHD-004).

Q: How do you ensure safety of look-alike and sound-alike medications?

A: By following the TALLman and shortMAN method of labeling, and by independent double-
checking by the nurses upon administration.

Q: What is a Near Miss?

A: According to Occurrence/Variance/Accident Reporting Policy (QMD-004) describes that

Near Miss is an event or situation that could have resulted in an accident, injury or illness,
but did not, either by chance or through timely intervention.

Q: What is a Sentinel Event?

A: According to Sentinel Event and Root Cause Analysis Policy (QMD-007), Sentinel event is
an unanticipated occurrence involving death or major permanent loss of function unrelated
to the natural course of the patient's illness or underlying condition. They are events that
require an immediate response from the hospital with root cause analysis and
recommendations to prevent future occurrences.

Q: Why reporting incidents is important?

A: To determine unusual events which can affect the clients of KAMC and to help the
management levels to take appropriate decisions to prevent or minimize risks or harms.

Q: How do you report events/incidents in the hospital?

A: We have electronic OVAR system, which we utilize according to policy QMD-004,

Occurrence/Variance/Accident Reporting Policy

Q: When are you supposed to report an incident?

A: According to Occurrence/Variance/Accident Reporting Policy (QMD-004), we must report

incidents immediately

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Q: What is your role in case of fire?

A: Rescue the patient, activate the alarm, confine the fire, extinguish the fire and evacuate
the patient (RACE)

Q: How do you extinguish the fire?

A: Pull the pin, Aim at the base of the fire, Squeeze the handle/lever, sweep from side to side
(PASS)

Q: What are the types of fire extinguishers that you have in the hospital?

A: We have ABC powder, Carbon Dioxide and FM200

Q: What are the two types of evacuation?

A: We have vertical and horizontal evacuation. In horizontal evacuation command is coming

from the charge nurse, head nurse or the safety office while the vertical evacuation,
command is coming from the CEO

Q: Where is the nearest: Emergency Exit? Fire extinguisher? Eyewash station? Evacuation
Map?

 Inform the surveyor about the locations of at least two Emergency Exits, show the
evacuation maps or the eyewash station if available in the unit.
 If you do not know, ask your LIAISON SAFETY OFFICER.

Q: What procedures do you follow in case of a chemical spill?

A: According to our Hazardous Materials and Waste Management Plan (GSC-009),

 Identify the chemical before attempting to clean up any hazardous chemical spill or
splash.
 Obtain MSDS on chemical. Follow the directions according to the established
procedures for cleaning up that kind of chemical spill or leak.
 Notify people in the immediate area, supervisor and Safety Officer.
 Activate CODE ORANGE + Location of the spill by dialing 16666.
 Evacuate all personnel from the area and close all doors.
 Ensure adequate ventilation.
 If a fire occurs, set off the fire alarm and extinguish flames.
 Wait by the spill area, well out of danger, until help arrives. Avoid tracking through
the spill.
 Obtain appropriate personal protective equipment. (See MSDS)
 Complete incidents report on spill or leak.

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Q: What procedures do you follow in case of a cytotoxic spill?

A: According to our Cytotoxic Agents Spill Management Policy (ONC-003),

 Secure the area; alert other staff that chemotherapy spill has occurred. Move family,
sitters, etc., far from the area. If possible, move patient away from spill area.
 Obtain chemotherapy “spill kit”.
 Put on all protective apparel in the spill kit. If no spill kit is available, all protective
apparel can be gathered individually.
 Place cytotoxic plastic bags one inside the other to provide double thickness. Turn
the tops of the bags outward to form “cuff”.
 Carefully pick up any broken glass using scoop provided and place inside sharps
container.
 Estimate the spilled amount of chemotherapy for possible replacement.
 Using absorbent paper towels begin containing spill moving from the outside of the
spill to the inside. Continue until area is dry.
 Place soiled paper towels and other contaminated items into the cytotoxic plastic
bag.
 Cover spill area with a blue absorbent pad.
 Remove outer pair of gloves and place inside double yellow plastic bags then remove
gown and other protective apparel and place in bag. Close the inner bag while still
wearing the last pair of gloves. Remove the remaining inner pair of gloves; dispose
them in the orange bag. Wear disposable gloves and close the last plastic bag.
 Place hands outside of double cytotoxic plastic bags under “cuff” and close and tie
bag.
 Place closed bag in dirty utility room.
 Wash hands according to Hand Hygiene Policy (as per IC-010).
 Notify Housekeeping that final cleanup of chemotherapy spill area is required.
 Notify pharmacy if additional dose of chemotherapy is needed.
 Initiate Occurrence/Variance/Accident Report (as per QMD-004).

