Performance Manager
PACE - Patient Care/Patient Safety - Starting FY'07
  Service:
  Building/Floor:
  Department/Division:
  Name:
  Type of Survey
  Date:
  If your survey shows that you are challenge free in an area, you need to answer only the bolded question for that section (there are 7 sections to the PACE Patient/Process Tracer Survey). Please write all comments at the end of the survey.  
  4. Health Care Quality- Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
PR1 Patient information is prominetly displayed in all patient waiting areas or provided at the bedside.
PR2 Learning materials displayed and easily accessed by patients and families.
PR3 Patient related discussions are conducted in private settings and not overheard by others.
PR4 Patient physical privacy is respected.
PR5 Patient information that needs to be disposed of is put in recycling bins or hand shredded
PR6 Charts in racks/vital sheets covered.
PR7 Computers are signed off when not in use.
PR8 Are patient records, sign-in sheets, faxes, etc., never in public view or left unattended for long periods of time.
PR9 If a white board uses a patient's name, the diagnosis info is coded.
PR10 If a white board uses diagnosis info, only patient initials given.
PR20 Out of date reference materials are removed from common use and work area
PR21 Medical record storage areas are locked
PR22 Patient records or information is attended by staff in public areas
  Comments:
  Patient/ Process Tracer Questionnaire  
  5. Staff Training and Orientation- Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
  Number of Staff Interviewed: 1-3 4-6 7-9
PT1 Staff can describe orientation provided to orient staff to BIDMC and where policies can be found
PT2 Staff can describe how they were oriented to job/area upon hire
PT3 Staff can describe the(annual)competency/continuing education offered on the job
PT4 Staff can describe age specific competency training they have received
PT5 Staff can describe off-site training they attended during the year
PT6 Staff can describe training required to maintain specific license or certification, etc.
PT7 Staff can describe how they are instructed in the use of new equipment
  6. Emergency Response & Security- Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
PT8 Staff are familiar with their role in Emergency Response and their work area's security
PT9 Staff know location of oxygen shut-off valve and understand when to use.
PT10 Staff know what to do if a suspicious person is observed in their area
PT11 Staff know how to report broken furniture/equipment
PT12 Staff know what to do if a vistor fell or was injured in the area
  7. Patient Rights-Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
PT13 Staff demonstate a clear understanding of patient privacy and dignity
PT14 Staff understand not to share patient specific info to non-staff/ clinicians not directly involved in the patient's care
PT15 Staff understand how Patients Rights apply to sharing patient specific info with family members
PT16 Staff understand rules applying to allowing photo/video to be taken during patient care
PT17 Staff understand under what circumstances restraint is used for patient care
PT18 Staff can describe when patient consent must be obtained
PT19 Staff are clear as how to ensure rights of a patient with disabilities (blind, hearing impaired, non-English speaking)
PT21 Staff know what to do when a patient refuses a treatment
PT22 Staff know what to do when a patient doesn't want a certain type of food
PT23 Staff know what to do when a patient doesn't want care from a particular provider
  8. Medication Management - Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
PT24 Staff can describe how they are trained on the proper management of medications
PT25 Medications are stored in a secure area
PT26 Patient is screened for herbal and nutritional supplement use
PT27 Staff know where provided patient education/materials regarding medications are stored
PT28 Staff can describe how and when medications can be given to patients
PT29 Staff can describe how they perform 24-hour medication reconcillation and documentation in the MAR
PT30 Staff nurses bring the MAR to the bedside to administer medications
PT31 Staff are familiar with the locations of all emergency medications
PT32 Staff know how to check if code cart medications are ok to use
PT33 Staff know what to do if an error was made in medication administration
PT34 Staff know how to document patient response to medications
PT35 Staff know the proper procedures for handling a patient who has developed severe reaction to a medication or unknown cause
  9. Assessment/ Care of Patients- Challenge Free:

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
PT36 Staff can describe how patients are assessed upon entry/admission to or exit/discharge from the unit (provide comments if not Yes/No)
PT37 Staff can describe how patients are assessed upon entry to the area for (1) pain (2) nutitional needs (3) functional/ADL needs (4) abuse/neglect (5) educational needs (6) medications (7) allergies
PT38 Staff can describe how an interdisciplinary care priorites/plan has been developed
PT39 Staff can describe how patients are involved in their own care decisions
PT40 Staff can describe how consults are requested and followed-up
PT41 Staff can describe how patient and family members are involved in discharge planning
PT42 Staff can describe how instruction and education is given to patient at discharge
PT43 Staff can identify any high risk or special request information that comes with patients from admission
PT44 Staff are able to determine if a patient has advance directive or Health Care Proxy
PT45 Staff are able to determine if a patient was a DNR status
PT46 Staff are able to describe the significant changes (triggers) in patient condition to relay to care providers
  Comments:
  10. Patient Safety Goals-Challenge Free:

Observe staff performing the following tasks to assess.

