PAKISTAN KIDNEY & LIVER INSTITUTE AND RESEARCH CENTE

JCIA HAND BOOK

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Vision Statement
To create a center of excellence in healthcare, starting with the treatment of kidney and liver diseases, to
deliver state-of-the-art medical care without discrimination, and to foster culture of prevention, original
thinking, research and medical education.
Mission Statement

• To provide advanced clinical care to patients with kidney and liver diseases irrespective of their
caste, color, gender, religion or financial status.
• To develop and implement strategies of preventive to reduce the burden of disease and its financial
implications on society.
• To offer the highest standards of medical education at undergraduate and postgraduate levels.
• To promote cutting-edge research and bridge the gap between scientists and clinicians.
You and Your Job Description

What is your role in the Department?

Answer: (Refer to your JDs) All JDs are available in Liver Transplant Data Office (Zaheen office)
What is the Scope of Services of Your Department?
Answer: The department provides services for hepatopancreaticobiliary diseases and is a specialized center
performing living donor liver transplants both for adults and pediatrics.
Refer to Scope of Service Liver Transplant Department

Q. Who does you report to?

I report to the (designation of your supervisor/HOD).
Q. Who does your boss report to?
A. He / She reports to (designation of his/her supervisor) Dr. Ihsan reports to Medical Director.

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Key Performance Indicators
Q. What is the KPI of your department/Are you aware of the quality indicator of your department?

Answer: Yes, we have 6 indicator for our department (3 CPGs KPIs and 3 Departmental KPIs)
and we are achieving as per following

What are that KPIs(please write kpis below)?

Departmental KPIs (Inclusion All LDLT Recipients)
1) Average Length of Stay of LDLT Recipient – Target = 18day (Achieve rate in Sept = 18days)
2) Re-Admission of LDLT Recipient within 30 days of discharge – Target ≤20% (Achieve rate in Sept = 22%)
3) 30 Days Mortality of LDLT Recipient – Target = ≤10% (Achieve rate in Sept = 10%)
CPG KPIs (Incl Criteria = Age Limit 16-50 years)
4) LDLT Recipient CVC Line removal compliance by POD 5 – Target ≥80% (Achieve rate in Sept = 88%)
5) LDLT Recipient Out of Bed Mobilization on POD 3 – Targe =≥80% (Achieve Rate in Sept 100%)
6) Average Length of Stay of LDLT Recipient – Target 18 Days (Achieve Rate in Sept 17 Days)

What is the compliance Rate of the Followings?

Hand Hygiene: 81%

Adverse Drug Events (Prescribing, dispensing and administrations: _______________________

Adverse Drug Reaction: _________________________________________________________

SSIs (if applicable): _____________________________________________________________

Care Bundle Compliance (if applicable): ____________________________________________

Q. Where does the data related to your departmental KPIs is displayed?

Answer: It is displayed on the noticeboard located at Liver Transplant Data Office

Orientations and Performance Evaluations

Q. How you are oriented to the Hospital?

A. Our orienation has three components;

1. Orientation to the Hospital

2. Departmental Orientation
3. Orientation to the Job Description.
How do you know if you are doing a good job?

Answer: My performance is evaluated annually and here my supervisor/line manager tells me how I
am doing and what improvements/trainings I need for the future development.

Q. How you ensure that doctors are practicing according to privileges?

A. We have list of granted privileges in the department all the times.

Q. Where is privileges List of your department?

A. It is online available at the desktop as well as it is available in hard files available in Liver Transplant Data
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Office and OPD.

Q. How to act if you find some doctors practicing against the privileges?

A.I will try to stop the doctor respectfully, and generate patient safety report through online reporting form.

International Patient Safety Goals

Q. What do you understand by IPSG?

A. These are a set of guidelines established by the Joint Commission International (JCI) to address common
patient safety issues in healthcare settings.

Q. How many IPSGs are there?

A. There are six international patient safety goals.
Why is patient identification is so important?
A. The wrong patient identification may result in erorr in whole patient journey and often result in irreversible
consequences.

Q. What are your duties for patients with risk of fall?

A. Appropriate intervention are taken, i.e accompanying a patient while moving, applying red band and a fall alert
tag on the door of the patient room.
Q. Do you apply restraints on your patients and how?
A. Monitor the patient frequently while they are restrained and adjust the restraints as needed.Document the reason
for applying restraints, the type of restraints used, the patient's response, and any adverse effects.

How do you identify patients?

• At PKLI we use two unique identifiers for patient identification. These are the Patient full name and
medical record number.
• Patient identification is done before every patient interaction such as history taking, examination,
drawing samples, blood and medication administration etc.
• In special circumstances, i.e. comatose, unidentified patients, a temporary name and medical record
number is assigned for the treatment.
Please refer to the Policy on Patient Identification for more details
What is the policy of hospital in verbal and telephone order?

• AT PKLI verbal orders are n ot allowed except in life threatening emergency situations only, such
as code blue and in sterile area (where it is assumed the physician is physically present but unable
to write).
• During telephonic orders nurse/doctors writes the order in this case and reads it back to
the physician and both are supposed to document the same in online notes within 24 hours.

