JCI Questions & observations

# Date Department Questions and observations

\Ward
1 23\05\2021 Main workflow and scope of service for the lab
Laboratory
Number of the staff (total and how many today)
How many years you are working here?
What kind of training you got?
Did you got any training related to safety?
Fire
Assembly area
Down time of the system
The policy of down time
Do you have any down time drill or real within the last 6
months?
(He observed the actual work steps and process
Observing the double checking of the blood samples
Checking the store
Checking the critical result and the way of communication

Chemical spillage
Code brown
QC checking
Compering the system documentation with manual
documentation
PPM
Data Backup
Disposing the biohazardous garbage ( the process and by whom
)
Fridge temperature checking it and checking the temp. chart
also
Store and the stock
Evacuation plan
MTB policy
Blood wormers (if it is available? where?
Checking the hazards materials cabinet
Again asking in the last one year do you have any spillages?
specially chemical? or biohazardous ?
Machine not on use (why it is not on use? )
Watching the hand washing of the staff
He asked to see the staff license
He asked to see if the lab having any quality accreditation
certificate
KPIs, action pans and QIP (from the FHI) he ask to explained it
Checking the staff contract
QC competency for the nurse in the wards and units
(Glucometer QC)
He checked the mandatory course certificates like FMS,
infection control …ex
Inventory of the equipment
Pure health Contract
2 Blood Bank KPIs
Process of blood donation
Blood products in the blood bank
Ask the cleaner about safety measures and how to use the
hazmat kit (spill kit)

Storage
Blood donation area, chairs, spoke to the donor

Checked medical gas valves and its distribution

Asked who will close the oxygen panel in case of fire?

Asked about the down time
Checked blood bank fridges, temperature
Comment on the difference of temperature of the fridges and
the other measuring tool (Dickson)

3 Radiology Asked about the total number of the employees

department
Machines PPM
x- ray apron for the patient (labeling and the maintenance date)
Consent form
What you will do if the patient arrested? what is your role?
Did you have any code blue drill or real activation?
 Hand over between the x- ray nurse and the ward nurse
(checking the documentation in the system)
Process of reporting the result during the down time of Wareed
system
Emergency exit
KPI, FOCUS PDCA.
when to terminate the KPI?
MRI exit door comments on safety and using lock

Checked MRI room and patient procedures

Checked Medical gas valves and distribution

4 Nuclear Checked patient process and procedures

Hot lab safety and handling of nuclear materials

What PPE you are using with hazardous materials?

Injection room

Ask cleaner how to clean after patient that received

radioactive?

5 24\05\2021 Mammogram Workflow, scope of service

Machines daily check. machines inventory
 QC. PPM
Store and items labeling
Duty Rota and on call Rota
Lead apron labeling
What kind of training received by the staff? according to your
scope of work
Mammogram check list

Play area door was not locked (outside, going to maternity

centre)

6 Physiotherapy How many rooms you have?

Checked the morse score (fall score ) and pain score for one
patient
Checked one patient medical record
Wareed down time
Treatment areas

Checked the nurse call in toilets

Comments on main ( exit door ) Door male gym with key

7 Dermatology Patient assessment

OPD
Procedures

Nursing documentation
 Any PCR done for the patient before coming to the OPD?
KPIs QIP
Nitrogen cylinder and PPE

Patient flow time in and out

8 ENT OPD Checked the initial nursing assessment

Checked the physician documentation
PPM of machines and maintenance
Glucometer QC
Patient flow
QIP and KPIs
Asked to see down time forms
9 25\05\2021 MMW Asked who is going to shut down the oxygen if you have fire
Checked the store
Checked where you are keeping the oxygen cinders?
MSW How many staff you have now?
How many beds you have?
Checking the exit door
10 Thalassemia Asked about the working hours?
How many patients you have?
Asked about Thalassemia center activities
Checked the KPIs
Code red
Exit door
11 ICU & CCU What type of evacuation you have?
Did you have evacuation drill before?
 What are the evacuation steps?
Length of patient stay in the CCU
12 Dialysis unit Checked the entrance
Asked about patient PCR for COVID19
How many staff you are having?
Asked about Water testing
Checked the staff ID card
Asked the staff if they have BLS training or not?
13 26\05\2021 NICU Checked the oxygen cylinders
Exit door, evacuation and as assembly area.
Saw the NICU layout
LR Layout
Did you have any event of baby miss identification?
What you learned from the evacuation drill?
Checked the staff BLS cards
15 Mat. W Checking the layout
Checking the exit door
Asked for how long you are working here?
Did you have any evacuation drill?
Did you have any incident of baby miss identification?
How many staff you have?
How many patients you have?
How many nursing staff in the night shift

Add points ( these areas I didn’t attend with the auditor and the team )
 24\05\2021 **Afternoon**
Engineering, FMS, IT, INFECTION control documents
Hospinorm assets and procedures for maintenance of medical equipment’s.

 **25\05\2021 Afternoon**
File section:
Filing system
Call centre
Like the Fire sprinklers in the facility
Closed file machines
Basement:
Checked all basement facility and it’s safety measures and medical air and vacuum room
MMW AND MSW
Ask about fire doors
Check exit doors
Ask staff about fire safety drills, fms training
Competency nursing
Check oxygen cylinders
Bariatric surgery and beds
Evacuation chairs and how to evacuate mechanisms
Ask 2nd floor security staff about his job and if he knows about covid ward
Gave note again about vending machine and it’s safety measures