1. Some Important Tips for JCI Survey

2. Common Questions & Explanation

3. Very Important To know
Their achievement is critical to full compliance with the JCI standards.
Any failing goals is consider a failing in JCI ACCREDITATION.

4. 1-What is the process of identifying patient? & when it must be used ?

5. Patient is identified (Hospital ID band).
before any treatment, collection of samples, blood transfusion, drug administration, diagnostic test or procedure is conducted

6. Patient’s complete Name, Hospital ID Number, National ID card/Iqama
Patient’s Full Name: Refers to the patient’s name to the Third Level.

7. For infant/ child:
Identification should be carried out by two hospital staff using identification information available in the Medical Records

8. Important: In the event identification band is lost
it must be reported as ‘Incident Report’ to prevent using the lost band in infant/child abduction.

9. IPSG.1 Identify Patient’s Safety:

10. 2-What is process for Telephone/Verbal Orders and when receiving Critical Values Result?

11. 1-Verbal Order:
limited to urgent situations where immediate written/ electronic communication is not feasible.

12. Verbal/ Telephone Order: will not be accepted for:
Physical restraints, Starting Patient Controlled Analgesia (PCA),
Starting Narcotic/ Scheduled medications, Initiating TPN therapy
Category of care (Code status), Withdrawal of life support, Chemotherapy.

13. Critical Test Reporting (Laboratory & Radiology):
‘Write Down, Read-Back, Confirm/Verify’

14. For Telephone Orders, responsible physicians requires to sign order within (24 ) h.

15. For Verbal Orders, physicians require signing order after situation is over Or before physician leave the area.

16. Handovers: See hospital wide Handover Form, used for communicating critical content between health care providers during handovers of patient care.

17. IPSG.2 Improve Effective Communication:

18. 3-What is your process to ensure safe identification, storage, preparation and dispensing of High Alert Medications (HAM)?

19. The hospital has a list of all high-alert medications, including look-alike / sound- alike medications that is developed from hospital-specific data.
Look-alike and Sound-Alike (LASA) medications are recommended to have Tall Man letters over the medication storage

20. Examples:
EPINEPHrine and EPHEDrine VinBLASTIN” and “VinCRISTINE.

21. All high alert medication shall be stored in a secured cabinets and clearly labelled.

22. Concentrated electrolytes are stored ONLY in areas that requires it with appropriate labelling.

23. - Storage bins for HAM based on its strengths shall be segregated.

24. It is the responsibility of MRP to prescribe medications within the approved formulary that includes orders and prescribing HAM.

25. Verbal orders for HAM are only allowed during Emergency or Life threatening situation

26. HAM orders must be double checked during preparation & before administration.

27. IPSG.3 Improve the Safety of High-Alert Medications (HAM):

28. 4-When does the Time-out conducted?

29. TEAM TIME OUT- applied to some procedures /first skin incision performed for paediatric patients:

30. All activities should be STOPPED and all members of the surgical/procedural team must fully participate in the TIME-OUT

31. Confirms all members are present and attentive.
Addresses the following standard information:
-Correct patient identity
-Correct type of procedure to be performed
-Correct procedure site has been marked (if applicable)
-Availability of correct equipment for the procedure.
Correct and appropriate documents and diagnostic images are available.
Any attending staff can identifies anticipated critical events

32. IPSG.4 Ensure Correct-Site, Correct Procedure, Correct Patient Surgery:

33. What is the process in your department to reduce HAI’s?
-You must be familiar with (MCWP Hand-Hygiene)

34. - You must be familiar with (5-Moments of Hand Hygiene)
Before touching a patient.
Before a procedure.
After a procedure or body fluids exposure risk.
After touching a patient.
After touching a patient surroundings

36. - You may be asked to demonstrate how to do:
1- Hand Rub Procedure.
2- Hand Wash and Hand Disinfection Procedure

39. • IPSG.5 Reduce the Risk of Health Care-Associated Infections:

40. 6-When is fall risk assessment/reassessment conducted ?

41. ASSESSMENT:
Upon patient admission in the unit.

42. REASSESSMENT:
Transfer of patient from one unit to another within the facility
Any changes in patients status/condition
Following a fall

43. -Patient initial fall risk nursing assessment performed Within (3) hours of admission using
the ‘Humpty Dumpty Fall Scale’ and
re-assessment daily or with any changes.

44. - Score is: Low Risk –
Activate low risk prevention protocol by nursing.

45. Score 12 and above is: High Risk –
Activate high risk prevention protocol by nursing

46. For Paediatric in-patients ages 3 months to 14 y/o,
Identified as high risk of fall:
Will be fitted with yellow ID printed with “FALL RISK” and a Humpty Dumpty to be placed outside the patient’s active medical file.

47. - For Neonates and/or Infants ages 0 to 3 months, Identified as high risk of fall:
Must have a
Humpty Dumpty sticker to be placed outside the patient’s active medical file and a
Humpty Dumpty poster placed at the bedside.

48. For Out-patient & ED:
Nursing Screening for fall risk, and if parameters are positive will receive a full risk assessment.
Use of assistive device i.e. Gait unstable, Poor balance and Focuses on apparent need.
Patient Re-assessment at each visit.

49. After a Fall What is Physician’s Role?:
1- Assess level of injury and treat any resulting problem.
2- Initiate diagnostic& treatment interventions for contributing intrinsic & extrinsic causes
3- Document post-fall assessment and treatment.
4-Find out probable cause of fall, such as history, physical factors, medications, and laboratory values.
5-Refer patient to appropriate services if needed.

50. Important:
All events of patients fall: An ‘Incident Report’ must be completed.

51. IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls:

52. International Patient Safety Goals (IPSG)
“Very ImportantTo know”
Their achievement is critical to full compliance with the JCI standards.
Any failing goals is consider a failing in JCI ACCREDITATION.