University Of Rochester Medical Center -Strong Memorial Hospital Nursing Practice – Office Methods, Procedures and Quality Control
JCAHO Readiness Job Action Card Date:
Page 1 of _ Position:
Immediate:
0-60 Mins.
Intermediate:
60-120 Mins.
Extended:
>120 Mins.
(until end of survey)
Job Action Cards(s) are to be shared with staff and used as a tool during unit/hospital drills.
Developed: DATE Revised: DATE
Figure 3. Blank Format
Assoc Director Nursing Support Operations/Assist Coord Nursing M P & QC Page 2 of 2 Intermediate:
60-120 Mins. Oversee Nursing Practice response to survey needs in concert with Chief Nursing Officer Extended:
>120 Mins.
(until end of survey)
- Participate in tracer activity
- Complete status reports to communication with managers throughout survey University Of Rochester Medical Center - Strong Memorial Hospital - Nursing Practice
JCAHO Readiness Job Action Card Date: 1/07
Page 1 of 2
Position: Associate Director Nursing Support Operations/Assistant Coordinator Nursing Methods Procedures & QC Immediate:
0-60 Mins.
1) a. Assign Nursing Escort(s) to Surveyor(s) in concert with Chief Nursing Officer – e.g.:
SURVEYOR NURSING ESCORTS
Nurse Doctor Admin.
Environmental Ambulatory Psychiatry
b. Disseminate Phone/Pager Lists(s) to Nursing Escorts and office secretaries
2) In concert with Director’s Office arrange for a meeting at the end of each day for Nursing Practice leadership for NPEC and Nursing Escorts for reporting
3) Keep track of trends identified by all Escorts (collect information/survey issues)
E-Mail Nurse Managers/Nursing Leadership at end of each day e.g. key issues, areas, findings 4) Assign office secretary to monitor Nursing Practice sign-in sheet
5) Remind Escorts to send staff names to Laurie Felice (Coordinator of Nursing Education) or designee and Nicole Grodis (Administrator, Time Management and Records) for potential personnel record review
6) Disseminate Administrative Phone/Pager List to Escorts
It is the responsibility of the Department Head/Supervisor to review content and notify the Office of Methods, Procedures and Quality Control with any corrections if needed.
Nursing Job Action Card(s) are to be shared with staff, used as a tool during unit/hospital drills and or survey.
Developed: 8/06 Revised: 1/07 ©2006 Nursing Support Operations
List names of nursing personnel that will serve as escorts
Figure 4. Associate Director Card
Figure
University Of Rochester Medical Center - Strong Memorial Hospital - Nursing Practice
JCAHO Readiness Job Action Card Date: 1/07
Page 1 of 2
Position: PATIENT UNIT SECRETARY
Immediate:
0-60 Mins.
Wear ID badge with name visible and if greeting survey team direct them immediately to Nurse Manager/Charge Nurse (NM/CN)
Review all patient’s charts:
o Assemble chart for any newly admitted patient
o Check printers and fax for any orders, lab reports, etc. and file in the patient’s medical record o Put all discharged patient’s records in “Discharge Pickup Spot”
(Be sure there is a plan to review each patient’s record daily.)
Additional readiness tasks as assigned by NM/CN
Check all computer screens for privacy screen – notify NM/CN if any are missing
Check desk area and assure there is:
o No Clutter
o No open patient records
o No forms/lists with patient information visible
Be prepared to discuss (if asked by surveyor):
o How long you have worked at SMH and on the unit
o Describe the length/content of your orientation and what educational opportunities you have participated in the past year
Intermediate:
60-120 Mins.
Report Status to NM/CN for each patient.
Page members of Health Care Team as directed by NM/CN
Call in staff as directed by NM/CN
It is the responsibility of the Department Head/Supervisor to review content and notify the Office of Methods, Procedures and Quality Control with any corrections if needed.
Nursing Job Action Card(s) are to be shared with staff, used as a tool during unit/hospital drills and or survey.
Developed: 8/06 Revised: 1/07 ©2006 Nursing Support Operations
Patient Unit Secretary Page 2 of 2 Extended:
>120 Mins.
