Joint Commission Basics
How do we achieve "continual readiness"?
Purposeful Rounding: Observe infection control practices, patient safety practices, environmental safety practices
Communication Practices: Legibility of documentation, Hand-offs, White Boards, System monitoring (Crash Carts, Temperature)
Collaborate with team members and provide education while rounding
Name one of the 2018 National Patient Safety Goals
Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.
Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Get important test results to the right person on time.
Use medications safely:
Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.
Take extra care with patients who take medicines to thin their blood.
Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Prevent Infection:
Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
Use proven guidelines to prevent infections that are difficult to treat.
Use proven guidelines to prevent infection of the blood from central lines.
Use proven guidelines to prevent infection after surgery.
Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
Identify Patient Safety Risks:
Find out which patients are most likely to try to commit suicide.
Prevent Mistakes in Surgery:
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
Mark the correct place on the patient’s body where the surgery is to be done.
Pause before the surgery to make sure that a mistake is not being made.
The corridors and hallways need to be clear of clutter. Nothing is to be left in the hallways for more than____
30 Minutes
What is a Patient Support Person?
An adult family member, friend or other individual, designated by the patient, orally or in writing, that supports the patient during the hospital stay.
This person can change during the hospital stay if the patient’s wishes.
This person may or may not be the decision maker
Each hand washing violation is...
A survey citation. A patient safety concern.
What is the "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.
Name one way you reduce the risk of health-care associated infections in your department.
Hand washing or using Alcohol-based hand rub with soap and water before and after each patient contact.
Alcohol-based hand rub can not be used if there is visible soiling of the hands.
What is the Emergency Operations Plan and where can you find the UM SRH Emergency Operations Plan? Who is the UM SRH Emergency Manager?
The Emergency Operations Plan outlines how the hospital/health system will organize itself to manage emergencies and how we manage major functions in emergencies. UM SRH Intranet, Policy Manager.
Beth Copp
Who is the UM SRH Safety Officer?
Michelle Kirk
Why do I need to clean my hands if I wear gloves when performing patient care?
Because bacteria can pass through tiny holes in gloves and because your hands can become contaminated when gloves are being removed, you still must remove your gloves and wash your hands or use alcohol hand gel after patient contact.
What is HIPPA? Name one way protected health information is kept private in your department? Who is UM SRH's Privacy Officer:
Health Insurance Portability and Accountability ACT. States that PHI may only be used for purposes of treatment, payment, healthcare operations. Examples of how to protect PHI: 1. Don't discuss patient information in the hallway or elevators, 2. Keep doors to exam rooms closed, 3. close/lock computer screens when away from PC, always log off.
Linda Pittman
How do you improve the accuracy of patient identification in your area?
Use TWO (2) patient identifiers when providing treatment, administering medications, collecting specimens, discharging the patient. Patient's FULL name, patient's FULL birthdate.
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
Who is the UM SRH Patient Safety Officer?
Tammy Curry (Interim)
Why do you have to "gown up, etc. when you enter an isolation room if you are just observing or providing verbal instruction, and do not intend to touch the patient?
Studies have shown that over 90% of the time a HCW enters the room, they touch either the patient or objects in the environment. This may be due to unexpected issues once the HCW enters the room (ex. alarms, IV devices)
What does the acronym "TJC" stand for?
TJC = The Joint Commission
Has there been a recent policy change at UM SRH regarding cleaning patient care equipment?
Yes - Cleaning Equipment and Medical Devices - IC 43
1) What should you do in the event of a medical equipment failure?
Take the equipment out of service. Sequester the equipment and disposable supplies used with the equipment.
Contact Biomed and report the details of the failure.
Enter an event report in UMMSafe.
Who do we contact when any regulatory body representative visits any of our UM SRH locations?
What must we verify with the visitors?
Do we send the visitors to their requested destination or have them wait in the lobby/waiting area for the UM SRH representative to arrive and greet them?
Tammy Curry, back up Michelle Kirk
Their identity
Have them wait in the lobby/waiting room.
Why can I not have food and drink in the patient care area?
OSHA’s blood borne pathogen standard – no food and drink in areas in which work involving exposure or potential exposure to blood or other potentially infectious material takes place, or where the potential for contamination (via touch or air) of work surfaces exists.
What are The Joint Commission surveyors looking to find?
System disconnects: How well do our systems work and our processes function.
Communication inconsistencies.
Compliance to the standards.
What is the name of the system utilized by UM SRH for safety event reporting?
UMMSafe
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"
What is the 3 second rule in answering surveyor questions?
If you are unsure of what is being asked, ask the surveyor to clarify the question.
Use the buddy system, ask a co-worker for help in answering a question or offer to help someone who is stumped.
If you do not know the answer to a question, don't get creative. Tell the surveyor you're unsure or don't know and either direct them to someone who can respond or tell them that you know where to find the answer and will get back to them as quickly as possible.
What must you follow, and have available for reference when cleaning patient care equipment?
MFIU - Manufacturer's Instructions for Use