Please refer to the Policy on verbal and telephonic Communication for more details
Q: what is the process for communicating and receiving critical diagnostic results?

• PKLI has a list of critical values for diagnostic tests that need to be reported immediately to the
appropriate physician or department by diagnostic department (Laboratory, Radiology, pulmonology,
cardiology, POCT and Nuclear Medicine).
• The diagnostic departments convey the patient’s medical record number and name, and the name of the
test and test results to the physician. The physician/department read the result back to individual
informing and will write a verbal and telephonic communication forms and electronic medical record,
confirming receipt of the result, together with details of any action, if taken.
Please refer to the policy on reporting of critical diagnostic results for further information

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What is the policy/process for the management of high alert medications and concentrated
electrolytes?

• PKLI has defined a list of High Alert as well as LASA medicines. High Alert and LASA medicines
have specific labeling (Highlighted stickers) and are stored separately with Tallman Lettering on
LASA medications.
• Moreover, system alerts are in place for double checking medication ordering/selection, preparation,
and prior to administration.
• Hospital has guidelines available on intranet for management of i.e hypokalemia and hyponatremia
to ensure safe use of concentrated electrolytes.
Please refer to the Medication Management and Use Manual for more details

What is the process for ensuring safe surgeries and performing time-out?
• In PKLI the correct operative/procedural site is marked, with the patient’s participation (when possible) with a
permanent marker, by means of an arrow sign.
• It is ensured that all documents imaging and equipment are at hand when a patient is shifted to the OR
• WHO surgical safety checklist is carried out in three phases. “Sign in” which is pre-induction of Anesthesia,
“time out” which is carried before the incision and “Sign Out” which takes place before the transfer of the
patient from the operating room
Please refer to the policy on ensuring safe surgery and Timeout for more details.

What is the hand hygiene policy?

• At PKLI there is a strict hand hygiene policy. All healthcare workers must perform hand hygiene before
and after every patient contact
• Regular audits are being done to ensure that staff is doing hand hygiene. Data is collected and
shared with relevant staff at regular intervals
Please refer to the Infection Control Program for more details

What are the care bundles applicable to your department?

• Hospital has adopted and implemented various “bundles” of care (CLABSI, VAP, CAUTI, SSI, and
sepsis) to improve the clinical care provided to its patients.

• All doctors and nurses working in AMU, dialysis inpatients and ICUs are familiar with these bundles.

• Regular audits are being done to ensure that these bundles are being practiced. Data is collected
and shared with relevant staff at regular intervals

Please refer to the Infection Control Program for more details

Q. How risk of fall is assessed in inpatients at your hospital?

A. All patients admitted to the hospital have a detailed falls risk assessment carried out.

Please refer to Policy on Patient Falls for further information

How risk of fall is assessed in outpatients at your Hospital?

Fall assessment is carried out in OPD nursing assessment rooms by the nursing staff and apply all the
applicable interventions.

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 Access to care and continuity of care
How does the hospital ensure that the patients seen in the hospital have needs which can be met?

The hospital has a OPD clinics where we have guidelines reviewed regularly to ensure that patients registered
for treatment are in line with the services available at the hospital and appointments are booked with a specialty
service in which case the OPD staff ensures that they are booked with the appropriate clinician as per their
needs.

(Please refer to policy on Patient Registration)

Does PKLI prioritize urgent and emergent patients?

Yes, according to the severity of their clinical condition and the type of treatment they need.

(Please refer to policy on Patient Flow)

How do you ensure effective coordination throughout patients stay?

Once admitted each patient has a named physician responsible for the overall management. Care between
different teams is coordinated through effective handovers and online notes.

What is the discharge process in the hospital when the patient no longer needs inpatient care?

All patients undergo discharge planning from admission onwards. Physicians do daily ward rounds in
which they also consider, and update discharge planning based on patient’s condition. A discharge
summary is provided on discharge with details of what treatment was given, medications to be taken at
home, and what follow up is needed. Patient/family are given the relevant instructions and education on
discharge as well as a copy of their discharge planning note.

(Please refer to policy on patient flow for more details)

What do you do if the patient decides to leave against advice?

We try to ascertain the reason for leaving, reassure them, try to persuade them to stay. Patients are
explained their condition, the treatment required (including the alternatives, if available) and the risks
involved in leaving. If despite all this, they want to leave, a LAMA form is completed and signed in the
presence of a witness, and a Most Responsible Physician is informed. The normal discharge process is
followed with arranging a follow up and offering copies of all relevant investigations.

What do you do if a patient leaves without notifying the hospital staff?

Every effort is made to contact patients or their family. This is documented in the patient's medical record. If
they can’t be traced, they are assumed to have absconded, and formally discharged. Nurse, in such a
case, generates a patient safety Report. A LAMA report will be signed by MRP.

