Regulatory,Mission Watch,

Inside UW Health,Mission Watch,Survey Readiness Resources,Survey Readiness: Questions of the Week

Week of September 4, 2017

Week of September 4, 2017 - Inside UW Health, Mission Watch, Survey Readiness Resources, Survey Readiness: Questions of the Week


Managers: Please review these Questions and Answers with your staff/teams this week.

Providers and Staff: Please review and be ready to answer these questions.

We are in the window for an unannounced site visit/survey by The Joint Commission. To access preparation resources, including the comprehensive Reference Guide, visit the Survey Readiness section.

If you have questions, please contact Lisa LeClair, Accreditation and Regulatory Specialist.

May inpatient and outpatient areas store medical/surgical supplies in cardboard boxes?

Cardboard containers are fine, except those used as outside shipping containers. Outside shipping containers (cardboard and other materials) may NOT be used in medical/surgical supply storage areas. These outside shipping containers are easily identified by shipping information noted on the outside of the container. Cardboard boxes from the inside of outside shipping containers are acceptable for storage.

What is Universal Protocol and where does it apply?

Universal Protocol is the patient safety process for ensuring right patient, right procedure, right site. Universal Protocol applies in the OR and non-OR settings such as inpatient units and ambulatory clinics. In general, any time consent is required, it is assumed there is enough risk to apply the Universal Protocol

  1. Steps to assure the Time Out is completed properly

i. Hands Off

ii. Eyes Up

iii. Feet Still

iv. Acknowledged by Word or Gesture

v. Silence in room (music off)

What patient equipment can be kept in the hallway?

Anything in egress corridor more than 30 minutes is considered storage. Exceptions: Carts allowed in corridor more than 30 minutes are crash carts, isolation carts, chemo carts. If the hallway looks cluttered, it probably is.

What is a common concern with fire doors?

A fire door that does not close properly or completely will be ineffective in maintaining fire and smoke containment.

When can a fire door be propped open?