Joint Commission Basics
Patient Safety
Fire Safety
What do WE as Management need to do to prepare
Joint Commission Etiquette
100
The doctors, nurses and staff
During the JC survey, the surveyors will talk primarily to: B. The doctors, nurses and staff YOU!!!!
100
NPSG 1- Improve accuracy of patient identification NPSG 2- Improve effectiveness of communication among caregivers NPSG 3- Improve safety of using medications NPSG 6- Reduce the harm associated with Clinical Alarms system NPSG 7- Reduce risk of health-care associated infections NPSG 9- Reduse the risk of falls NPSG 15- The hospital identifies safety risk inherent to the patient population
Name one of the 2017 National Patient Safety Goals
100
30 Minutes
The corridors and hallways need to be clear of cludder. Nothing is to be left in the hallways for more than____
100
6
What is the number of copies of our schedule need to be brought to the command center?
100
do not over-speak (if you are not asked) or mis-speak (if you do not know the answer).
How to answer surveyors?
200
Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.
What is "tracer methodology"?
200
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!
Name one way you reduce the risk of health-care associated infections in your department.
200
R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish
What does the acronym R.A.C.E stand for?
200
8am
What is the latest time schedule information must be brought to the command center?
200
Inform surveyor that you have to address the needs of a patient and/or hand off to a colleague
When interacting with a surveyor, it is okay to:
300
Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations.
What is HIPPA?
300
Patient's FULL name Patient's Medical Record Number
How do you identify a patient with an ID band in your area?
300
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
What does the PASS acronym stand for?
300
7:30am
What time should I be here during a joint commission visits?
300
Do what would normally be done if there wasn’t a survey, consult with your manager or co-worker.
If staff are unable to locate something in a patient’s EMR during a survey, what should they do?
400
The Joint Commission’s state-of-the-art standards focus on patient safety and quality of care. The Joint Commission standards are updated regularly to reflect the rapid advances in health care and medicine. The hospital accreditation standards number more than 250, and address everything from patient rights and education, infection control, medication management, and preventing medical errors, to how the hospital verifies that its doctors, nurses, and other staff are qualified and competent, how it prepares for emergencies, and how it collects data on its performance and uses that data to improve itself.
What do standards focus on?
400
-Patients FULL name -Date of Birth (Month/Day/Year)
How do you Identify a patient without an ID band in your area?
400
Smoke or Fire condition
What is Code Red?
400
Sweeps
What is the very first thing I do when I come to work?
400
Be welcoming and polite – SMILE! If caring for a patient, politely indicate you will be right with the surveyor; and arrange for someone to cover your patients. Be enthusiastic and confident – Remember, you know your job better than anyone else.
What is the way we interact with the surveyor?
500
c) Every 3 Years
The Joint Commission survey is conducted: a) Annually b) Every 2 Years c) Every 3 Years d) Every 4 Years
500
4min=Orange Top 2min=Purple Top
What are the wet times for the two types of Sani-cloth wipes that we use to disinfect equipment.
500
18"
Per Life Safety Standards there needs to be ___inches or more of open space maintained below the sprinkler deflector to the top of storage.
500
Immediately accessible and responsive to calls/emails/texts
What is your state of readiness during TJC visit?
500
slow down, smile, take a breath, and relax.
What do you do if you get flustered?
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