Prince Sultan Cardiac Center

Nursing Department

JCI and CBAHI

Accreditation
How to Face the Surveyors
Nursing CQI&PS

Prepared and Compiled by Nursing CQI&PS

31 October 2020
 Prince Sultan Cardiac Centre
Nursing Department

TABLE OF CONTENTS
Dos and Don’ts: Survey Tips Page 2
The International Patient Safety Goals (IPSG) Page 3
The Essential Safety Requirements (ESR) Page 4
Frequently asked questions on JCI & CBAHI Page 5 - 25

1| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

Survey Tips
 Always wear your ID badge, greet the  Don’t panic or try to hide from the
surveyors and introduce yourself surveyors

 Ask the surveyor to rephrase the question if  Don’t rush to answer. Take your time.
you are unsure or do not understand.

 If you do not know the answer – Tell them  DO NOT guess – Tell surveyor that you
you will refer to someone who knows, such will show them the information by
as your Charge Nurse / Head Nurse referring to e.g. policies or by asking
your CN/HN for assistance.
 “I have an answer to your question, but to  DO NOT Say – “I don’t know” or “I am
make sure, I can refer you to my CN/HN” not sure”

 Keep your answers FOCUSED and SPECIFIC  DO NOT give more information than
- If they ask for explanation / examples, you what is being asked for
should respond with what you know - if the question requires ONLY a
“YES/NO” answer – DO NOT
according to our PSCC policies.
volunteer further explanation
 Show surveyor we have a unified approach  Do not begin an answer with the words
to care by answering: “According to our “Usually”, “Most of the time” or
Policy…..” “Sometimes” when asked questions
regarding processes or procedures
 Keep the conversation professional  DO NOT BLAME or COMPLAIN about
others or other departments
 DO NOT discuss your personal issues /
problems
 Acknowledge any Non-conformance(s)  NEVER Argue with the surveyors. Tell
 When describing your job, BE POSITIVE the surveyor that the finding is noted
about it because it is your system, show and that you are committed to
pride as a professional continuously improve your services
guided by the standards and policies.

 Be prepared to show SPECIFIC and  DO NOT SHOW any documents, policies,

UPDATED documents, policies, guidelines guidelines or manual that are outdated
or manual or expired.
 You must know how to access and locate  DO NOT show you are Hesitant re where
Documents, Policies/Guidelines, Manuals, to access Documents,
Privileges through the PSCC Portal Policies/Guidelines. Manuals, Privleges

2| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

3| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

HR. 5 The hospital has a process for proper credentialing of staff members
licensed to provide patient care
MS. 7 Medical staff members have current delineated clinical privileges
PC. 25 Policies and procedures guide the handling, use and administration of
Blood and Blood Products
PC. 26 Patient at risk for developing venous thromboembolism (VTE) are identified
and managed

QM. 17 The hospital has a process to ensure correct identification of patients

QM. 18 The hospital has a process to prevent wrong patient, wrong site, and wrong
surgery / procedure
AN. 2 Anaesthesia staff members have the appropriate qualifications
AN. 15 Qualified staff perform moderate and deep sedation / analgesia
IPC. 4 There is a designated multidisciplinary committee that provides oversight
of the infection prevention and control program

IPC. 15 Facility design and available supplies support isolation practices

MM. 5 The hospital has a system for the safety of High-Alert Medications (HAM)
MM. 6 The hospital has a system for the safety of Look-alike and sound-alike
(LASA) medications
MM. 41 The hospital has a process for monitoring, identifying and reporting
significant medication errors, including near misses, hazardous conditions,
and at risk behaviors that have the potential to cause patient harm

LB. 51 The blood bank develops a process to prevent disease transmission by

blood / platelet transfusion
FMS. 9 The hospital ensures that all its occupants are safe from radiation hazards
FMS. 21 The hospital has an effective fire alarm system
FMS. 22 The hospital has a fire suppression system available in the required area(s)
FMS. 23 There are fire exits that are properly located in the hospital
FMS. 24 The hospital and its occupants are safe from fire and smoke
FMS. 32 The hospital ensures proper maintenance of the medical gas system

4| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

5| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

IPSG 1 Identify Patient Correctly

ESR The hospital has a process to ensure correct identification of

QM. 17 patients
No Question Answer
01 How do you identify your patient Using 2 unique identifiers
1- Full name to the 3rd level
2- MRN

Patient/[aren’t/carer must be
ACTIVELY INVOLVED in the process of
patient identification

IPSG 2 Improve Effective Communication

No Question Answer
02 When can the physician use Verbal or Verbal Order
Telephone orders? - Sterile procedure
- During Emergency

Note: The physician must countersign

The Verbal Order before leaving the
area

Telephone Order
- Urgent situation where
immediate written or
electronic communication
is not feasible.

Note: The physician must countersign

the Telephone Order within 24 hours

03 How do you receive Verbal/Telephone Write Down – Read Back – Confirm

order from physician?

04 In which situation will Verbal/Telephone 1- Restraints

orders not be acceptable? 2- DNR
3- Narcotic or scheduled
medication
4- TPN

6| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department
05 How do you receive a critical result Write down – read back – verify
through telephone?

06 What do you document upon receiving 1- Full name & MRN

the critical test result? 2- Type of specimen & test
3- Date & time specimen
collection
4- Name of ordering physician
5- The critical result (s)
6- Name of Lab Technician
phoning the result

07 What do you do if you received the Contact the 1st on-call

critical test result after office hours? physician
↓
If no response within 5
minutes, contact the 2nd on-
call.
↓
If no response within 5
minutes, contact the 3rd on-
call.
↓
If no response within 5
minutes, Consultant should be
notified.

*If any on-call physicians fail to

respond to a call, document and
submit an Incident Report.

08 What tool is used in clinical handover? ISBAR

7| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

IPSG 3 Improve the Safety of High Alert Medications

ESR The hospital has a system for the safety of High-Alert

MM. 5 Medications (HAM)

No Question Answer
09 What are High Alert Medications (HAM)? HAM is a medication involved in a
high percentage of errors and/or
sentinel events, risk for abuse or
other adverse outcomes.

10 Can you give examples of HAM? *P-I-N-C-H

Guide surveyor to the approved list of

HAM that is updated annually by P&T
Committee

11 What is Independent Double Checking? 2 Registered nurses Separately Check

(alone and apart from each other,
then compare results) each
component of prescribing, dispensing
and verifying the medication before
preparing & administering to the
patient.

12 How do you store HAM? 1- In a secure room with lock

2- Red Bin
3- Standardized HAM label
13 What is the beyond used date (BUD) for 28 days
multi-dose vials medication?

ESR The hospital has a system for the safety of Look-alike and Sound-
MM. 6 alike (LASA) medications

No Question Answer
14 What are LASA Medications? Medication with Generic and Brand
Names that look or sound alike other
medication names, which may lead to
potentially harmful medication
errors.
15 Can you give examples of LASA Guide surveyor to the approved list of
medications? LASA Medications that is updated
annually by P&T Committee

8| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department
16 How do you know the prescription of 1- Written legibly & clearly
LASA Medication is correct / complete? 2- Using both Generic & Brand
Names
3- Include Medication’s
indication for use
17 How do you store LASA Medications in 1- Use Tall Man Lettering
your unit? 2- Stored in YELLOW BINS. If
yellow bin is not available,
YELLOW STICKER attached to
the storage area.
3- Labelled with auxiliary labels
that state LASA
4- Stored separately from their
pair (e.g. DOPamine/
DOBUTtamine)

ESR The hospital has a process for monitoring, identifying and

MM. 41 reporting significant medication errors, including near misses,
JCI hazardous conditions, and at-risk behaviours that have the
MMU.7.1 potential to cause patient harm

No Question Answer
18 What is Medication Error? Any preventable event that may
cause or lead to inappropriate
medication use or patient harm.

