Overview of State Hospital Licensing Survey Linda L. Foss PhD, RN Executive Director Clinical Care Facilities Office of Inspections and Investigations Department of Health Linda L. Foss Executive Director Clinical Care Facilities

Survey Process Regulatory Framework

Survey Purpose of survey is determine compliance with state licensing requirements State licensing requirements are minimum

What are we looking for?

Compliance

SurveyComponents Observations Interviews Record review

Washington Administrative Code Purpose and Applicability Licensing Patient Care Environment of Care Management Design, Construction Review, and Approval of Plans

Hospital Responsibilities Comply with RCW Set up only the number of beds licensed Notify with 2 business days of completion accreditation survey Notify in writing of accreditation decision or status change in 30 days

Governance Informing patient of any unanticipated outcomes Establish and review governing authority policies Performance Plan Organizational Management Reporting Practitioners

Governance Approve an appoint medical staff Authenticated of orders by authorized practitioner Approve and Review Medical Staff bylaws

Criminal history, disclosure, and background inquiries Employee, Contractor, Volunteer, Student Access to Children under 16 Vulnerable adults Developmentally disable individuals

Patient Rights/Organizational Ethics Respect Dignity Confidentiality Privacy Complaint resolution, Spiritual care Communication Free from abuse and neglect

Patient Rights/Organizational Ethics Involved in care Right to refuse care Advised of unanticipated outcomes To be informed and agree with care Advanced directives Request DNR Right to donate organs Access protective services

New Definitions Victim of sexual assault" means a person is alleged to have been sexually assaulted and who presents as a patient. Vulnerable Adult-includes hospitalized adults.

Leadership Assessing patient and family satisfaction of services Posting Complaint Hotline Provide patient with written billing statements

Leadership Provide for safe haven for abandoned newborns Provide of organization wide performance improvement activities

Leadership Assign a nurse at the executive level Establish hospital wide patient care services

Adverse Events Reporting Process is now outlined in the WAC Reported to Linda Furkay PhD, RN Toll Free Hotline for Reporting Adverse Events

Reportable Events Failure or facility system malfunction such as Heating, ventilation, fire alarm Water supply electrical Information management Must Notify DOH-Office of Inspections and Investigation.

Notification Who Linda Foss Phone Fax number wa.gov wa.gov What Type of event Date of event

Management of Human Resources Job descriptions Staff performance Assure qualified staff Supervision of staff State licensure, certification, registration TB screening

Education for staff Orientation Education Blood borne pathogen exposure control HIV Multi-drug resistant organisms

Qualified Staff License, registration certification Job description Orientation Performance evaluation Supervision Staff working within scope of practice Competency

Medical Staff Bylaws Verification Appointment Reappointment Delineated clinical privileges Reporting practitioner Assessment of performance

Management of Information Control access of patient information Confidential, secure, and integrity Medical record for every patient

Infection Control Program Education Policies Patient care practices Environmental management and housekeeping functions

Improving Organizational Performance Hospital Wide Periodically evaluated Interdisciplinary Includes one member of the board

Requirements for Food and Nutrition Services Linen and Laundry Services Pharmaceutical Services Laboratory, Imaging and other Diagnostic Services Safe Patient Handling Patient Care Services

Patient Care Units Surgical Anesthesia Recovery Care Obstetrical Neonate and Pediatrics Critical or Intensive Care Alcohol/Chemical Dependency Psychiatric Long-Term Emergency Dialysis

Patient Care Plan for Patient Care Assessment of Patient Standards of Care Qualified Staff Equipment

Patient Care All patient access to safe and appropriate care Adopt and implement P&P for patient care and nursing practice Individuals conducting business in hospital comply with P&P

Patient Care Services Provide personnel, space, equipment, reference materials, training A registered nurse available for consultation in the hospital at all times Policies and procedures around care process

Emergency Contraception 24/7 emergency care to victims of sexual assault Provide medically and factually accurate and unbiased written and oral information about emergency contraception

Safe Patient Handling Develop a policy Hazard assessment Annual performance evaluation of the program Annual staff training Procedures for hospital staff to follow Types of equipment

Management of Environment of Care Manage environmental hazards and risks, prevent accidents and injuries, and maintain safe conditions for patients, visitors, and staff.

Self-Assessment Tips.

Read the regulations

How are you meeting the regulations?

Where is the documentation that demonstrates compliance ?

Questions