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Questions – Environment of Care Inspection, Testing and Maintenance of fire testing equipment. Reviewed documentation. Does the hospital or fire department do quarterly inspection of connection to the fire department? This is currently done annually by the fire department. Percent of PM’s done on time: 98% - Reported to Safety Committee monthly – Outside clinics done per schedule without any access problems. Defibrillator checks – should always be checked unplugged. Multiple discharge assessment done with PM’s. Possible PI Indicator – PM’s, Corrective Maintenance, User errors Emergency Preparedness – done every 6 months. Where is the designated alternate site? Fire Drill Process – may want to expand number of compartments assessed (must be at least 20% of functioning areas). Could use as an opportunity to do staff education. Discussed evaluation of scope and effectiveness of the seven EC plans. These can also be used to evaluate opportunities for improvement (re: two for one approach). Questions – Human Resources How do we know we have the proper number, mix and qualifications of staff within the organization? What outcomes are used to assess the need for the number, mix, and qualifications of staff? How do you collect data for this? What outcomes do departments use? How do you determine your education and training needs for employees? May want to add feedback from education needs assessments to HR board report. Is competency being validated on a timely basis? Do you have an education and training budget? What percent is it of the operating budget? Nursing does trend the number of education hours. What are the mechanics of general orientation followed by department specific orientation? Does it include volunteers? What is your documentation of re-education? How do you evaluate age specific competency training? Policy re: employee’s ability to discourage? Age specific training for volunteers? Job description? Evaluation? Do you do primary source validation? Do you do background checks? Forensic training for outside organizations? Some validation and follow-up for contract staff? Looking for training of staff in neglect and abuse. Need to be done annually.
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