Q: From where can you obtain information about safe handling and chemicals used in your
area?

A: Information can be obtained through Material Safety Data Sheet (MSDS), which explains
the safe handling and storage of chemical used in the unit or department.

Q: What is your role during an Internal / External Emergency/Disaster?

A: According to KAMC Internal and External Disaster Plans,

My role being a physician/nurse/technician/support service staff is ………..
(Kindly refer to the plan and identify your role in KAMC External Disaster Plan (GSC-014)
and KAMC Internal Disaster Plan (GSC-015) ACTION CARDS).

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Q: What do you do in case a patient locked bathroom's door and fainted inside?

A: There is a mechanism by which bathroom doors can be opened from outside (you might
be asked to show how).

Q: Where should you keep flammable materials?

A: Inside Safety Cabinets

Q: What is the voltage rating for KAMC?

A: 220 volts

Q: What are the types of isolation precautions do you know?

A: Types of isolation are

 Droplet Precautions
 Airborne Precautions
 Contact Precautions

Q: What are the components of standard precautions?

A: According to Standards precautions policy (IC-011), components of standard precautions

include:
 Hand hygiene
 Personal protective equipment as per need
 Equipment disinfection/sterilization.
 Proper sharps disposal
 Safe injection practices
 Proper disposal linen and wastes.
 Patient Placement
 Healthcare workers immunization.
 Environmental Control
 Cough etiquette and Respiratory Hygiene

Q: When do you implement standard precautions?

A: According to standard Precaution Policy (IC-010), all healthcare workers will practice
standard precautions in any setting where healthcare is delivered regardless of patients’
health condition.

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Q: What are the transmission- based precautions?

A: These are precautions applied based on method of transmissions of the organisms and can
be classified as follows:
 Contact precautions organisms transmitted by contact such as MRSA.
 Droplets precautions for droplets transmitted diseases like influenza
 Air-born precautions for air-born transmitted diseases like Pulmonary tuberculosis

Q: What do you mean by Contact Precautions?

A: Contact precautions means to prevent organisms and infection transmitted by touch

including:
 Keeping patient in single room or cohort with other patients with same organism
 Keeping contact precautions signage outside on the room door
 Wearing gown and gloves when contacting patients
 Posting “Contact Precaution” signage in the patients room door/entrance.
Examples:
MRSA, VRE, C. difficile, draining wounds

Q: What do you mean by Droplets Precautions?

A: Droplet precautions means precautions taken to prevent infections transmitted by droplets

within three (3) feet distance, including;
 Keeping patient in single room or cohort with other patients with same organism
 Keeping droplets precautions signage outside on the room door
 Wearing surgical mask if close to the patient within three feet (1 meter) distance.
 Applying the above with standard precautions
Examples:
Influenza, Meningococcal meningitis

Q: What do you mean by Air-borne precautions?

A: Air-borne precautions means a precaution to prevent infection transmitted by air

including;
 Keeping patient in Negative pressure room
 Keeping Air-born precautions signage outside on the room door
 Wearing N95 mask before entering the room
 Applying the above with standard precautions
Examples:
Open pulmonary TB, Chicken pox, Measles

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Q: What will you do if you get needle stick injury?

 I will wash the injury site with soap and water

 Stop the bleeding by covering the injury site
 I will write O.V.A. Report and submit to my supervisor.
 I will go to infection control department for recommendations.
 I will go after that to staff clinic during working hour or ER outside the working hours,
receive any necessary medications, and have serology tests done.

Q: Can you tell me how to prevent needle stick injury?

 I should be very careful during use of sharp.

 I will keep the sharp box close to me during procedures.
 I will dispose the sharp needle along with the attached syringe immediately as one
piece in the sharps box and will not recap or give it to somebody to dispose it.
 I will keep the sharp box within the reach of my hand.
 I will not walk with the sharps in my hand.

Q: When will you change the sharp box/container?

A: When the sharp container is 2/3 full according to our policy.

OTHER POSSIBLE QUESTIONS RELATED TO OTHER

STANDARDS/CHAPTERS

Q: How are patients accepted for admission or outpatient care at KAMC? What are the
eligibility criteria?

