TJC Basics
What is The Joint Commission (TJC)?
An independent, non-profit organization that evaluates health care organizations to ensure they maintain a high level of patient care. TJC accreditation is needed for health care organizations to treat commercially insured patients.
What is the number one way to reduce the risk of health-care associated infections?
Handwashing
How soon after medication administration should pain re-assessment occur?
within 30 minutes of IV administration, within 1 hour of oral administration and non-pharmacological intervention
What is the focus of the environment of care standards?
safety, fire prevention, and maintaining a safe physical environment for patients and staff
What is the “dry time” for purple top Sani-Wipes and what does that mean?
3 minutes
The time needed for disinfection.
What should you say and do if a surveyor asks you a questions that you don't know?
Say "I know how to find the answer" and then use your resources to find the answer or ask someone who knows.
What is your personal responsibility when you hear a "Pediatric Abduction Alert" called?
Take inventory of all patients/infants on unit & report to charge RN, monitor all exits from the unit and ensure no individuals enter or leave the unit, report any suspicious individuals
How much clearance should be between storage and the bottom of sprinkler heads?
18 inches
What do the acronyms RACER and PASS mean?
Rescue, Alarm, Contain, Extinguish, Relocate
Pull pin, Aim, Squeeze, Sweep
True or False: When preparing surgical instruments for transport to SPD, it is not necessary to ensure instruments are free of debris and bioburden.
False - instruments must be free of debris/bioburden and sprayed thoroughly with pre-cleanse prior to packaging and transfer to SPD.
What does "HIPAA" stand for and what is it?
Health Insurance Portability and Accountability Act. It states that protected health information (PHI) may only be used for treatment, payment, and/or healthcare operations.
What steps need taken if a patient falls in our department?
Address patient injury, notify provider and leadership, enter SafeDay incident report.
What is the purpose of root cause analysis (RCA) in a healthcare setting?
To investigate the underlying cause of a serious safety even and implement improvements to prevent future occurrences
Who is responsible for ensuring compliance with environment of care standards in the FBC?
Everyone! Including you!
What color outlet should critical and/or lifesaving equipment be plugged into?
Red
Name some ways that PHI is kept private in our department.
Examples: Don't discuss patient info in on-stage areas, keep exam room doors closed, close computer screens when away from it, verify patient identifiers over the phone, etc.
True or False: All activities/conversations must be halted during a pre-procedure or pre-incision Time Out.
True! Everyone must engage in the process to ensure patient safety.
Who is authorized to shut off medical gas valves in patient care areas during a fire response?
Nursing, RT, Plant, Public Safety
If you sustain a non-emergent injury at work, what are the three things you need to do?
Notify manager, Call Employee Health, Complete event report
If you notice a medical gas panel alarming, what do you do?
Notify plant at 2-6295
How often are TJC surveys conducted?
Every 3 years
What is the primary focus of tJC's Universal Protocol in prevention errors in surgical procedures?
During an active shooter situation, what should you do if you are NOT in the active area?
Silence alarms, phones, TVs, etc., secure your area and shelter in place until you receive notification that it is safe
Corridors and hallways must be clear of clutter. What is the longest period of time that something can be left in the hall?
30 minutes
True or False: if you are engaging with a surveyor, you are not allowed to seek support from your peers.
False! Teamwork makes the dream work - if you see a colleague engaging in a discussion, join in and offer support. You aren't expected to have all of the answers all the time, you are expected to utilize your resources, which includes each other!