19 What is a Near Miss? Event that could have resulted in

unwanted consequences but did not
reach to the patient because of
timely intervention.

20 What is a Sentinel Event? An error that reaches a patient

resulting in any of the following:
1. Death
2. Permanent Harm
3. Severe Temporary Harm

21 How do you report Medication Errors and Incident Report Form

Near Miss?

22 What is a hazardous situation? Any condition which may lead to a

medication error such as confusion
over look-alike/sound-alike drugs or
similar packaging or using of
prohibited abbreviations

9| JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department
23 What will you do if a patient experiences 1- Stop the medication
an adverse drug reaction (ADR)? 2- Notify physician immediately
3- Assess patient
4- Complete ADR Form and ADR
alert slip within 24hrs
5- Incident Report

IPSG 4 Ensure Safe Surgery

ESR The hospital has a process to prevent wrong patient, wrong site,
QM. 18 and wrong surgery / procedure

No Question Answer
24 How can we ensure Correct-site, 1- Verification
Correct-Procedure, and Correct-patient 2- Site marking
Surgery? 3- Time Out
(OR)

25 Does your unit perform any invasive Time Out

procedures? If yes, what process will be
performed prior to the start of the
invasive procedure?
(Non-Operating Room)

26 What are the components of TIME OUT?  Correct patient identity

 Correct procedure to be
performed
 Correct site if applicable.
 Availability of
equipment/devices/implants

27 What are the indications of doing site  Bilateral (left or right)

marking?  Multi-structural (Fingers/toes)
 Multi-level (spine)

28 Who is allowed to do the site-marking?  Physician performing the

procedure

29 What is the mark for site-marking in  Upward Arrow ()

PSCC?

10 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

IPSG 5 Reduce the Risk of Health Care-Associated Infections

ESR - IPC.4 There is a designated multidisciplinary committee that

JCI - PCI.2 provides oversight of the infection prevention and control
IPSG 5 program
ESR - IPC.15 Facility design and available supplies support isolation
JCI - PCI.7 practices
No Question Answer

30 Do you have a Policies and Procedures Yes, we do have.

for Infection Control?
Show the Infection Control Manual
at Nurses Counter.

31 What are the types of Isolation you  Airborne precautions

know?  Droplet precautions
 Contact precautions
32 Do you have signage or posters indicating Yes. We have specific signage
the types of Isolation a patient is indicated for each type of Isolation
admitted to? Precautions as follows:

Airborne Isolation Yellow

Droplet Isolation Blue

Contact Isolation Red

33 What TYPES of infections require 1. Measles

AIRBORNE PRECAUTIONS? 2. Varicella (Chicken Pox)
3. Pulmonary TB
34 Where you should place a patient with an Airborne Infection Isolation Room
AIRBORNE INFECTION? (AIIR)

35 What is the acceptable pressure for an Minimum Negative (-) 2.5 pa

AIIR?

36 What will you do if the AIIR negative 1- Inform HVAC technician

pressure is out of range? 2- Arrange for transfer of patient
to another functional AIIR
3- If another AIIR is not available,
HEPA filter is used

11 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department
37 How many Air Exchanges per Hour At Least 12 Air Exchanges per Hour
(ACH)? (ACH)

38 What are the required Personal - N95 Mask

Protective Equipment (PPE) to be used
when entering a patient room under - Powered Air Purifying
Airborne Precautions? Respirators (PAPR) must be
used by staff who failed the
N95 Fit Test or who have
Demonstration on how to use N95 mask
beard/facial hair

39 How many times can you re-use your N95 Up to 5 times if manufacturer does
mask? not provide recommendation

40 How do you don (wear) your PPE? Sequence of Donning PPE:

1- Gown
2- Mask or Respirator
3- Googles or Face Shield
4- Gloves

41 How do you doff (remove) your PPE? Sequence of Doffing PPE:

1- Gloves
2- Googles or Face Shield
3- Gown
4- Mask or Respirator

Note: Hand Hygiene must be done

after each step if hands are
contaminated and Immediately after
removing all PPE

42 What is the most effective method for Hand Hygiene

prevention of infection transmission in
hospitals?

