Joint Commission Basics
Name one of the 2024 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- Reduce 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
The corridors and hallways need to be clear of clutter. Nothing is to be left in the hallways for more than____
30 Minutes
A FULL NURSING ASSESSMENT SHOULD OCCURE WITHIN _________OF ADMISSION
24 HOURS
TRUE OR FALSE
IF I WORK NIGHT SHIFT, I WILL NEVER SEE A TJC SURVEYOR?
FALSE-IT IS POSSIBLE FOR AN AGENDA TO LIST AN 0500 START TIME DURING A FOUR DAY SURVEY
TRUE OR FALSE
TJC DOES NOT REQUIRE HMC TO HAVE A CYBERSECURITY COMMITTEE
FALSE
A PATIENT HAS ORDERS FOR ACETAMINOPHEN 1000 MG P0 EVERY 6 HOURS PAIN 4-6 AND PERCOCET 1 TAB PO Q 4 HOURS PAIN 4-6.
HOW DOES THE NURSE DECIDE WHICH TO ADMINISTER FOR PAIN OF 5?
NOTIFY PROVIDER FOR CLARIFICATION
IF PROVIDER CANNOT BE REACHED, ADMINISTER NON-OPIOD FIRST
HMC POLICY- MEDICATION ADMINISTRATION-MM
IF A TJC STANDARD IS NOT AS STRICT AS THE HMC POLICY ABOUT THE SAME STANDARD, WHICH I AM REQUIRES TO COMPLY WITH/
THE HMC POLICY
What is HIPPA? Name one way protected health information is kept private in your department? Who is HMC's 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.
Janis Blackwell Ext 52108
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.
How do we interpret for non-English speaking patients?
Approved Language Services/Cyracom – staff do NOT translate! If a patient/family refuses translation services, a waiver must be signed & placed in the medical record
TJC DOES NOT HAVE ANY STANDARDS RELATED TO DOCUMENT CONTROL LIKE DNV DOES
TRUE OR FALSE
FALSE
HOW MANY LIGATURE FREE ROOMS DOES HMC HAVE FOR PLACEMENT WHEN CARING FOR AN INPATIENT AT RISK OF HARM TO SELF?
NONE-WHICH IS WHY WE UNIVERSALLY PLACE 1:1 AND CLEAR ALL EQUIPMENT THAT IS NOT MEDICALLY NECESSARY
WHEN THE "CODE INFO" IS ANNOUNCED, _______________ SHOULD BE PLACED IN AN EMPTY PATIENT ROOM OR STORAGE AREA
NOTHING
WHO CAN PROVIDE INFORMED CONSENT?
Does my signature on the witness line of an HMC Procedure Consent form indicate I witnessed Informed Consent?
The individual credentialed to perform the procedure.
NO!!!!!- It means I witness the patient's signature on the form...the patient is signing that they received informed consent and that all their questions were answered.
WHO IS ULTIMATELY RESPONSIBILITY ACCOUNTABLE FOR THE SAFETY AND QUALITY OF CARE, TREATMENT AND SERVICES AT HMC?
THE GOVERNING BODY. THE HMC ADVISORY BOARD-
CREATES A CULTURE OF SAFETY AND QUALITY
HOLDS MEDICAL STAFF ACCOUNTABLE
SETS PRORITIES FOR PI ACTIVITIES
PROVIDES RESOURCES NEEDED TO MAINTAIN SAFE, QUALITY CARE, TREATMENTS AND SERVICES
The Joint Commission survey is conducted: a) Annually b) Every 2 Years c) Every 3 Years d) Every 4 Years
c) Every 3 Years-Widow opens 18 months after last survey
WHEN PLACING A PATIENT IN A POSEY VEST AT HMC, WHAT EXTRA PRECAUTION IS NECESSARY?
NONE-WE DO NOT USE POSEY VESTS AT HMC
WHAT IS HMC'S MISSION STATEMENT?
WHAT IS HMC'S PURPOSE STATEMENT?
Hillcrest Medical Center is a premier provider of health care services, delivered with COMPASSION for patients and their families, RESPECT for all employees, physicians and other healthcare professionals, ACCOUNTABILITY for our fiscal and ethical performance, and RESPONSIBILITY to the communities we serve.
Changing Lives for the Better, Together