Patients: Do no harm. Provide safe and effective care for our patients.
Process: Report near misses and safety concerns openly. Evaluate and make systems changes to improve patient care.
Property: Protection for our physical plant, equipment, supplies, clinics, and prepare for natural disasters.
Examples of ESRD Core Survey Medical Director Interview Questions
Patient and staff voice/culture of safety
- What do you do to set the tone for the culture of this facility?
- How do you and facility management encourage patients and staff to openly voice concerns, suggestions and report grievances and errors or near misses?
- How do you review, evaluate, and act on patient and staff suggestions/complaints/incidents?
Staffing
- How do you monitor and address staffing issues, such as staff turnover at this facility?
- How do you work with the governing body to ensure there is sufficient qualified staff to meet patients’ needs?
Staff education/training/knowledge
- How do you ensure that all staff at this facility are appropriately trained and competent to perform their job responsibilities, including PCTs and anyone performing water treatment and reprocessing (if applicable)?
Staff & patient partnership in care planning
- How do you ensure that patient plans of care are individualized and patients are encouraged to attend plan of care meetings
Adverse events
- When and how are you alerted of adverse events/ occurrences or problems at the facility?
- What is your role regarding the review of occurrences and taking actions to prevent recurrence?
QAPI
- What is your role in the QAPI program?
- How do you ensure that the QAPI team regularly monitors all required/appropriate quality metrics, and segments the data for each modality and dialysis setting?
- What is the QAPI process at this facility for data analysis and identification of areas needing improvement?
- How are these areas prioritized and addressed for performance improvement?
Modality
- What is this facility’s process for ensuring that every patient receives fact-based unbiased education about transplant and all possible dialysis modalities and settings?
- What is this facility’s process for referring candidates for transplant evaluation and to other facilities for dialysis modalities and settings not offered here?
Infection Control
- How are staff, including medical staff, and patients educated about infection prevention?
- How does this facility monitor whether staff members are following infection control policies & procedures?
Admission & Involuntary transfer/discharge
- What do you do to prevent situations with patients that may lead to involuntary transfers/discharges?
- How do you work with the interdisciplinary team and patient care staff to resolve the issues of concern?
- How do you assure that the interdisciplinary team follows admission/discharge/transfer policies and procedures?
Medical Director Responsibilities
- What are your responsibilities as medical director at this facility?
- How do you participate in the development, review, and approval of the facility’s “patient care policies and procedures manual” and assure that all policies and procedures are adequate, accurate, and up to date?
- How do you provide oversight to assure that other medical staff members who provide care in the facility are informed about QAPI activities and goals and are adhering to facility policies and procedures?
- How do you ensure that the water for in-center dialysis and home dialysis (if applicable) is chemically and biologically acceptable?
Is there anything else you would like to tell me about this facility?
Disaster Preparedness
DaVita Emergency Management’s (DEM) role is to assist with emergency preparedness and response to events that impact the Village.
Your role:
- Have a plan for your facility
- Educate on the plan and update information
- Practice with your teammates and patients
Resources/Tools:
- Emergency Preparedness Checklist
- OneView Knowledge Base Resources