A: Based on patients identified needs and KAMC mission and resources. Acceptance for
care at KAMC is criteria based. Refer to Patient Eligibility Criteria (PAD-003), Admission,
Discharge, Transfer Policy (ACC-001), Patient Registration (PAD-001)

Q: Is there a type of patient that you would not admit to KAMC?

A: Patients whose identified needs cannot be met at KAMC are not accepted for
admissions at KAMC based on KAMC mission and resources. Refer to Patient Eligibility
Criteria (PAD-003),

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Q: What are the assessments and tests required before admitting patients to KAMC?

A: Assessments and tests required before admitting patients are based on the patient's
identified medical and nursing needs and the service specific requirement (Refer to
Interdisciplinary Assessment and Re-Assessment Policy (AOP-001) and Admission,
Discharge and Transfer Policy [ACC-001]).

Q: How are patients prioritized for care at ED KAMC?

A: Patients with emergent, urgent and immediate needs are given priority for
assessment, treatment and admission.
Refer to ED Triage Policy (ED-001), the triage process is evidence based. Patients are
prioritized based on urgency of their needs and managed accordingly.

Q: What information is provided to patients and families upon admission to KAMC?

A: Patients and families are provided information on the proposed care, expected
outcome of that care and any expected cost to the patient for care.
Refer to Admission, Discharge and Transfer Policy (ACC-001), patient information
booklet and Rights and Responsibilities of Patients and Family Policy.

Q: What are the barriers to access to care and delivery of services at KAMC? How are those
barriers managed and overcome?

A: Language barrier is the most common barrier occurring in terms of access to care and
delivery of services. However, KAMC - Patient Services Management provides social
services and translation for patients with language barriers according to
Communications with Patients-Visitor with Special Needs Policy (ACC-004).

Q: What criteria are used to admit and transfer patients to and from Intensive and Special
Care Units?

A: Intensive and special care units have admission, transfer and discharge criteria as per
Admission and Discharge in ICU (CCC-007) and CCU Admission and Discharge Criteria
Policy (CC-CD-001). Criteria are physiologically based. (Refer to individual unit criteria)

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Q: How do you find out who is the attending consultant responsible for the care of the
patient?

A: All patients admitted to KAMC are admitted under the care of an attending consultant.
The attending consultant is responsible for the care of the patient. The patient is
informed of his attending consultant. This can also be checked through our medica plus
system and the patient medical records.

Q: How are patients managed in the ED when there is no bed available on the desired
service or unit or elsewhere at KAMC?

A: If there is no vacant bed in the hospital for the emergency case, patients are held for
observation and treatment in ED until a bed is available or stabilized for transfer to
another institution. (Refer to Observation of Patient held in Emergency Department-
ACC 009)

Q: How are patients informed of delays or waiting periods for diagnostic or treatment
services?

A: Patients are informed when there are long waiting periods for diagnostic and/or
treatment services and the process of placement in waiting lists.
Patients are informed of the reasons for delays and are provided with information on
available alternative CONSISTENT with the clinical needs and this is documented in the
patient's record. Refer to Admission, Discharge, Transfer Policy (ACC-001)

Q: How is continuity of care ensured after discharge/transfer?

A: Discharge planning starts soon after admission to KAMC, Discharge planning begins
early in the care process and involves the family. Patients are referred and/or
discharged based on their health status and needs for continuity of care. The patient's
readiness for discharge is determined by the use of relevant criteria to ensure patient
safety. Discharge/transfer planning process considers the patient's need for social,
nutritional, financial, psychological and other support upon discharge/transfer. Refer to
ACC-010- Multidisciplinary Discharge Planning

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Q: What are the follow up instructions given to the patient/family upon discharge to ensure
safety and continuity of care?

A: Patients and their families or caregivers are provided with understandable FOLLOW UP
Instructions. The instructions include any return for follow up care, when to obtain
urgent care, instructions for care as necessary to the patient's condition. (Refer to
Discharge Summary)

Q: How do you manage and follow up patients who leave against medical advice?

A: When inpatients or outpatients choose to leave the hospital against medical advice, the
risks related to inadequate treatment that may result in harm on death are fully explained
to the patient and family. The primary consultant, the primary care or referring physician,
and the patient relation personnel are involved in the process of discussing further of the
risks and benefits of patient well-being. In addition, discharge medications and discharge
summary is given to the patient (Refer to Discharge Against Medical Advice Policy [ACC-
003].

