Joint Commission Basics
These are the people that TJC surveyor's are most interested in interviewing.
Who are the doctors, nurses and staff (YOU!)?
Identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery. These represent a category that are driven by high volume mistakes made throughout health care institutions.
What are National Patient Safety Goals?
This is the code called when there is a fire.
What is Code Red?
During an interview with a TJC surveyor, I will do these things.
What is ONLY answer their specific question and not offer more than what was asked.
These should be worn above the waist and on at ALL TIMES when at work.
What is my hospital ID badge?
1) Follow the experience of care for individuals through the entire health care process when focus is on the integration of related processes and the coordination and communication among disciplines and departments in those processes.
What are individual and system "tracers"?
This is the way you reduce the risk of health-care associated infections. It may involve soap and water before and after each patient contact or an alcohol-based hand rub if there is no visible soiling and C. Diff is not suspected.
What is handwashing?
RACE is the acronym used in this type of situation.
What do you do in case of a fire? Rescue Alarm Confine Extinguish/Evacuate
Smile and introduce yourself.
What should you do if a surveyor approaches you?
I will do this if I see something in the wrong place or where it doesn't belong.
What is pick it up and put it where it belongs?
Health Insurance Portability and Accountability Act states that Protected Health Information (PHI) may only be used for purposes of treatment, payment, healthcare operations.
What is HIPAA?
We use these 2 patient identifiers to ensure we have the correct patient and/or the correct record.
What are the patient's name and date of birth?
You use this acronym to guide the use of a fire extinguisher - include what each letter of the acronym represents. PASS
What is PASS?
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 at base of fire
Will be sure to complete this task should a surveyor ask to speak with me while I am in the middle of providing patient care.
What is Patient Handoff (SBAR)?
NOTE: You can always explain you are in the middle of patient care and can ask if it is OK to finish what you have started.
These can never be stored in clinical space or left on the floor as they may harbor bugs and other critters
What are carboard boxes?
They care the "gatekeeper" for CMS and ensure that patient care is delivered in a safe manner, by qualified individuals, and in an environment that is safe for everyone. If they find concerns, an organization could be placed on conditional status which could jeopardize the organizations ability to operate.
Who is the Joint Commission?
UTMC follows this United Nations Agency to guide its approach to Hand Hygiene
What is the WHO - the World Health Organization
This is needed on the bottom shelf of any clean/non sterile storage location to prevent splashing when floor is cleaned.
What is solid shelving?
I can do this if I am not sure of what the surveyor is asking or am having trouble finding the answer.
What is "Can I ask that you word that question differently?"
NOTE: Team members can help OR if you know where to find the answer you are allowed to use your resources.
These need to be segregated between full and partially used
What are oxygen tanks?
The Joint Commission survey is conducted on a regular basis. This is the time frame for that survey.
What is every 36-39 months. (every three years)
I will be never leave a patient alone should they present with this criteria.
What is suicidal ideation?
This is the minimum number of unobstructed inches needed from the ceiling so that sprinklers will work properly.
What is 18 inches?
I should NEVER place anything in front of these in my clinic area. Medical Gas Valves and Fire Extinguishers/Pulls
What are fire pull stations and extinguishers?
This is the code that refers to severe weather.
What is code gray?