Q. Who accompanies the patient during transfer between the units?

A. Doctors, Nurses and porter accompanies the patient based on the clinical need of the patients.

What is the process for patient transportation from your hospital?

Within the hospital, after informing and explaining the rationale of transfer to the patient and their family
members, an online consultation is generated to request for a transfer of service. The accepting team
reviews the case and on acceptance, a fresh handover is completed prior to the transfer.

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 Patient-Centered Care
How are patient informed of their rights?

The hospital has developed a form where patients’ rights and responsibilities are defined which is given to
them at the time of their registration with the offer to explain it to them in a language that they understand.
Patient himself or his/her legal guardian signs the patient rights and responsibility form. Additionally,
standees are placed at prominent places regarding the rights and responsibilities.

(Please refer to Policy on Patients’ rights & responsibilities)

How do you ensure confidentiality of medical information?

All information related to a patient is stored in the Sisoft. This is password protected and access level to this
information is dependent on the staff member’s designation and role in the hospital.

(Please refer to Policy on Patients’ rights & responsibilities and Policy on medical records)

How & when is general consent taken?

A general consent is taken from all patients at the time of their registration. The staff at registration taking
the consent explains the scope of this consent to the patient in a language they understand. This consent
generally covers routine investigations and treatment such as blood sampling, physical examination, history
taking etc.

How do you ensure patient privacy?

Patient assessment, examination, and treatment is always carried out behind drawn curtains. Sisoft
accounts are password protected. Passwords are never shared. Systems are logged log out when finish
using a computer.

Note: Do not discuss patient issues in public areas such as lifts, corridors and the cafeteria.

What happens if a patient refuses treatment?

A detailed discussion regarding the patient’s decision is made and the consequences of not undergoing the
proposed treatments are explained.

Alternatives are communicated if available and ensure patient care is not compromised in any way due to
this refusal to agree with the proposed treatment.

What if a patient wants a second opinion?

We respect the right of the patient to seek a second medical opinion, which in most instances will be
provided by an PKLI’s credentialed physician/specialist.

How do you resolve conflict in patient care such as regarding withdrawing life sustaining treatment
or

DNR order?

The primary medical team in that case offers an independent medical opinion from a second physician to
the family. If the conflict persists then the case can be referred to the hospital ethics committee.

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How can a patient voice a complaint or express dissatisfaction with the treatment being offered?

Where a patient is dissatisfied with treatment, he/ she may voice his concerns through the established
complaint mechanism (online and physical).

Patient/family can request a change in his/her treating physician for any reason, with the approval of the
existing consultant and the Medical Director.

How does the hospital ensure appropriate education material is distributed to the patients?

All educational material is approved by the institute’s management and printed in a prescribed format for
consistency. These brochures, standees and signs are then made available to patients (in English and Urdu
language) in all relevant clinical locations. Furthermore, it is the responsibility of healthcare provider to
ensure any barrier to receive education are overcome.

Who is responsible for patient and family education and how is it documented?

All doctors, nurses and healthcare staff are responsible for patient education. All assessments and actions
taken in this regard are documented in the clinical notes.

(Please refer to Policy).

What factors are kept in mind when assessing a patient’s educational needs?

The following factors are kept in mind when assessing a patient’s educational needs:

• literacy level;

• emotional, physical and cognitive barriers;

• willingness to learn; and

• the clinical situation.

Assessment of patients

What is the procedure of assessment of patients by doctors?

All admitted patients must have a complete H&P which includes medication history, psychologic
socioeconomic, spiritual and cultural assessment, on the prescribed template in Sisoft within XXX hours of
admission. Similarly, all patients when visiting an outpatient clinic in the hospital for the first time have a
detailed H&P documented on the same template.

What is the procedure of assessment of patients by nurses?

When admitted a comprehensive nursing care plan has to be completed for each patient within 24 hours of
admission. This covers screening questions for further specialized assessments if needed by nutritionist,
psychologist or physiotherapist.

(Policy on Continuity of Care)

What assessment is done for patients undergoing diagnostic procedures at PKLI&RC?

Patients undergoing diagnostic services under radiology, pathology and nuclear medicine have
assessments done on prescribed templates according to the investigation being done such as MRI and
PET CT. Patients availing endoscopic services through Gastroenterology are registered and undergo a full
H&P.

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Further details refer Policy on Continuity of Care.

How do you assess patients for pain?

Pain is assessed as the fifth vital sign by the nurses on a regular basis in the inpatient setting using a
numerical or FLACC scale. According to the degree of pain further specialized assessments and
reassessments are then carried out. If any intervention such as analgesia is administered, then the nurse
assess the patient again within 60 minutes.

Care of Patients
How is a plan of care developed for each individual patient?

All patients have a comprehensive medical and nursing assessment on admission following which a care
plan is documented in the notes and followed. This care plan also includes the patient’s multidisciplinary
needs such as psychology review etc. The care plan is reviewed and updated at defined intervals.

Is there a system for early recognition of the deteriorating patient?

