Joint Commission Basics
This person is the one that the Joint Commission staff will want to talk to.
YOU! That's why you are playing this game, right?
Name one of the 2025 Hospital National Patient Safety Goals
NPSG 1- Identify patients correctly; NPSG 2- Improve staff communication; NPSG 3- Use medicines safely; NPSG 4- Use alarms safely; NPSG 5- Prevent infection; NPSG 6- Identify patient safety risks; NPSG 7- Improve health care equity; NPSG 8- Prevent mistakes in surgery
The corridors and hallways need to be clear of clutter. Nothing is to be left in the hallways for more than____
30 Minutes
What are staff required to do if they hear the fire alarm and are not in the immediate fire area?
Remain where they are, close all doors, and await “All Clear” instructions from Security or the Administrator on Call.
What should staff do if they see a stained ceiling tile, water leak, or tripping hazard?
Report it immediately to the Engineering Department through the CMMS (work order system) or by calling Engineering.
Surveyors use information from an organization to follow the experience of care, treatment, or services for a number of patients through the organization’s entire care delivery process.
What is "tracer methodology"?
What is the most important way to prevent infections?
Hand Hygiene! Hand hygiene with alcohol-based hand sanitizer or soap and water. Follow compliance with CDC or World Health Organization hand hygiene.
What should staff do if they see a suspicious package or unattended bag?
Do not touch it; clear the area and call Security at 7102.
What number should you dial to report a fire, active security threat, or major spill emergency?
7102 – Direct line to Security
What should you do if you find a damaged or frayed electrical cord on a piece of equipment?
Immediately remove the equipment from service, tag it “Do Not Use,” and report it to the Engineering Department for inspection or repair.
This states the PHI may only be used for purposes of treatment, payment, healthcare operations. Examples include: 1. Don't discuss patient information in the hallway 2. Keep doors to exam rooms closed, 3. close computer screens when away from desk. 4.don't keep papers with patient information on counters or desks.
What is HIPPA?
How do you improve the accuracy of patient identification?
Asking patient's FULL name and patient's FULL birthdate before providing treatment, administering medications or collecting specimens.
What should you do if you notice someone without a badge or wearing the wrong type of badge?
Politely stop them and contact Security – all staff, patients, visitors and contractors must have proper identification.
How do you verify physician privileges?
Intranet – Departments – Medical Staff – Credentialing Roster
What color are emergency power outlets and what are they connected to?
Red outlets – connected to the emergency generator system.
What does the acronym "TJC" stand for?
TJC = The Joint Commission
How, when, and who should report a patient safety event?
All safety events should be entered in SPEAK as soon as possible by the person that has first hand knowledge of the event details.
What is the hospital’s shelter-in-place procedure for severe weather?
Move patients and staff away from windows into hallways or interior rooms; close doors; await “All Clear.”
Who should be contacted if there’s an issue with temperature, lighting, or door hardware in a patient care area?
The Engineering Department – they manage all facility-related repairs and comfort adjustments.
What is the purpose of a Safety Data Sheet (SDS), and where can staff find them?
To provide information on handling, storage, and emergency procedures for chemicals – found in the department SDS binder or online via the main intranet page.
How often does TJC survey Shriners?
The Joint Commission (TJC) conducts a triennial survey which is an unannounced, on-site inspection of accredited healthcare organizations, conducted every three years to evaluate our compliance with quality and safety standards and patient care.
How are patients and families educated on methods available to report concerns related to care, treatment, services, and patient safety issues?
At the time of admission/registration in the Patient Rights and Responsibilities brochure and surgical patient are given a surgical education binder in Who Participates in Your Care section.
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"
How do we handle complaints at Shriners?
Staff are empowered to listen, apologize, express thanks for bringing the matter to our attention, resolve, and notify manager. If the patient/family is not satisfied, involve your manager and if your manager is not available involve the closest manager. If the concern cannot be resolved, involve the Director of Performance Improvement/Risk Management.
When using extension cords, what is the most important safety rule?
They are for temporary use only and cannot replace permanent wiring; must be plugged directly into a wall outlet, not into a power strip.