Joint Commission Basics
Use at least two patient identifiers when providing care, treatment, and services. Improve effectiveness of communication among caregivers, ex. Report critical results of tests and diagnostic procedures on time. Make improvements to ensure that alarms on medical equipment are heard and responded to on time. Reduce the risk of health care–associated infections by following CDC hand hygiene guidelines. Reduce the risk of suicide. Improve health care equity. Prevent mistakes in surgery.
What are 2024 National Patient Safety Goals?
Keep hallways clear of clutter. Do not block exits, fire extinguishers or fire alarms.
What are ways to increase fire safety.
Simply answer the question.
How to answer surveyors? do not over-speak (if you are not asked) or mis-speak (if you do not know the answer).
Above the waist.
Where should your hospital ID be worn?
1) Follow the experience of care for individuals through the entire health care process. 2) Evaluate the integration of related processes and the coordination and communication among disciplines and departments in those processes.
What are individual and system "tracers"?
Handwashing.
Name one way you reduce the risk of health-care associated infections in your department. Wash 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!
RACE
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? Remember, this is an open book test. YOU know your job the best.
Pick it up!
What do I do if I see garbage on the floor?
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 HIPPA?
2 patient identifiers
What are the Patient's Full Name and MRN?
PASS
How do you use a fire extinguisher? 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
Patient Handoff
What do you do if you are caring for a patient prior to speaking with a surveyor?
EVS has agreed to maintain patient microwaves and Dietary handles patient refrigerators (we are responsible for staff break room microwaves and refrigerators) . If you see that either is in need of attention, please notify those departments.
Who cleans the patient microwave and refrigerators?
Patient rights and education, infection control, medication management, preventing medical errors, hospital staff verification of qualified and competent staff, emergency preparation performance data collection and its use towards improvement.
What do the Joint Commission Standards focus on?
kept short, clean, and natural, meaning no artificial nails or extensions, with the length generally not exceeding a quarter inch past the fingertip; this is to minimize the risk of harboring bacteria and spreading infection to patients. Polish free of chips. No acrylics, gels, stick-on or false nails of any kind.
How are fingernails required to be in the clinical areas?
Code Red
What code is called in the event of a fire?
Ask for help from colleagues or clarification of question from surveyor.
What do I do if I have trouble answering a question or navigating the medical record? They want to see how we work together. If you get flustered, take a deep breathe, smile and relax. If you see someone struggling, jump in to help! Have each others back.
The only place that full oxygen tanks are kept. All other oxygen tanks are considered partial (anything less than 100% full) or empty (anything less than 500psi).
What is the code cart and facilities?
Approximately every 3 years.
How often The Joint Commission survey is conducted?
Proactively round on patients to reduce the need for call bell use. Customize telemetry alarms based on provider parameter orders. Change electrodes per policy to prevent false alarms.
What are ways to reduce Alarm Fatigue?
Relax! Be confident, you know this stuff :) It's okay to say you don't know something as long as you let them know you will find out the answer. It's okay to ask your coworkers for help. This is an open book test!
What you should remember when being questioned by a surveyor?