5-Diamond Patient Safety Program

To increase facility staff and patient awareness and knowledge of emergency planning, response, and recovery.

• Complete the in-service training module Are You Ready? Emergency Preparedness for Dialysis Facilities.
• Complete Patient Needs Assessment Questionnaires , available in English or Spanish.
• Submit Disaster Contact Information to Network 11.

• Perform internal disaster drills involving facility personnel and patients (with pre-drill education and post-drill evaluation).
• Complete a Facility Hazard Assessment.
• Develop Emergency Management Plan for your facility.
• Develop a Facility Emergency Box and Patient Emergency Kit, the latter of which would be displayed in the waiting area for patients to view.
• Create a maze of the building and have patients find their way to the nearest fire extinguisher and emergency exit.
• Distribute word search to patients.
• Furnish all patients with an Emergency Data Set and Emergency Diet instructions.
• Children's Activities (coloring books, puzzles, etc.) from the American Red Cross.

• Emergency Preparedness for Dialysis Facilities.
  • Hazard Assessment Form.
  • Drill Critique Form.
  • Drill Attendance Record.
  • Emergency Response Checklist.
  • Evacuation Kit for Dialysis Physical Site Damage Assessment Form.
  • Equipment Damage Assessment Form.
  • Supply Checklist for Dialysis Treatment.
  • Home Emergency Equipment & Supplies.
  • Emergency Facilities.
• Network 11 Patient Emergency Guide: A Resource for ESRD Patients in English and Spanish.
• CMS Emergency Preparedness: A Guide for People on Dialysis in English and Spanish.
• Medical History and Medication List.
• Making Alternate Arrangements for Treatment.
• Emergency Kit (supplies, meds/medical supplies, food).
• Emergency Diet.
• How to Disinfect Water.
• Getting off the Dialysis Machine.
• Resource List.
• Patient Needs Assessment Questionnaire in English and Spanish.
• KCER Coalition Disaster Plan Template.
• Network's Position Statement on Disaster Contacts.
• ESRD Conditions for Coverage.
• Fact Sheet on Water Systems from CDC.
• Emergency Dataset for HD and PD.
• Disaster Patient Activity Report (DPAR).
• Patient Emergency Kit Word Search.
• Emergency Preparedness FAQ

Websites of interest:

• http://www.esrdnet11.org/resources/disaster_prep.asp
• http://www.kcercoalition.com
• http://www.kidneydisasters.org
• https://dialysisunits.com
• http://www.ready.gov

• 100% of staff participate in in-service on emergency preparedness and at a minimum, hold biennial staff in-servicing on emergency preparedness.
• 90% of patients complete a Patient Emergency Planning Needs Assessment Questionnaire with the assistance of facility staff.
• Facility must submit its Disaster Contact information to the Network.

After you have completed this module, and have documented the required measures, please submit the following documents via mail or fax.

5-Diamond Patient Safety Program
1360 Energy Park Drive, Suite 200
Saint Paul, MN 55108
651-644-9853 Fax

1. Completed project reporting form.
2. In-service attendance log. (Please note that the facility in-service must be completed as a group.)
3. Completed Patient Needs Assessment Questionnaires ,available in English or Spanish.
4. Completed Disaster Contact Information form.

For more assistance contact us at 5diamondsafety@nw11.esrd.net or at 651-644-9877