TJC Basics
During the TJC survey, the surveyors will talk primarily to: A. The hospital leadership B. The doctors, nurses and frontline team members C. The patients D. The Wisconsin State Journal
What is B? The doctors, nurses and frontline team members
This is a broad requirement established by TJC that outlines expectations for quality and safety in healthcare organizations
What is a standard
Employee badges should be worn _______
What is at chest level with no stickers on the badge
A hospital TJC survey lasts for _____ days
What is 4
Name one of the top 10 most cited standards
What is....Handling of hazardous materials; uniform use of diagnosis codes, procedure codes and abbreviations; reducing risk of infections associated with medical supplies and devices; providing a safe physical facility; resuscitation services available; process to identify pts are risk of suicide & self harm; medication properly stored; safe prescribing; process to evaluate quality and safety of patient care by each medical staff member; process to improve safety of high-alert medications
It is when TJC evaluates compliance with standards related to care, treatment and services provided to a patient (The surveyor will follow the path of a selected patient through the organization)
What is individual tracers (Patient tracers)?
This is the name of the individual who guides the surveyor and help facilitate the introduction to unit/area leaders during the survey
Who is the survey escort
If I hear active shooter overhead, I should . . .
What is run, hide, and fight?
This is how many years an organization is accredited for after a successful survey
What is 3 years
Dr. X is starting his shift. He walks down the hall. Starbucks in hand, and waves "hi" to the nurses, PCPs. He rounds the corner, going through the propped open fire door to stand in front of the board. He notes that there are 2 patients with the same initials on the board. He dumps his empty coffee cup in the trash, and logs into Epic. Where's TJC violation?
Only special fire doors may remain open. Doors may not be propped open.
These are the areas in which UW Health has received Joint Commission accreditation
What are the hospital, home care and laboratory
I am an individual who is well versed in TJC regulatory standards and can assist with questions in my area
What is a content expert
When there is a fire, team members should RACE and PASS. What do the mnemonics stand?
R- Rescue/Remove people from smoke/fire, A- Alarm - pull fire alarm and call, C- Contain the fire (close doors) E- Extinguish the fire when it is safe to do so or 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
True or False: Because we are TJC accredited we do every have to worry about CMS requirements or surveys
What is False
This is the area or group you can reach out to for TJC readiness plans and questions
Who are he Accreditation and Regulatory Readiness Specialists, the Director of Quality and Patient Safety and our Chief Quality Officer
A ______ is the very first thing that happens during a Joint Commission survey
What is an opening conference?
This is a specific criterion or measure that is used to evaluate compliance with a TJC standard
What is a measurable element or element of performance
True or False: It is acceptable to have items in the areas beneath sinks
What is False
This is the most effective way to stop the spread of hospital acquired infections
What is hand washing/hand hygiene
What card should you have behind your badge?
What is Emergency Response Codes?
What is July 23, 2024?
This person records surveyor questions and key issues throughout the survey process
What is a survey scribe
True or False: It is facilities responsibility for keeping the environment of care safe for patients, families and team members.
What is false? All team members are responsible!!
Their accreditation process involves rigorous evaluation of healthcare organizations to ensure they meet specific performance standards related to _____ and______.
What is quality and safety
What is....
I would ask my leader, I would look up the answer on U-Connect, I would look at the policy