43 What are the INDICATIONS of Hand Five (5) Moments of Hand Hygiene
Hygiene?
1. Before touching the patient
2. Before clean/aseptic
procedures
Note: May refer the poster if needed
3. After touching the patient
4. After body fluid exposure
5. After touching patient
surroundings
12 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

44 What are the methods of hand hygiene? 1- Hand Washing using soap and
water
2- Alcohol Based Hand Rub
45 How long should you perform hand Hand Washing – 40-60 sec
hygiene?
Alcohol Hand Rub – 20-30 sec until
Perform Hand Washing & Alcohol Based the alcohol is dry
Hand Rub

46 When should you do Hand Washing? When hands are VISIBLY SOILED.

47 What will you do if you get a needle stick As per the policy, we should
injury? immediately:

1- Wash the needle stick injury

and cut with soap and water
2- Apply alcohol 70%
3- Bandage
4- Report the needle stick injury
to Head Nurse
5- Complete an incident report
6- Attend preventive medicine
during office hours
7- Attend ED after office hours,
weekend and National
Holidays
Note: Report the exposure within 24
hours of the incident for risk
assessment of the exposed staff and
prophylaxis where indicated

48 How do you dispose of waste?

We have a waste segregation (separation) scheme.
Black Plastic Bag General Hospital Waste
Yellow Plastic Bag/Yellow Container Infectious Waste
with Biohazard Label
Orange Plastic Bag/Orange Container Chemotherapy Waste
with Biohazard Label
Red Plastic Bag with Biohazard Label Pathological Waste
(Human body parts, Tissues or
Organs)
Sharp Containers with Biohazard Needles and sharp objects
Label

13 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department
49 When will you change the sharps When the sharps container is 3/4 full
container?

50 Is your unit informed regarding the rate Yes.

of Hospital Acquired Infections (HAI)?
Show the HAI results such as CLABSI,
Key Performance Indicators Results? CAUTI, VAP,VAE, MDRO

Show the KPIs such as Hand Hygiene

Compliance

51 Do you recycle SINGLE-USE items or No

devices?

IPSG 6 Reduce the Risk of Patient Harm Resulting From Falls

No Question Answer
52 What are the tools used to determine the Adult – Morse Fall Scale
risk of fall? Paediatric – Humpty Dumpty

53 When do you do your fall risk 1- Every shift

reassessment? 2- Changes of condition
3- Following a transfer from one
unit to another within facility
4- Following a fall

54 How do you identify which patient is at  Yellow ‘Fall Risk’ ID band

HIGH risk for fall?  High Fall Risk” stickers are
displayed on patient’s active
folder

 Paediatric: ‘Fall Risk’ ID band

 Humpty Dumpty label on
active folder and bedside

14 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

ESR- HR. 5 The hospital has a process for proper credentialing of staff
JCI-SQE. 13 members licensed to provide patient care

No Question Answer
55 What is Credentialing/Primary Source Credentialing is the process of
Verification (PSV)? obtaining, verifying and assessing the
qualifications of a healthcare
professional to determine if that
individual can provide patient care
services for the organization.

