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
What are the two patient identifiers approved at NCH?
Name and MRN
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
What is the “dry time” for gray 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 "Code Adam" called?
Monitor all entrances to your floor (elevators and stair wells) and call security if you see anyone matching the description.
What PPE is required for contact/droplet precautions and where is it kept?
Mask, gloves and gown. All supplies should be stocked daily in the isolation carts by the PCAs
What do the acronyms RACE and PASS mean?
Rescue, Alarm, Contain, Extinguish
Pull pin, Aim, Squeeze, Sweep
How do you clean patient toys and is there a difference for stuffed animals and books?
Wipe hard toys with gray Sani-Cloth wipes and let dry for 3 minutes. If toy might go in a patient's mouth, then rinse with water. Soft toys and books must be given to patients to keep.
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.
Where are the fire pull stations and extinguishers in clinic?
Pull stations are by the stairwells
At least 5 extinguishers throughout clinic/diagnostics
What types of nail manicures are approved at NCH?
Only polish that can removed in less than 30 seconds. (i.e. no acrylics, dip, gel, shellac, etc.)
What code is a bomb threat and what is the process if you receive one over the phone?
Code Black
Use orange card to collect information and them notify the ECC at x23333 immediately.
What does "IFU" stand for?
Instructions for Use
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.
What steps need taken if a patient falls in our department?
Address patient injury, notify provider and leadership, enter SafeDay incident report.
Where are the medical gas shutoffs in clinic and who is allowed to turn them off?
At the front desk. Managers or charge nurses can turn off in emergency, otherwise Respiratory Care or Engineering should turn off.
If you sustain a non-emergent injury at work, what are the three things you need to do?
Notify manager, Call Employee Health, Complete SafeDay report
What equipment at NCH needs an IFU?
All patient equipment
How often are TJC surveys conducted?
Every 3 years
What is the ECC and what do they do?
Emergency Communications Center. Emergency operator for Code Blue, Medical Assist, Protective Services Urgent, etc.
How many inches of open space are needed around sinks? What is this area called?
10 inches of open space called the Splash Zone
Where do you find the emergency procedures in the event the computers are down?
Red Emergency Preparedness manual at the front desk
How do you look up an IFU?
Common Equipment Disinfectant List or the OneSource online database. Both of these are on ANCHOR.