JC Basics
During the JC survey, the surveyors will talk primarily to: A. The Hospital Administrators B. The doctors, nurses and staff C. The patients D. The Houston Chronicle
B. doctors, nurses, and staff
Name one of the 2020 National Safety Patient Goals
(1) Identify patients correctly (2) Improve staff communication (3) Use medicines safely (4) Use alarms safely (5) Prevent infection (6) Identify patient safety risks - suicide, (6) Prevent mistakes in surgery
How do we support a culture of safety?
Event reporting, near miss reporting, encourage and support speaking up
How do you document in your procedure note that you confirmed the correct identity of the patient and the correct site of the procedure?
Document on the Universal Precautions form found in forms anywhere
What quality performance data are collected in your area and how are you involved?
Group response
What does the surveyor expect a nurse to do before participating in the unit tracer?
Surveyor will watch for the nurse to hand-off patients to another nurse
Name one way you reduce the risk of health-care associated infections in your department.
Handwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 15 seconds. Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected. Use of artificial or long fingernails is prohibited. LATHER UP!
What process is used when patients or visitors are either verbally or physically aggressive?
APT - Aggression Prevention Team
What's wrong with this order?
Morphine 2 mg q2h prn pain rating 4-7
Dilaudid 2 mg q2h prn pain rating 4-7
Duplicate therapy
What is the TJC violation?
walking down hall with coffee cup with lid in place
entering an isolation room with PPE on
fire door propped open
HH performed upon exit of a patient room
Doors may not be propped open.
What is HIPPA? Name one way protected health information is kept private in your department.
HIPPA: Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. (1) Shredders, (2) don't discuss patient information in the hallway or elevators, (3) keep doors closed or curtains pulled, (4) close computer screens.
How do you improve the accuracy of patient identification in your department?
Use TWO (2) identifiers when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's name and Patient's MRN
What do RACE and PASS mnemonics stand for when there is a fire?
R - Remove patients and others, A- Alarm, C- Contain the fire (close doors), E- Extinguish the fire when it is safe to do so or E - Evacuate P- Pull the pin, A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle form side to side
What's the fifth vital sign that we document on ALL patients and where do we document it?
Pain score
How do you know a piece of equipment (e.g. defibrillator, ultrasound) is okay to use?
Check on the equipment for a dated sticker that has been serviced by biomed.
How many days is our TJC survey?
Three
How are you improving the effectiveness of communication between caregivers?
(1) Telephone orders are read back (2) Critical lab values are read back (3) hand off report (4) use of standardized abbreviations and avoiding certain unapproved dangerous abbreviations
What should you do in the event of a hazardous material spill?* * Material more hazardous than cafeteria food, but less hazardous than anthrax
Evacuate at a safe distance, notify security/EVS
True or false Can a minor sibling translate for a parent if the minor is 13 years old, clearly fluent in both languages and both the minor and the parent consent to using the minor as the interpreter.
False
What is an appropriate response to the surveyor when asked a question you do not know the answer to?
Can I get that to you later?
I would ask....
I would look....
How often are fire drills conducted?
We conduct them quarterly.
What evidence based secondary screening tool do we use for SI patients?
CSSRS - Colombia Suicide Severity Rating Scale
Where do we shelter staff during an emergency?
3rd floor
Provider performing the procedure
What are two Performance Improvement Projects currently under way?
Group answer