PSV for all newly hired staff (from

January 2016 onwards)

CBAHI HR. 6-7 New employees go through a General Hospital Orientation

Program + Departmental and Job Orientation before
JCI - SQE.7
allowed to work independently

No Question Answer
56 Do you have new employees in the unit? 1. Hospital Wide Orientation
(Less than 1 year)
If Yes - FMS
- Infection control
Interview new employee - HR
- MMRU
 What orientation program did you - Security
receive? - CQI&PS
 How were you oriented to your 2. Departmental Orientation
job? (General Nursing Orientation)

- Manual handling
- PI Prevention
- Medication calculations
- Care delivery system
- Introduction to JCI/CBAHI
3. Unit-specific / Job-specific
Orientation

- Introduction to unit
- Ward routine
- Unit specific
competencies

15 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

CBAHI - HR. 8- The hospital has a process for initial evaluation of the
9 competency and conduct of the new employees + Regular
evaluation of staff performance
JCI - SQE.2

No Question Answer
57 How many types of evaluation do you Two (2)
have in the hospital?
1. Probationary Period Evaluation
2. Annual/Re-contracting
Evaluation

ESR - MS. 7 Medical staff members have current delineated clinical

JCI - privileges
SQE.10

No Question Answer
58 How will you access the clinical privileges Staff must be aware on how to access
of the medical staff? the physician Medical Privileges:

1- PSCC Portal
2- Medical Privileges
3- Select the appropriate folder
4- Select the physician name

59 What will you do if the physician is not Stop the Physician and advise that
privileged to do the procedure? he/she is not privileged to do such
procedure and refer to the
Consultant

CBAHI – QM 4 Quality Improvement Program

JCI – QPS 2

No Question Answer
60 Does your unit collect any data for your Study well your KPI folder and
unit specific KPIs? compliance.

61 What is the methodology used for F-O-C-U-S PDCA

Quality Improvement (QI) Projects in
PSCC?

16 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

CBAHI – MOI 9 System Downtime

JCI – MOI 14

No Question Answer
62 What are the procedures during system Manual Records should be used
downtime? during system downtime

CBAHI – LB 18 Laboratory Services- Turn Around Time

JCI – AOP 5

No Question Answer
63 Do you have Laboratory Manual as To show Laboratory Manual
reference for blood sample Turn Around *Staff to know the location of the
Time? manual

17 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

JCI Assessment of Patient (AOP)

ESRJCI Patient
Careatofrisk for developing
Patient (COP) venous thromboembolism (VTE)
26 are identified
PC.CBAHI Provision and managed
of Care (PC)

No Question Answer
64 When do you assess patients for VTE? The admitting physician MUST assess
all Adult Inpatients for risk of VTE
within 24 hours of admission

(Not applicable for patient <18 years old)

65 When do you reassess patients for VTE? The admitting physician must
reassess when there are changes in
patient’s condition

ESR - PC. 25 Policies and procedures guide the handling, use and
JCI - COP. 3.3 administration of Blood and Blood Products

ESR - LB. 51 The blood bank develops a process to prevent disease

JCI- AOP. 5.11 transmission by blood / platelet transfusion

No Question Answer
66 Who can request or order blood and blood Only Physician
products?
67 What is the validity of a Group & Save or 90 hours
Cross-match sample?
68 Explain the process of obtaining cross- Two (2) staff verifies patient identity
match sample? prior to drawing blood sample and
cross-match wristband applied.
69 What measures do nurses take to prevent  Start blood transfusion within
bacteria proliferation in the blood 30mins of blood unit removal from
products? blood refrigerator
 Maximum time of transfusion is
4hrs
 Special transport box with cool
pack

70 What are the elements of an informed  The physician will secure a written
consent for blood transfusion? consent for transfusion from
patient/family after explaining the
(Document check) following elements:
 Transfusion process
18 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department
 Risk & benefits
 Consequences of refusing
 Their right to accept or
refuse
 The right to ask questions
71 What is the validity of the consent for  Valid throughout the patient’s
blood and blood products? admission
72 How frequent do you monitor your Every 15mins for the first 1/2 hour.
patient’s vital signs during blood Then Hourly until 1hr post-transfusion
transfusion?
73 What will you do in the event of blood 1. Stop the infusion immediately.
transfusion reaction? 2. Flush the IV cannula and keep
the vein open with 0.9% Normal
saline
3. Check the patient’s vital signs
4. Verify all documentation to
make sure the correct unit was
given to the correct patient
5. Notify the MRP and the Blood
Bank immediately
6. Transfusion Reaction
Investigation Form should be
completed by the person who
witnessed the reaction and
signed by Attending Physician
7. Send the following together
with the Transfusion Reaction
Form to Blood Bank:
i. The unit causing the
reaction with the whole
administration set still
attached
ii. 7mls EDTA crossmatch
sample for adult and
minimum of 2mls for
infant or small child.
iii. Urine sample
8. Initiate an Incident Report