The hospital has adopted the AEWS including and PEWS system. These early warning scores are
calculated thrice a day and appropriate escalation to involvement of Rapid response team led by the
Consultant Intensivist occurs, when required.

How do you ensure safe blood transfusion at your hospital?

• identification of the clinical need

• written orders for transfusion
• consent for blood transfusion
• issuance of blood from blood bank
• administration after confirming identity, clinical need
• monitoring of the patient during transfusion and reporting of transfusion reactions
(Please refer to Policy on Use of Blood and Blood Products for more details)

How is the patient's care transferred to another unit such as ICU or another clinical team?

If the primary medical team thinks that the patient needs a different level/team of care, a consultation
request is generated. For more urgent reviews, the patient is discussed with the team being asked to see
the patient. The consulted team reviews the patient and if in agreement transfers care to their service after
consent from the patient and explaining the need to transfer to them. At the time of transfer a fresh
handover is completed along with the transfer request.

How do you look after high risk patients?

The institute has identified groups of patients considered to be vulnerable, or at high risk. The extra care
and monitoring needed for these patients is carried out in accordance with the hospital policy on
vulnerable patients. Apart from that if a patient is identified to have any extra care needs then the
consultant in charge documents those in the care plan and the appropriate medical and nursing teams
ensure this is done.

(Please refer to Policy on Continuity of Care for more details)

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What happens when there is a cardiac arrest?

A code blue is announced by dialing extension 3333. The Cardiac arrest team led by ICU personnel is
available round the clock for all areas of the hospital.

(Please refer to Policy on XXXXX for more information).

Does the hospital run a transplant programme?

Yes, this is overseen by the transplant evaluation team. Whenever a potential patient is identified for
possible transplant, the medical team informs the transplant evaluation team which then ensures further
care and treatment plan is in accordance with institutional policies and local laws and coordinated amongst
all care givers.

How does hospital ensure that patients’ pain is managed effectively in in-patients?

All patients are screened for pain as part of initial physician and nursing assessment. If pain is present
comprehensive pain assessment is completed. Nurses administer analgesia (if already prescribed) or ask a
physician to review the patient. When an intervention is performed for pain management, patient is
reassessed for pain within 60 minutes.

(Please refer to Pain Management Policy for more details.)

How does hospital ensure that patients’ are not at a risk for suicide or self-harm?

All patients are screened for risk for suicide and self-harm as part of initial physician and nursing
assessment in OPD and in-patient setting. If a patient is considered to be at a risk for suicide or self-harm,
psychiatrist consultation is done along with required monitoring and interventions.

(Please refer to Policy on Suicide and Self-Harm for more details).

Anesthesia and Sedation

How is procedural sedation administered when needed?

Sedation where needed is administered by qualified and privileged anesthetist. When a patient is sedated,
appropriate monitoring and resuscitative equipment is available at handy access and the nursing staff monitoring
the patient during and after sedation need to have undergone training to achieve competency.

(Please refer to Policy on XXXX for more details)

How does your hospital ensure safe anesthesia services?

Anesthesia is administered by trained anesthesiologists. All patients needing Anesthesia Services undergo a
pre-operative anesthesia assessment and discuss the perioperative management plan with the patient, take a
detailed informed consent and inform them of any alternatives if applicable. During anesthesia, patients are
monitored closely by qualified staff. After the completion of surgical procedure/non-surgical procedure, the
patient is transferred to PACU for on-going recovery where post anesthesia monitoring is done as per laid down
guidelines and once patient stabilizes and meets the prescribed discharge criteria, they are discharged.

What are the essential components of the operative note?

The operative note is filled out on the prescribed template in the medical and contains the following:

• pre- and post-operative diagnosis

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 • name of operating surgeon and assistants

• procedures performed and description of each procedure findings

• perioperative complications

• surgical specimens sent for examination

• amount of blood loss and amount of transfused blood; and

• date, time, and signature of responsible physician

The operative note is completed and signed in the OR, before transfer of patient to the PACU.

Medication Management & Use (MMU)

How are medications added into the hospital’s formulary?

Recommendations for new medications are brought to the Pharmacy and Therapeutics
Committee(P&T) Committee.
(Please, refer to Medication Management and Use Policy)
What are the SEVEN Rights of medication’s safety?
1. Right patient identification (Full name & MR No.)
2. Right medication
3. Right dose
4. Right route & rate (if applicable)
5. Right time and frequency
6. Right Documentation
7. Right Reason
Medicines are verified with physician’s orders before administration while using 7R’s.
(Please, refer to Medication Management and Use Policy)
How are medicines stored in the departments?
Medicines for patients are dispensed through unit-dose system. Multi-dose medicines are properly labeled
(Opening date & Expiry Date) by nurse. Unit stock medicines are stored in locked cabinets, daily checked
by nurses & replaced once used. When medications are used from the unit stock an appropriateness
review must be done. Narcotics are stored in double lock cabinet.
Fridge items are stored in medicine fridge according to the recommended guidelines for
temperature. Emergency medicines are stored in locked crash cart at designated locations. Pharmacy
department conducts monthly inspections.
Note: Concentrated electrolytes are not stored outside Pharmacy except in designated units such as OR &
ICUs.
What are High Alert Medicines (HAM’S)?
High-alert medications are those medications involved in a high percentage of errors and/or sentinel
events, as well as medications that carry a higher risk for abuse or other adverse outcomes. Examples
of high-alert medications include investigational medications, controlled medications, medications with a
narrow therapeutic range, chemotherapy, anticoagulants, psychotherapeutic medications, and look-
alike/sound-alike medications (LASA).