Q: When and how are patients transferred to other institutions?

A: Patients are transferred to other institutions based on status and the need to meet their
continuing care needs. The staff, equipment and supplies needed for safe transfer are
identified. To ensure that the receiving institution can meet the patient's continuing care
needs. The patient clinical information or a clinical summary is transferred with the
patient. The summary includes patient status procedures and other interventions
provided and the patient's continuing care needs. Refer to Admission, Discharge and
Transfer policy ACC-001

Q: Tell me about the process of patient's transfer and transport?

A: During transfer, a qualified staff member monitors the patient's condition.

Depending on patient condition, patient may need continuous nursing or medical
oversight. The patient condition and status determines the appropriate qualification of
the staff monitoring the patient during transfer. The transfer process is documented in
the patient's record (Refer Admission, Discharge and Transfer Policy ACC-001 and Refer
to (EMS 001-EMS workflow and Ambulance Transport Process)

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Q: What is the timeframe for initial assessment?

A: The initial medical assessments are completed within 24hours and nursing i n i t i a l
a s s e s s m e n t a r e c o m p l e t e d w i t h i n 1 2 h o u r s after the patient's
admissions as inpatients or earlier as indicated by the patient condition and policy.
The initial medical assessment is documented before anesthesia or surgical treatment.
The medical assessment of surgical patients is documented before surgery. Medical,
Nursing, Nutritional and functional assessments are completed as part of the initial
assessment. All inpatients and outpatients are screened for pain and assessed when pain
is presented. When pain is identified from the initial screening, the patient is
referred for a comprehensive assessment. Additional, specialized assessments are
performed for specified needs patient population. Reassessments are conducted and
documented in the patient's records:
 At regular intervals, during the care of patients.
 Daily for acute care patients
 In response to significant change in patient's condition.

Q: How is multidisciplinary care integrated and coordinated at KAMC?

A: MRP shall overview the plan of care of all healthcare providers including physician, nurses
and others. MRP shall review this initial and ongoing plan of care and document the review
on (MRP –CONSULTANT PLAN OF CARE REVIEW FORM)

Q: When does patient's pain must be re-assessed

A: Refer to Pain assessment and management policy COP-006

Q: How are patients approaching the end of life cared for at KAMC?

A: Palliative care is provided, appropriate treatment of symptom according to the wishes

of the patient and family. The patient and family are involved in all aspects of care.
(Refer to End of Life Care Policy [COP-004])

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Q: Are patients with emergency or immediate needs given priority for assessment and
treatment?

A: Yes.
 The Emergency Department uses the Triage System (Canadian Triage and Acuity
Scale) which Categorizes physiological symptoms the patient presents with on 1-5
triage score.
 Prioritization of patient care in these areas is based on these established criteria.
(Refer to Triage Policy [ED-001])

Q: Are assessments from outside facilities accepted in KAMC?

A: No.
KAMC policy requires that all patients transferred from other facilities be
reassessed when presenting to KAMC facilities for treatment. (Refer to
Interdisciplinary Assessment and Reassessment Policy [AOP-001])

Q: Have all patients been assessed for skin integrity and how can this be identified?

A:
 Refer to Pressure Ulcer Prevention and Management Policy (COP-007)
 All patients shall be assesses as to their risk of developing pressure ulcers using the
Braden risk assessment tool on admission, transfer in, and with any deterioration of
condition.

Q: When you go on vacation, how do you hand over your patients?

A: I inform my patients of the name of the clinician who will be caring for them when I am
on vacation.
 I also write a summary in the record of the patient’s condition, what care
the patient has received, the responses to the care received and what the
plan of care currently entails.
 I also document the transfer of care to the named clinician in the
record. (Refer to Patient Care Responsibility Assignment and Transfer Policy
[ACC-007])

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Q: How is patient care integrated and coordinated in KAMC?

A:
 All staff members involved with the delivery of patient care use the patient’s
record to document and review the patient’s current treatment, assessments, test
results coordinating care with other health care workers.
 The I n t e r d i s c i p l i n a r y Progress Notes i s one of the tools u s e d t o coordinate
patient care delivery.
(Refer to Patient Care Planning Policy [COP-001], Patient Health Documentation Policy
[MRC-001]

Q: Are patients at risk identified and competent staff assigned to provide their care? Give
examples.

