The Joint Commission Survey Readiness Game

Joint Commission Basics

100

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. YOU! That's why you are playing this game, right?

200

What is "tracer methodology"?

Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.

300

What is HIPPA? Name one way protected health information is kept private in your department? Who is Northports Privacy Officer:

Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. Examples of how to protect a Veterans PHI: 1. Don't discuss patient information in the hallway or elevators, 2. Keep doors to exam rooms closed, 3. close computer screens when away from PC and lock screen and take PIV card if leave area. Nicole Mattila, Bldg 9 Rm 242 x 4544

400

What do the acronyms "TJC" and "CSR" stand for?

TJC = The Joint Commission CSR = Continuous Service Readiness

500

The Joint Commission survey is conducted: a) Annually b) Every 2 Years c) Every 3 Years d) Every 4 Years

c) Every 3 Years

Patient Saftey

100

Name one of the 2014 National Patient Safety Goals

NPSG 1- Improve accuracy of patient identification NPSG 2- Improve effectiveness of communication among caregivers NPSG 3- Improve safety of using medications NPSG 6- Improve the safety of Clinical Alarms NPSG 7- Reduce risk of health-care associated infections NPSG 9- Reduse the risk of falls NPSG 14- Prevent health care-associated pressure Ulcers NPSG 15- The organization identifies safety risk inherent to the patient population Universal Protocol

200

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!

300

How do you improve the accuracy of patient identification in your area?

Use TWO (2) of the 3 identifiers used at Nothport when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's FULL name, patient's FULL Social Security Number and/or patient's FULL birthdate.

500

Name 3 of the unapproved abbreviations.

(1) .U or u (unit) (2) IU (international unit) (3) Q.D., QD, q.d. (daily) or Q.O.D., QOD, q.o.d. (every other day) (4) 1.0 (no terminal zeros) .5 (always use a leading zero - "always lead never follow" (5) MS, MSO4,MgSO4 (morphine sulfate or magnesium sulfate)

Work Place

100

The corridors and hallways need to be clear of cludder. Nothing is to be left in the hallways for more than____

30 Minutes

200

If you wanted to know what your role is in a bomb threat, which binder would you find the information in?

The Red binder

300

What do RACE and PASS mnemonics stand for when there is a fire?

RACE - 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 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

400

1) What should you do in the event of a Minor hazardous material spill? 2) For Major Spills?

1) Check the MDS book and follow instructions 2) Evacuate patients and staff away at a safe distance and Call 2555

500

Per Life Safety Standards there needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.

18"