(until end of survey)
Recheck all of above each day of survey
If a patient is picked for a tracer:
Assist staff nurse in gathering all components of patient’s medical record:
o Current and thinned record (Call Medical Records X52602 if needed for thinned records) o All Nursing documentation forms (from bedside binders etc.)
o Care planning; Interdisciplinary rounds documentation forms
Figure 5. Patient Unit Secretary Card
University Of Rochester Medical Center -Strong Memorial Hospital – Nursing Practice
JCAHO Readiness Job Action Card Date: 1/07
Page 1 of 2 Position: NURSE MANAGER/DESIGNEE (Inpatient)
Immediate:
0-60 Mins.
Alert all staff and assure all staff are wearing ID badge with their name visible
Distribute job action cards to [Staff RN(s), PCT(s), Safety Nurse], Patient Unit Secretaries
Assess need for extra staff and arrange for staff to be called in Nurse Manager/Charge Nurse (NM/CN):
Assigns unit staff to immediately review all charts for:
1. Nursing Admission History/Risk Screens completed within 24 hours and referrals made/responded to as indicated 2. Care planning forms completed
o Staff need to be able to describe interdisciplinary care on the unit 3. Patient teaching record completed and up-to-date (No blanks on forms) 4. Restraint documentation completed and up-to-date (No blanks on forms) 5. Pain – assessment and reassessment documentation is complete
6. Transfer forms complete, if applicable
(Be sure there is a plan to review each patient’s record daily)
Assign staff to complete all tasks on unit specific job action cards and assign additional tasks to staff as appropriate
NM/CN identifies surveyor escorts (and/or back-up people) to greet surveyor when they appear on unit and instruct them to direct Survey Team to NM/CN
Prepare for Tracers by:
o Notifying Medical Director and Team
It is the responsibility of the Department Head/Supervisor to review content and notify the Office of Methods, Procedures and Quality Control with any corrections if needed.
Nursing Job Action Card(s) are to be shared with staff, used as a tool during unit/hospital drills and or survey.
Developed: 8/06
Revised: 1/07 ©2006 Nursing Support Operations
Nurse Manager Page 2 of 2
Gather or complete the following
o Staffing book with current staff plan o Competency grid
o Personnel records
o Unit specific education materials, competencies, etc.
Work with facilities to complete any repair(s)/replacement(s) needed (e.g. soiled ceiling tiles, broken doors) and general cleaning up of units (e.g. nothing on floor, no under sink storage, storage is 18” from ceiling sprinklers in room, secure O2
tanks, etc.) Intermediate:
60-120 Mins.
Report status of unit to Associate Director of Nursing
Assure there is follow-up/someone assigned to complete and/or monitor all tasks on unit job action cards
Unit Safety Nurse/Designee, Staff Nurse and/or PCTs
Staff Nurse (Documentation Focus)
Patient Unit Secretary
Remind staff to be prepared to discuss patient care planning/delivery on their assigned patients if selected for a tracer
Staff should be prepared to speak with surveyors and respond to questions – regarding how they use 2 patient identifiers and other national safety goals. How long they have been employed, describe unit orientation and what education have they had in past year.
Extended:
>120 Mins.
(until end of survey)
Recheck all of above each day of survey
Contact other disciplines/departments as indicated to correct all areas of non compliance
Figure 6. Nurse Manager Card
Figure
University Of Rochester Medical Center
Nursing Practice – Office Methods, Procedures and Quality Control
JCAHO Readiness Job Action Card Master List Date:
Page 1 of 2
Nursing Practice Responsible Person
CNO and Administrative Assistant Associate Director(s)/Service Office Designee(s) (Oversight Needs and Responsibilities)
Administrator, Nursing Time Management and Records
Nurse Manager/Designee
Unit Safety Nurse/Designee/Staff Nurse Staff Nurse (Documentation Focus) Patient Unit Secretary
Associate Director Nursing Support Operations/Assistant Coordinator Nursing Methods, Procedures & Quality Control Ambulatory Staff Nurses
Ambulatory Nurse Managers Ambulatory Safety Nurse/ Clinical Technicians/Designee
Ambulatory Clerical Staff Cancer Center Volunteer OR Nurse Manager
OR Nurse Leader/ Nurse Educator (Focus Documentation)
OR Nurse Leader/ Nurse Educator (Focus Environmental of Care)
PACU Nurse Manager PACU Staff Nurse Respiratory Care:
Director/Clinical Coordinator/AA Supervisor Change Therapist Respiratory Therapist