What extra precautions do you take while handling HAM’s?

HAM’s is double-checked and verified before preparing, and administration to include visual and verbal
verification for accuracy of dose and route.

What is Medication Reconciliation?

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It is the process comparing a patient’s best-known list of current medications against the physician’s
admission, readmission and/or discharge orders, designed to decrease Adverse Drug events (ADE’s) and
potential ADE’s on all inpatient units.
How do you report medication errors?
All staff members are expected to report medication errors by completing online Patient Safety Report.
How are drug-related near misses dealt with in our hospital?
All near miss are reported via the online patient safety reports. These are analyzed initially by the relevant
department and then referred to the P&T Committee.
What is Adverse Drug Reaction (ADR) & How are ADR’s reported?
An ADR is a response to a drug which is noxious and unintended, and which occurs at doses normally
used for prophylaxis, diagnosis, or cure of disease or for the modification of physiological function.
Reportable ADR's are those that potentially contribute to death, are associated with an unanticipated and
significant event or illness or result in an unplanned intervention.
What is the formulary system?
The P&TC has a system whereby medications are evaluated, appraised, and selected based on
clinical/published evidence and are made available for patients. The Hospital formulary is maintained in
such a way that the need for use of non-formulary items is minimized. Items listed on the hospital formulary
are available whenever required throughout the PKLI&RC.
How are Narcotics handled in your hospital?
Narcotics are kept in double locked cabinet in approved quantity in designated departments.
Narcotics are prescribed by doctors & are verified before administration. Empty vials are returned to
Pharmacy with record of administration.
What has been done to reduce the risk of medication errors in your area?
Identify patients using two unique identifiers – full name and MR number before prescribing, dispensing and
administering
Refrain from using unauthorized abbreviations in medicine use
Segregate look-alike and sound-alike drugs
Follow the high alert medication policy, standardized protocols for management of electrolyte
replacement, and guidelines for use of single and multi dose vials
• Reporting medication near miss and errors
• Using TALL MAN lettering system
• Appropriateness review by nurse and pharmacy in case of emergency medication use.
• For radioactive, hazardous and investigational medications, our pharmacy department carries out
regular risk assessment to ensure their safety.
What is the medication recall system?
Medications, including those compounded in hospital, dispensed to the patient are recalled, if the
drug is expired, contaminated during handling or reconstitution, recalled by the company or drug regulatory
agency. The hospital pharmacy is responsible for the whole drug recall process.
What is Adverse Drug Event (ADE)?
An ADE is an injury resulting from the use of a drug. This definition includes harm caused by the drug as a
result of adverse drug reactions, drug-drug interactions, product quality problems or drug overdoses
(whether accidental or intentional)
Severity levels are:
Mild. An event that requires no intervention or minimal therapeutic intervention such as discontinuation of
drug(s)
Moderate . An event that requires active treatment of adverse reaction, or further testing or
evaluation to assess extent of non-serious outcome.
Serious. An ADE is serious when the patient outcome is death, life-threatening, requiring hospitalization-
initial or prolonged, leads to disability or permanent damage, causes congenital anomaly.

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Who performs the appropriateness review of medications?
A licensed pharmacist performs appropriateness review of all orders that are entered in the Sisoft. In
situations where a pharmacist review is not possible / delayed, a trained individual staff nurse can do
appropriateness review of medications from unit emergency stock.
Trained individual staff nurse will conduct a review of critical elements a) through d) for the first dose and a
full appropriateness review will be conducted by the designated licensed pharmacist within 24 hours.
• Allergies.
• Fatal drug/drug interactions.
• Weight based dosage; and
• Potential organ toxicity
A specific note template in Sisoft is added to document this appropriateness review. Pharmacist
will fill this template based on the guidelines developed for appropriateness review whenever
they administer a medication from the unit emergency stock.

PREVENTION AND CONTROL OF INFECTION

What are the five moments of hand hygiene (HH)? (Refer to Hand Hygiene Policy)
a) Before touching a patient
b) Before clean/aseptic procedure
c) After a procedure or body fluid exposure risk
d) After touching a patient
e) After touching the patient’s surroundings
What is the duration of hand hygiene procedure?
Hand washing : 40-60 seconds
Alcohol based hand rubbing: 20-30 seconds

What is Respiratory Hygiene and Cough Etiquette?