19 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

 Restraints  CPR
 Abuse and Neglect  Pain Management
No Question Answer
74 Who orders patient restraint? PHYSICIAN

75 How are restraint orders made? WRITTEN - strictly NO VERBAL or

TELEPHONE order.

76 How frequent do you assess a patient HOURLY and as appropriate

who is being restrained?
77 What is the validity of a restraint order? 24 hours

78 What are the types of restraint? 1. Mechanical

2. Chemical
3. Physical

79 How frequently do you check the Crash Every shift

Cart?

80 Demonstration of Crash Cart checking 1. Defib battery (UNPLUG the

cord)
2. Oxygen tank
3. Suction machine
4. Ambu bag and reservoirs
5. Lock number
6. Drug calculations chart
7. Sharps box
8. ETT for neonate, paediatric
and adult

81 What type of patient is considered as 1. Terminally ill

vulnerable patient? 2. Elderly and frail
3. Neonate and infant
4. Paediatric patients
5. Adolescent patients (12-18
years old)
6. Comatose
Note: Staff must know how to access the 7. Immuno-compromised
policy 8. Disabled individuals (with
limited physical mobility,
impaired mental function,
learning disability)
9. Suspected case of
abuse/neglect

82 How do you report a case of suspected 1- Inform physician

abuse/neglect?

20 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department
2- Physician report to Domestic
Violence and Neglect
Note: Staff must know how to access the Protection Centre in PSMMC
policy 3- Reporting cases during and
after working hours (call
centre number please refer
to the flowchart provided)

83  Comprehensive Pain Assessment Ensure staff complete:

and management
 Frequency of pain reassessment 1- Pain assessment
 Items included in pain assessment 2- Reassessment form
(intensity, type, duration, 3- Multidisciplinary Patient &
frequency, location and progress) Family Education

(Document check)

ESR - AN. 2 Anaesthesia staff members have the appropriate

JCI - ASC.2 qualifications

ESR - AN. Qualified staff perform moderate and deep sedation /

15 analgesia
JCI -
ASC.3.1

 These question are for procedural sedation areas

No Question Answer
84 Do you assist in any procedure requiring Yes.
conscious sedation (mod-deep sedation)?

85 Are you qualified to do so? Yes.

86 What qualifications are required if you 1- Sedation Course +

are involved in mod/deep sedation? competency
2- Certified ACLS or PALS

 For Physician (Anaesthetist)

– staff must know how to
access the medical privileges

21 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

ESR - The hospital ensures that all its occupants are safe from
FMS. 9 radiation hazards

No Question Answer
87 Checking for safe from radiation hazards 1- Radioactive materials are
clearly labelled and safely
stored
2- Lead aprons are available to
cover patient and staff needs
3- Personal radiation dosimeters
(TLD card) are available and
tested every 3 months

ESR-FMS. 21 The hospital has an effective fire alarm system

JCI- FMS.7

No Question Answer
88 Do you know where the nearest fire Show surveyor the location of the
alarm system is? nearest fire alarm system

*All staff must know all fire alarm

systems in the unit

ESR-FMS. 22 The hospital has a fire suppression system available in the

JCI- FMS.7 required area(s)
No Question Answer
89 What will you do in case of fire? R - Rescue
A - Alarm
C - Contain
E - Extinguish/Evacuate