If no, please identify area(s) of challenge and provide detail at the end of this section:
Yes No Not Completed
PS1 Staff are observed using at least two patient identifiers, such as name and unit number or name and date of birth to identify patients reliably.
PS2 Staff are observed asking patients to state their identifiers ("What is your name?")rather than asking Yes/No questions ("You're Jane Doe?")
PS3 All inpatients and all outpatients undergoing conscious sedation or invasive procedures are wearing BIDMC identification bands
PS4 Nurses: When taking telephone reports of critical lab results, nurses write down name, unit number, and result and read back the information for confirmation
PS5 Unit coordinators: When taking telephone reports of critical lab results, unit coordinators write down name, unit number, and result in the critical lab result notebook and read back the information for verification
PS6 When receiving verbal orders, nurses write down the name and order, read back the information, and ask the physician for verification
PS7 Staff do not use prohibited abbreviations in any clinical documentation
PS8 Staff use a pre-operative (or pre-procedure) verification checklist to confirm that appropriate documents (e.g. patient identification, site marking, final time out) have been performed
PS9 Staff use a process to mark the surgical (or procedure) site and involve the patient in marking process.
PS10 Prior to the start of any surgical or invasive procedure, staff conduct a final verication "time out"
PS11 Staff know what a free-flow error is (the rapid infusion of IV medication caused by unchecked, gravity-induced flow)
PS12 Staff know how to prevent a free-flow error
PS13 Staff can identify all clinical alarms that might be heard on a unit
PS14 Staff understand exactly who is to respond to each alarm
PS15 Response to alarms is rapid
PS16 Alarms are clearly audible in all areas of the unit, including break rooms, conference rooms, etc.
PS17 Cal-Stat dispensers (wall mounted or free standing) are located in convenient areas where staff are likely to use them before and after patient contact
PS18 Cal-Stat dispensers are reliably filled and in good working order
PS19 Staff use Cal-Stat or soap and water berofre and after every patient encounter
PS20 Staff who have direct and indirect* clinical contact with patients do not wear artifical nails
PS21 Staff who have direct and indirect* contact with patient keep fingernails trimmed 1/8 inch or less beyond the fingertip
  *Providers of direct patient care are those who would touch patients in the course of providing care. Providers of indirect patient care are those who would touch critical items that would come in contact with patient. Critical items include but are not limited to medications, IV solutions, blood products, and instruments/equipment for sterilization and disinfection  
PS24 Patient who have been assessed as at risk to fall are easily identified
PS25 For patients found to be 'at risk' for falls: interventions and plans of care are communicated among providers
PR15 Patient bed alarms are in use
PR16 Patient call bell is accessible
PR17 Patient bed rails are up and secure when patient is unattended
PS26 Staff can describe methods tools and processes used during hand off communication
PS27 Hand off communication content is accurate and contains up to date information regarding patient care, treatment and services, condition and any recent or anticipated changes
PS28 Emergent and non emergent admixtures are prepared only by pharmacy staff in a sterile environment
PS29 Labeling of solution concentrations and drug per mL are clear to all caregivers and the solution concentration is clearly indicated on the label
PS30 Staff are aware of look alike/sound alike drugs and have access to reference list
PS31 All medications/solutions removed from original packaging to another container are properly labeled
PS32 All labeled medications are verified both verabally and visually by 2 qualified individuals
PS33 Staff can describe the process for medication reconciliation from previous provider of service -- reconciliation must occur anytime orders are rewritten and anytime the patient changes service, setting, provider or level of care and new medication orders are written
PS34 Staff can describe how patients are actively involved in their own care as a patient safety strategy.
PT20 Staff know what to do when a patient wants to file a complaint
PS35 Patients at risk for suicide are properly assessed. (Applicable only to those patients being treated for emotional or behavioral disorders in hospital setting)
PS36 When patients have been identified to be at risk for safety, interventions and information is shared among care providers.
  Comments:
          



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