• Cover your cough and sneeze.
• If you use tissue paper , immediately dispose of in the nearest waste bin and perform hand hygiene.
• Use elbow to cover, if tissue paper is not available.
• Wear face mask, if you have persistent cough and sneeze, and during hospital visit and stay in
COVID pandemic
What is the correct order of wearing and removing the PPEs (Personal Protective Equipment)?
1. Put on in this order: Hand hygiene(HH), gown, mask or respirator, goggles or face shield and
gloves
2. Remove in this order: Gloves, HH, goggles or face shield, Gown, mask or respirator, Hand
Hygiene.
How do you reduce the risk of cross infections?
We follow the practices set in infection control program like:
• Hand hygiene
• Cough etiquettes, safe work practices, social distancing
• Wearing mask all the time while attending respiratory ill patient, social distancing
• Personal hygiene, following dress code, vaccinations up to date
• Patient placement, isolation as per needs
• Care of cannulas, lines, catheters, and wounds
• Safe injection practices
• Environmental cleanliness
• Training and educations of staff and patients and their families
• Audits and monitoring, IC workshops, awareness sessions
• Epidemic drills

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What will you do in case of needle stick injury (NSI)?
• Wash the area with copious amount of water & soap
• Clean the area with any antiseptic available
• Cover the site with waterproof dressing
• Inform the supervisor on duty
• Note patient name and MR number & diagnosis
• Fill in a Needle Stick Injury Report and send to Infection Control Department
• Contact Employee Health Clinic from Monday – Friday at 09:00am to 05:00pm
• Contact Acute Medical Unit when Employee Health Clinic is closed
• Infection Control Manager will follow the case and inform the employee, as appropriate
• Departmental heads are responsible to educate their staff about the risks of needle
• stick injury and the importance of standard precautions while handling sharps
How do you handle and dispose of sharps?
Dispose of all used and unused opened sharps (blades, metallic pins, slides and glass bottles) in an
approved sharps container
Promptly dispose of needles without recapping, with gloved hand into a sharps container
• Do not recap, bend, break, or cut needles
• Recapping is only acceptable for sterile needles
• Needle can be recapped only when it is mandatory for example; sampling of Blood gases, nuclear
medicine etc. For these situations one hand technique (scoop
method) must be used
• When the sharps container is filled to the red marked line, the lid must be closed & kept separate for
collection by housekeeping staff
• Do not leave sharps unattended (at patient’s bed side or on counters). Sharp objects must not be
carried around or placed in pockets while working.
What is the process of waste segregation at unit level?
At unit level, the waste is segregated in specified color bags:

Household waste in White Bag

• Used tissue paper, Cardboard and kitchen refuse

Infectious Waste in Yellow Bag

• Used: Dressings, catheters and stoma bags, Gloves, Drainage bottles, IV tubing, Burettes,
Blood transfusion sets, Blood Transfusion bag.
Cytotoxic Waste in Red Bags
• Chemotherapy bottles, IV tubing used for chemo, Chemotherapy bottles wrapper
Sharp Containers for Sharp Objects
• Syringe , needles, cannula stylet, Blades, Broken glass, Injection ampoules
What Personal Protective Equipment (PPE) are necessary for each type of isolation?
The sign indicates exactly what is necessary. Staff must be aware of sequence of donning and
doffing.
• Airborne - N95 mask
• Contact - Gown and gloves
• Droplet - Surgical mask
When patients in contact isolation needs transfer to another department, what do you do?
We try our best to limit these patients’ movement, but when their transfer cannot be avoided, we
take
the following steps:
• We inform the receiving department of the isolation status of patient
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 • We cover or contain potentially infectious body fluids before transport
• We discard the contaminated PPE before transport
• And we wear clean PPE as per patient’s isolation status to handle the patient at the
destination.
(Please refer to infection control program)
When patient with droplet or airborne precautions needs transfer to another department,
what do you do?
We try our best to limit these patients’ movement, but when necessary, we take the following
steps:
• We inform the receiving department of the isolation status of patient
• The patient must wear a surgical mask during his/her transport.
• When at destination, we follow the precautions and wear clean PPE as per patient’s
isolation status.
(Please refer to infection control program)
What precautions do you take when seeing patients with TB?
Use Airborne Isolation Precautions whenever the physician writes an order for AFB culture and
smear, or for patients exhibiting symptoms of TB or who have been diagnosed with TB. This
includes placing the patient in a separate isolation room with negative pressure and wearing the
N95, personal respirator mask. Patients should remain in their room with the door closed. When
outside their room, the patient is masked.
When are patients with TB removed from isolation?
When the physician rules out TB as a diagnosis or if the patient has three consecutive negative
AFB sputum smears collected on different days.
How do you identify patients for isolation?
Standees everywhere asking patients to report if they have a cough or bringing up phlegm as well
as containing information about cough and cold etiquettes.
If a patient reports after reading above to the counter the OPD staff give him a mask
& Call Infection control nurse or fellow for advice.
In AMU or on scope triage if there is such a suspicion patient is moved to Isolation and Infection
control manager or ID consultant called for advice.
What is a biohazard?
The term biohazard is used for any type of biological waste such as blood and body fluids, soaked
dressing, all types of used catheters, used linen and sharps. Often, these biological wastes are
pathogenic in nature and capable of inducing disease in humans such as HIV, HBV, and HCV. It is
recommended that the waste of biohazards is discarded in the Yellow bags and nonclinical waste
in white bags. Liquid waste should be discarded in designated place.
How to manage spillage of hazardous material?
(Refers to Blood and Body fluid Exposure policy)
Steps To Be Taken Immediately:
• Stop source of spill , cover the spill , Call for help & Evacuate area if required
• Bring the spill kit at the site of spill
• Inform Shift in charge to inform to patient/family for delay of service (if needed)
• Stop activities, Inform to patient / family about spillage
• Restrict personal access by displaying the CAUTION sign
• Assess & record amount of spillage, area/ site involved
• Isolate affected individual (staff/ patient) for management
• Follow the procedure for spillage management given in flow sheet
Refer to XXXX policy.