A: Yes.
 Staff providing care to patients receiving conscious sedation, chemotherapy,
intensive care and other specialized care such as the operating room receive
specialized training and maintain competencies based on the needs of the area
where they are assigned.
 Additionally, all inpatients are assessed for falls risk, and appropriate
interventions are applied based on that risk. (Refer to policy)

Q: How do you deal with patients deteriorated in the wards?

A: Refer to Policy COP-009 – Rapid Response Team

Q: How do you ensure the patient's right to confidentiality?

A:
 Expect that information, communication and other records pertaining to care
including the source of payment for treatment are to be treated as confidential.
 Discussions or consultations involving the patient’s case conducted discreetly.
 Discussing and performing care only in the presence of the patient or in the
presence of others only after permission by the patient.
 Never discuss with a patient what treatment another patient is receiving.
 Patients should never be discussed in hallways, the cafeteria, on elevators or in
other public areas.
 Restricted Access to Patient’s File and Ensuring all patient-related information is
safeguarded.
 Refraining from discussing patient information publicly or at home.

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  Keeping electronic and paper medical records and patient data secure at all times.
 All patient information should be accessed on a need to know basis, whether
the information is accessed by computer, paper or spoken word.
 Knocking before entering the room.
 To be transported to their scheduled procedure in a proper and respectful way
(Covering our patients during transport).
 Privacy curtains pulled, doors shut during treatment and care
(Refer to Rights and Responsibilities of Patients and Family Policy [PRRD-002])

Q: What is your Role in providing Patient/Family Education?

A: There is comprehensive patient and family education provided by care givers

(giving appropriate information about illness and possible complications, hand
washing technique, treatment and possible surgical procedures, use of equipment, pre-
operative preparations and post-operative care, proper use of post-operative
medications, x-ray procedures, dietary restrictions, when to seek medical
assistance, and follow up appointment).
(Refer to Interdisciplinary Patient and Family Education [PFE-001])

Q: When are your patients' learning needs assessed?

A: Learning needs are assessed as part of the admission assessment and each time the
patient’s condition or needs change.

Q: Where do you document patient teaching?

A:
 Interdisciplinary Patient and Family Education Policy (PFE-001) describes a process
that will provide accurate and complete information with regard to patient
assessment, barriers to learning, specific interventions and continued educational
needs.
 Educational documentation is documented in Interdisciplinary Patient and Family
Education Record Form

Q: What tools can be used for patient education?

A:
 One‐to‐one individual sessions with a health care provider through verbal and/or
written information, and demonstrations based on the assessment.
 Lectures and/or seminars and group therapy designed to increase the knowledge‐
base of Patient/family and the general population.
 The Patient and Family Education department provides pamphlets, and other
printed materials along with direct patient educational sessions.

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 (Refer to Interdisciplinary Patient and Family Education Policy (PFE-001) Policy)

Q: What is the proper patient identification process?

A:
 Refer to Patient Identification Policy (PSG-001)
 Two patient identifiers (MRN and Patients verbalization of Full Name composed of
four digits)

Q: When do you STRICTLY use two (2) unique identifiers of patient?

A: Use two (2) unique patient identifier (MRN & Pt. Name) is used when:
 Administering medications
 Administering blood and blood products
 Taking blood samples
 Taking other samples for clinical testing
 Providing treatment or procedure

Q: How are patients at risk of falls identified?

A:
 Refer to Falls Prevention and Management (PSG-006)
 All patients are to be assessed as to their risk of falling on admission, transfer in, with
change in condition and post a fall using the approve age appropriate risk
assessment tool (e.g. Morse Fall Scale) and every shift.
 Adult patients identified as at risk are to wear a PURPLE patient identification band
having and fall stickers on patient's chart.
 Take action to decrease or eliminate any identified risks.

Q: Quality Improvement and Patient Safety (QPS)

A:
 QPS processes provide the framework for the organization and its leaders to
achieve a commitment to provide quality patient care in a safe, well-managed
environment and reduce risk to patients, staff and visitors.
(Refer to Quality Management and Patient Safety Plan; KAMC Risk
Management Plan; Occurrence Variance Accident Report Policy)

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Q: What are indicators used for?

