adavis_proceduresforcompliance_12323
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School
Rasmussen College, Florida *
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Course
HSA3422
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
7
Uploaded by CorporalPower12090
Module 5: Procedures for Compliance
Ariel Davis
Rasmussen University
H340/HSA3422: Regulation and Compliance in Healthcare
Rebecca Mangali
12/3/2023
Clinical Staff Members Must Wash Their Hands Between Patients
A crucial part of a compliance program is to monitor the effectiveness of the procedures set in
place. Monitoring tools allow staff to find any errors in the compliance plan and actively work to
fix them. I have put several different monitoring tools into action regarding the hand washing
policy.
Sign-Off Sheet
To keep track of whether people are washing their hands, I have administered a sign-off sheet
that is located at every hand washing station. The sign-off sheet would consist of writing the time
the employee washed their hands, answering yes/no if they followed the required hand washing
guidelines and whether the wash station needs to be restocked. The sheet will need to be signed
by the employees each time they wash their hands throughout their shift. At the end of the day
the supervisor will sign off and make sure that each employee washed their hands before and
after every patient. The sign-off sheet will help keep employees on top of their responsibilities
and will also help keep supplies stocked. Hand hygiene compliance increases dramatically when
these observers, who are usually well known to the staff, are circulating in the unit (Infectious
Disease News, 2014). Having supervisors check off on the sign-off sheets will allow for more
compliance from staff.
Electronic Monitoring Systems
Use of electronic monitoring can be a valuable tool for educating healthcare workers on their
hand hygiene performance, and tracking hand hygiene performance improvements (Infection
Control, 2013). Electronic monitoring systems can have a great impact on hand hygiene
compliance. An electronic monitoring system can help improve workflow because it does not
require healthcare workers to record information. Although a sign-off sheet requires employee
attention, it’s important to make sure that a monitoring system works properly before eliminating
the sign-off sheet requirement. A monitoring system can also help save money because they can
easily be attached to existing features, unlike other expensive hospital equipment. Electronic
monitoring systems continuously monitor and process data on employee hand washing.
Visuals
Hand washing visuals are an important monitoring tool that should be displayed throughout the
hospital. The visuals should consist of step-by-step instructions on how to correctly wash your
hands. These visuals will make it less likely for staff members to forget to wash their hands in
between patients. Hand washing visuals will also show patients how seriously our hospital staff
takes hand hygiene compliance.
Conclusion
There are several monitoring tools that can help the hand washing compliance process. I believe
that sign-off sheets, electronic monitoring systems, and visuals can have a great impact on hand
hygiene. Hand washing is not a complicated process, so I do not believe that training is
necessary. If employees cannot follow the hand washing guidelines correctly then training may
be the next best option for this hospital.
Employees Must be Knowledgeable in the use of Fire Extinguishers
It is a crucial part of a compliance program to monitor how effective each compliance plan is. I
have put several different monitoring tools in action, regarding the use of fire extinguishers. The
following monitoring tools will help ensure that every staff member is knowledgeable and
comfortable while using a fire extinguisher.
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Training
The most important monitoring tool regarding the use of fire extinguishers is training. Staff will
only become knowledgeable in the use of fire extinguishers if they are properly trained. I have
ordered that staff needs to be trained in person every four months. The training will cover the
steps on how to put out a fire, what to do if you cannot put it out, and how to take care of patients
when a fire erupts. Training will cover any questions and concerns that staff members might
have.
Online Training Software
OSHA requires employers who provide fire extinguishers in the workplace that are available for
employee use to also provide an "educational program" for affected workers that covers the
principles of fire extinguisher use as well as the hazards of incipient-stage (early stage)
firefighting (OSHA Training, 2011). Along with the quarterly in-person training, there will also
be online training software. Each staff member will be required to do online training to be
certified to use the fire extinguishers. At the end of the online training, each staff member that
successfully completes the course will be given a certificate of completion.
Someone Monitoring
Having staff supervisors monitor the fire extinguisher inspections can help staff members feel
more comfortable in using the fire extinguisher. It’s important that every fire extinguisher is
frequently inspected so that employees are not harmed when they need to use one. Each person
monitoring must make sure that every fire extinguisher is up to code. Fire alarms and fire exits
should also be monitored often.
Conclusion
Auditing and monitoring processes help health care organizations stay compliant with federal
and state rules and regulations by implementing internal checks and reviews of compliance
program operations. Monitoring includes ongoing checks to ensure quality control and verify
that all procedures are functioning as they should within the compliance program (Tait, 2018).
There are several monitoring tools that can help staff become more knowledgeable in the use of
fire extinguishers. I believe that in-person training, online training software, and staff monitoring
can help with the fire extinguisher compliance plan. Each of these monitoring tools can help
implement a safe working environment.
Sign-off Sheet Procedure for Washing Hands
A sign-off sheet is an important monitoring tool that can help staff members to not forget to wash
their hands in between patients.
Procedure
The sign-off sheet procedure is as follows:
1.
Each staff member must sign their name each time they wash their hands.
2.
Staff members must also write what time they washed their hands, so that way
supervisors can figure out if it was in between a patient or not.
3.
Staff members must also check-off if the wash station is fully stocked or not. They should
make sure that towels, soap, and hand sanitizer is not running low. If the garbage is
getting full and they cannot throw away towels, they must let a supervisor know.
4.
Each staff member must have a supervisor sign off on their sheet at the end of every shift.
5.
The supervisors will have to go through their assigned employees sign-off sheet and
make sure the times that are written align with the staff member’s schedule.
6.
If the supervisor finds an error with the sign-off sheet, they must shadow said staff
member in the next few days.
7.
If errors continue, then the staff member will face consequences.
Conclusion
It’s important that all steps of the procedure are followed, to ensure a safe and clean workplace
for patients and staff.
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REFERENCES
Infection Control. (2013).
Electronic Monitoring Systems Can Improve Healthcare Hand
Hygiene Compliance
https://www.infectioncontroltoday.com/hand-hygiene/electronic-monitoring-systems-can-
improve-healthcare-hand-hygiene-compliance
Infection Disease News. (2014).
Infection Prevention in Hospitals: The Importance of Hand
Hygiene
https://www.healio.com/infectious-disease/nosocomial-infections/news/print/infectious-
disease-news/%7Bdd1e115b-8a00-4889-9e85-8566391f2541%7D/infection-prevention-in-
hospitals-the-importance-of-hand-hygiene
OSHA Training. (2011).
Portable Fire Extinguisher Training Resources
https://www.oshatraining.com/portable-fire-extinguisher-training.php
Tait, Emily. (2018).
Health Care Auditing and Monitoring Tools for an Effective Compliance
Program
https://www.complianceresource.com/publications/health-care-auditing-and-monitoring-
tools-for-an-effective-compliance-program/