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Sterile Supplies and Equipment Management
What is the shelf life of patient care items and supplies by CSSD?
• All items have a sterilization date and a use by date.
• Sterile packages processes by CSSD that are not used within 1 year must be
returned to CSSD for re-sterilization
• All sterile items must be stored in a place where their temperature and humidity monitored.
What is the process of reporting Communicable Diseases to the Regulator Bodies?
Dengue, HIV, and Mycobacterium Tuberculosis positive cases should be reported to office of
secretary health Punjab, Punjab AIDS control program and national TB control program,
respectively.
Do we re-use single-use devices?
No. The process of reuse of a single-use device is strictly prohibited.
Facilities Management and Safety

Does the hospital have a safety and disaster management plan?

Yes. It is available on the intranet.

What are the emergency codes and helplines?

CODE COLOR EMERGENCY DIAL

Blue Cardiac Arrest 3333

Red Fire 3400

Pink Child Abduction 3845

Yellow Chemical spill 3845

Orange Patient violent 3845

Green Evacuation 3845

Black Patient Influx 3845

Purple Bomb Threat 3845

Grey Utility Failure 3750

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What is RACE?
It is a mnemonic which stands for;
➢ Rescue people from the affected area.
➢ Alarm (Raise) and call Ext. 3400
➢ Confine-close doors to contain fire.
➢ Extinguish if trained or safe to do so otherwise Evacuate.

What is PASS?
It is a mnemonic which stands for;
Pull the pin.
Aim at the base.
Squeeze the lever.
Sweep side to side.

What is MSDS?
MSDS stands for material safety data sheet. It provides information about hazardous material.
Please ensure you are aware which chemicals are present in your working area and where MSDS
is kept in your department.

What is the meaning of the following symbols?

Who maintains your medical equipment?

Biomedical department, in coordination with the vendor where needed, is responsible for all preventive
maintenance whereas routine inspection and monitoring is done by the end user.
What happens in the event of a loss of power, gas or water supply?

We call 3750 or Facility Management Department.

What is a radiation dose-monitoring badge and how should it be worn?

➢ Every radiation worker is provided a radiation monitoring badge by the hospital. The purpose of this
badge is to estimate your exposure to radiation in PKLI&RC.
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 ➢ The badge is typically worn on the outside of clothing, around the chest or torso. The badge is worn
inside the lead apron during the procedure.

How are radiation badges monitored?

Radiation monitoring badges are sent to suppliers (i.e. PINSTECH, Islamabad) at regular intervals for
reading.

What are the cardinal principles of radiation protection?

Three Cardinal Rules of radiation protection are:

(TDS) Time, Distance, and Shielding from ionizing radiation.

What does ALARA stand for?

As Low as Reasonably Achievable.

Is any medical screening of employees wearing radiation badges needed?

As per PNRA regulations radiation workers undergo annual laboratory tests i.e.

• CBC
• Urine complete
Quality and Patient Safety

Does the hospital have a quality and patient safety plan?

Yes, we have a detailed quality and patient safety plan. This plan is available on the intranet.
How do employees participate in the hospital quality plan?
Employees participate in data collection for the KPIs of their work area. They can highlight any
concerns with regards to breach of established policies and procedures and fully participate in any
investigations identifying errors to reduce patient harm. Employees are expected to raise patient
safety reports or complaints whenever they see a near miss or an actual adverse/harm event.

How are employees made aware of quality related data being collected?
All the QIPS reports are published on the intranet. Apart from that most clinical areas have the
latest data on the relevant KPIs displayed on the Quality boards and hospital clinical quality
indicators are available on the hospital’s intranet.