90 How do you use Fire Extinguisher? P - Pull the pin

A - Aim at the base of fire
S - Squeeze the lever
S - Sweep side to side

91 Do you know the location of:

*All staff must know the location of
- Fire extinguisher these in the unit
- Stand pipes and hose
- Evacuation plan
22 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

ESR-FMS. 23 There are fire exits that are properly located in the
JCI- FMS. 7 hospital

No Question Answer
92 How many fire exit doors in your unit? Staff must be aware of the fire exits.
Do you know the location of your nearest
fire exit? *Please make sure all fire exits are not
BLOCKED or LOCKED (lock released on
alarm)

ESR - FMS. 24 The hospital and its occupants are safe from fire and smoke
ESR – FMS. 32 The hospital ensures proper maintenance of the medical
gas system
JCI- FMS. 7

No Question Answer
93 How are storage areas properly and 1. Shelves and racks are sturdy
safely organized? and in good condition.
2. No items are stored directly
on the floor
3. Items should be stacked on a
flat base
4. Heavier objects are close to
the floor and lighter/small
objects are higher
5. Items are not stacked so high
to prevent it from blocking
the sprinklers
6. Stock must be maintained:

 18 inches (45cm) from the

ceiling level
 10 inches (25cm) from the
floor
 2 inches (5cm) from the wall

94 Who is responsible for shutting off the Head Nurse / Charge Nurse
oxygen valve in case of fire? After office hours: Shift in-charge

95 Where is the Oxygen Shutdown Valve  Staff must be aware of the

located? Oxygen Shutdown Valve
location

23 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

CBAHI-FMS 14 Ensure safe management of Hazardous Materials

JCI- FMS 5

No Question Answer
96 What is MSDS and where is it available Material Safety Data Sheet (MSDS)
contains information for the safe
handling and storage of hazardous
chemicals used in the unit

97 What does an MSDS tell you  Identification

 Hazard(s) Identification
 Composition/Information on
Note: You may refer to the MSDS folder Ingredients
 First-Aid Measures
 Handling and Storage
 Exposure Controls/Personal
Protection
 Stability and Reactivity

98 NFPA diamond

The National Fire Protection

Association (NFPA) developed a
hazard identification system for
emergency responders.

The NFPA diamond provides a quick

visual representation of the health
hazard, flammability, reactivity, and
special hazards that a chemical may
exposed during a fire

99 Where can you find biohazard spill kit? Show surveyor the biohazard spill
kit

24 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS
 Prince Sultan Cardiac Centre
Nursing Department

CBAHI-FMS. 26 Medical Equipment Management Program

JCI- FMS. 8

No Question Answer
100 What to do if medical equipment is Should not be used.
overdue for PPM? Should be sent to Clinical Engineering
for PPM

CBAHI-FMS. 8 Safety and Security

JCI- FMS. 4

No Question Answer
101 What to do if a patient fainted inside the Staff should say that the locks of
bathroom and the door is locked? patient bathrooms are designed in a
way that can be opened from
outside.

102 Staff should be aware of the location of Eyewash station

these: Fire blanket

CBAHI-FMS. 16 Disaster Preparedness

JCI- FMS. 6
No Question Answer
What is the Emergency Code?
Dial Code Emergency
444 Blue Cardiac Arrest
555 Red Fire
555 Orange Major Chemical/ Biological/
Radioactive Spillage
555 Pink Abduction/Missing Child
43333 White Combative Abuse
43333 Silver Active Shooter
43333 Black Bomb Threat
Overhead Tannoy Yellow External/Internal Disaster King Khalid
International Airport
Overhead Tannoy Amber Mass Casualty Receiving Hospital
Overhead Tannoy Gray Severe Weather
Overhead Tannoy Brown Utility System Failure

25 | JCI and CBAHI Accreditation – How to Face the Surveyors – 31 October 2020
Nursing CQI&PS