A:
 To track improvement activities
 To measure day-to-day operation
 To provide strategic directions
 To compare performance to an established norm (e.g. benchmarking)
 To reflect achievement of positive outcomes.

Q: How do you receive communication about changes in the organization?

A: Depending on the type of change in the organization, communication can be

provided through:
 The Communications from CEO and Management through the chain of command
 Committee minutes and reports
 Electronic e-mail notices
 Posters
 Presentations
 Direct verbal communications

Q: How do you access your departmental KPIs?

A: QPA Dashboard on 'Dropbox" then proceed to KPI folder and search for your
departments' folder for the list your key performance indicators

Q: What are the hospital wide quality and patient safety priority in KAMC?

A: Refer to patient safety committee portfolio (PSC-003) and Quality Management and
Patient Safety Program (QPA-011)

Q: Do you know what model KAMC uses for Quality Improvement?

A: KAMC is using the FOCUS-PDCA improvement model.

F : find an opportunity for improvement
O : organize a team work
C : clarify the current process
U : understand the problem
S : select the desired outcome
This focus requires the chosen process to go through the (Plan – Do – Check – Act) cycle
in order to bring about an improvement.

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Q: How are KAMC staff involves in Quality Improvement?

A:
 All KAMC staff are involved in quality improvement through various activities such as:
KAMC Quality Workshops and Lectures, KAMC Standing Committees in each chapter,
education awareness lecture, KAMC grand round lectures, IPSG campaign.

Q: How are clinicians involved in Quality Improvement?

A:
 Clinicians perform peer review activities and audits.
 Each department monitors important aspects of care, analyzes the data and reports
findings on a quarterly basis to the KAMC QM Department where they are
aggregated and shared with Medical Management.
 Members of key committees also participate in QI activities by their ongoing analysis
of data provided to the committee for action.

Q: What type of PI projects is your Department involved in?

A:
 (Educate yourself with the Performance Improvement Projects (PI) occurring in your
Department)
 Each Department and services has a PI projects identified by the related Quality
Improvement Committee. Use the KAMC PI form and you should be able to inform
why that project was chosen.
Examples: Prevention patients' falls, Prevention of pressure ulcers, Medication errors,
Triage in Emergency Department and Documentation in the Medical Records.

Q: What is KAMC policy on Informed Consent?

A: According to KAMC Patient Consent for Diagnosis, Treatment and Intervention policy
(LAD-001), it is a process in which the physician; qualified credentialed to perform the
treatment or procedure; provides adequate information for the patient or patient's legal
representatives to make an informed decision on the proposed treatment, including
medications or procedure.

Consent states patients have a moral, legal and ethical entitlement to be fully informed
regarding the risks, benefits, alternatives and options of treatment to certain types of
procedures as well as the consequences of not doing that procedure.

Consent must be obtained from a patient, legal guardian or authorized person in behalf
of the patient(should the patient be unable to give consent) for all treatments,
procedures/ interventions on one of the following consent forms:
 General Consent

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  Blood Product Transfusion Consent
 Surgical and Medical Interventional Consent
 Anesthesia and Sedation Consent
 Chemotherapy Administration Consent
 Photography/ Videotaping Consent
 Informed consent must be signed and witnessed using the appropriate consent
form.
 For procedures listed in the policy specifically including blood and chemotherapy
administration.
(Refer to policy)

Q: What's the process for ordering and monitoring restraint?

A: Complete order must be written in patient's file before restraining the patient. The
order must be renewed every 12 hours. Nurses monitor the patient every hour for any
blood circulation issues related to restraint. The restraint must be released every two
hours for 15 minutes when the situation permits. Refer to Use of Restraint Policy COP-003

Q: What is the physician's signature time frame for verbal and telephone order in KAMC?

A: For verbal orders, it is only done through emergency and the physician must sign the
order before leaving the unit or after the situation ends. For telephone orders, the
physician must sign the order within 24 hours. Refer to Verbal and Telephone Order
Policy PSG-002

Q: What is the process for receiving telephone orders?

A: Write the complete order, read back to the physician, and sign with a witness. Refer to
Verbal and Telephone Order Policy PSG-002

Q: How do you deal with critical rest results reported by the laboratory technician?

A: We utilize the critical test result form and receive the results with a witness and
verifying all the information including the technician's name and ID and the result. The
result must be relayed to the physician in no more than five minutes and actions must be
taken as per physician's order. Refer to critical result reporting policy PSG-008

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