What is the mechanism of raising a Quality and patient safety issue in your hospital?
There is a patient safety report and complaint form is available on the website. Whenever any
error or a potential for error occurs, employees can file report which is investigated by the HOD in
liaison with the QPSD to ensure any human or system errors can be identified and rectified to
reduce patient harm.
What is a sentinel event?
A sentinel event is a patient safety event (not primarily related to the natural course of the patient’s
illness or underlying condition) that reaches a patient and results in any of the following:
a) Death;
b) Permanent harm;
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c) Severe temporary harm (its defined as critical, potentially life-threatening harm lasting for a
limited time with no permanent residual but requires transfer to a higher level of care/monitoring
for a prolonged period of time, transfer to a higher level of care for a life- threatening condition, or
additional major surgery, procedure, or treatment to resolve the condition);
Does your hospital have a process in place to monitor the quality and safety of
transportation used to transport hospital's patient(s), including a complaint process?
Yes, hospital has a feedback form to assess the quality of service that is provided to them.
What is RCA?
RCA or root-cause analysis is a process for identifying the basic or causal factor(s) that underlies
variation in performance, including the occurrence or possible occurrence of a sentinel event.
Root-cause analysis determines the multiple, underlying contributing factors resulting in the event.
Q. Do you know the hospital’s quality priorities?

Yes, it includes the Patient safety and risk management, Clinical performance of the hospital,
Patient satisfaction, Utilization management (Optimum usage of facilities), and
continuous improvement of the internal processes.

Staff Qualification and Educations

Do employees receive any training with regards to their scope of work?

All staff undergo training to help them carry on their duties more effectively. Staff are trained to use any
equipment that they may need during patient care. All nurses are at least BLS qualified and nurses from
selected clinical areas such as ICU, AMU etc. as well as all doctors are ALS qualified through internal
resuscitation trainings. Apart from this employees have their training needs identified and discussed during
annual appraisals and then every effort is made both by the hospital as well as individual staff members to
meet those training needs.
Are employees made aware of what a staffing plan is?
Yes, staffing plans are developed by individual HODs in liaison with the Human Resources as well as
leadership of the organization keeping, staff requirements to meet the standards and scope of services of a
particular area, as well as the skill mix needed.
Does your organization have any employee Health Safety Program?
Yes there is an approved employee safety program, and it is available on the intranet.
Management of Information

How does the hospital ensure availability of information to practitioners in a timely manner for ease of
patient care?
The patient medical record (online and hardcopies) has all clinical information available at all times. Access
to Sisoft is password protected. Each individual staff member’s password gets them access to information
within the system according to the need of their job.
What happens if Sisoft(HMIS) stops working? What are the contingency arrangements?
Without compromising the patient care of emergent patients we wait for 30 minutes to respond the HMIS,
if it not happens, we start using manual forms that are available in the contingency folder of the computer
and hard copies.

What role do you play in the protection of patient data?

I never discuss patient details in public areas. I do not share my password with others and I
always log out of a computer when I have finished using it.

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How does hospital ensure confidentiality, security and integrity of patient data?
The Hospital Information System is password protected software which can only be accessed by authorized
users. The hospital has established a process to grant access-privileges to patient data and information, and
rights to make entries in the medical record based on individuals’ role in the hospital.
(Policy refers to Privacy and Confidentiality for more details).

How do you delete a wrong note written in the patient’s medical record?
Any corrections to the medical record such as a wrong entry etc. can only be done through
writing an addendum to that particular note.

Do you use any abbreviations when writing notes in a patient’s medical record?
The hospital has a defined list of abbreviations accessible through intranet. Any abbreviations used must be
from that list. Any addition to the list may be requested to Medical Directorate office. A list of never to be
used abbreviations also exists.
However, abbreviations are prohibited on patient related documents i.e consents, patient family
educations, and discharge summary.

Dos and Don’ts of Survey – Don’ts

Dos

➢ Welcome the surveyor to your area

➢ Allocate appropriate space for the tracer team to do the interviews

➢ Be truthful, describe your regular practice

➢ Be professional in your attitude and appearance

➢ Reply to surveyors’ questions directly and concisely

➢ Answer with confidence “according to policy, we”

➢ If you don’t understand something, ask the surveyor to clarify or explain

➢ If unsure of the answer, the safest response is that you’d check the policy or ask your
supervisor

➢ Don’t panic, or exhibit inappropriate body language

➢ Don’t argue with the surveyor

➢ Don’t try to mislead the surveyor

➢ Don’t volunteer unnecessary information

➢ Don’t Provide non requested documents

➢ Don’t Use phrases such as, “most of the time”, “we usually”, “well, sometimes we do”.

➢ Don’t Talk about the future plan of the department

➢ Do not answer on behalf of your colleague

➢ Do not use abbreviations

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Patient’s privacy & Confidentiality During Survey

➢ Log-out after using the computers in patient care areas

➢ Knock before entering a room

➢ Close doors and curtains during treatment and examination

➢ Cover patients appropriately during treatment and transport

➢ Modulate voice volume in areas where privacy could be compromised.

➢ Do not share computer passwords.

➢ Do not discuss patient-specific information in public areas like elevators, cafeterias and
hallways.

➢ Do not display patient-specific information on notice boards accessible to the public.

➢ Do not leave medical records in public areas or unattended by staff.

➢ Do not give treatment or perform physical examination or procedures if the patient belongs
to the opposite gender, without the presence of a person/chaperone/care-provider of the
same (patient’s) gender present.

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