Joint Commission

Accredidation

100

Hospitals must undergo this in order to earn and maintain Joint Commission accredidation

What is on-site survey by the Joint Commission

200

Rountine Joint Commission re-accredidation surveys take place within every ___ years

What is ~3 years (can occur unannounced between 18-36 months from last survey)

300

Launched in 1996, this website allows consumers to search for Joint Commission accredidated and certified organizations and provides each organization's quality report

What is Quality Check Website (www.qualitycheck.org)

400

In 2004, the Joint Commission and Centers for Medicare and Medicaid Services began working together to align measures common to both organizations. These standardized commons measures are integral to improving the quality of care provided to hospital patients and bring value to stakeholders by focusing on the actual results of care

What is the Hospital Quality Measures

500

Hospitals are required to collect and transmit data to the Joint Commission for a minimum of 4 core measures sets or a combination of core measure sets. These include: (name 3)

What is acute myocardial infarction, heart failure, pneumonia, perinatal care, hospital-based inpatient psychiatric services, children's asthma care, surgical care improvment project, hospital outpatient measures, venous thromboembolism, and stroke

Accountability Measures

100

As a part of the priority focus process (PFP) and strategic surveillance system (S3), accountability measures are rated higher or lower than non-accountability measures?

What is higher

200

Joint Commission accredited hospitals (not critical access hospitals) are required to meet this composite compliance target rate (%) for performance on ORYX accountability measures

What is 85%

300

The too is available to hospitals accredited by the Joint Commission in order to provide actionable data and information that can be used to prioritize and drive quality and safety improvement. It provides a series of risk assessment and comparative performance measure reports to help hospitals improve their care processes

What is the Strategic Surveillance System (S3)

400

This online tool was made available in May 2011 to facilitate sharing of success stories regarding how accredited hospitals and critical access hospitals attained excellent performance on core measures so they can learn from each other

What is the Core Measure Solution Exchange

500

Name 3 of the accountability measures for heart attack care

What is 1) aspirin at arrival 2) aspirin prescribed at discharge 3) ACEI or ARB for LVSD 4) beta blocker prescribed at discharge 5) Fibrinolytic therapy received within 30 min of hospital arrival 6) primary PCI received within 90 min of hospital arrival 7) statin prescribed at discharge

Standards for Hospitals

100

This concentration of KCl and NaCl are considered concentrated electrolytes and should therefore not be stored on patient care units

What is greater or equal to 2 mEq/mL for KCl and greater than 0.9% of NaCl

200

Can an anesthesia cart containing medications be left unlocked in an OR suite between cases?

What is yes, If the individual operating room is part of a larger OR unit that is manned at all times in a fashion which monitors access to the operating room and assures constant surveillance of the anesthesia cart to prohibit access by unauthorized individuals - locking of the cart between cases would not be required

300

If therapeutic infusions of heparin are used as VTE prophylaxis in orthopedic patients, does NPSG. 03.05.01 need to be followed? (NPSG regarding anticoagulation)

What is yes, NPSG.03.05.01 applies to those situations when anticoagulant is administered therapeutically and not prophylactically regardless of the medication type (warfarin, heparin, low molecular weight heparin, etc.). However if it is usual practice for patients to be kept on therapeutic ranges of anticoagulant for several days as a prophylactic strategy then NPSG.03.05.01 is applicable.

400

This resource should be available for prescribers and staff to know which products, strengths and dosage forms of medications are available within the organization

What is formulary

500

Refridgerated medications should be maintain at this temperature

What is the there is no specified range. The Joint Commission does not specifically require temperature logs for refrigerators and freezers used for medication storage. Standard MM.03.01.01, EP2 requires that medications be stored according to manufacture's recommendations. Additionally, EC. 01.01.01 requires that organization describes and implement processes to maintain and monitor equipment performance. If your organization chooses to use temperature monitoring to achieve this, the monitoring method must track temperature in an ongoing fashion to indicate whether or not internal temperature has deviated from the required ranges for all drugs stored. In addition, the organization should have a defined process outlining disposition of medication from a refrigerator or freezer which has deviated from the recommended temperature range

National Patient Saftely Goals

100

According to NPSG.03.05.01, this needs to be assessed prior to initiating or continuing a patient's home dose of warfarin

What is a baseline INR

200

The NPSG program was established in this year to help accredited organizations address specific areas of concern in regards to patient safety.

What is 2002 (first NPSGs were effective in 2003)

300

This NPSG was added in 2012 to address the most frequent type of hospital acquired infection which represents ~80% of all hospital acquired infections

What is NPSG.07.06.01: implement evidence-based practices to prevent indwelling cather-associated urinary tract infections

400

This group of patient safety experts (made up of physicians, pharmacists, nurses, clinical engineers, and other professionals) advises the Joint Commission on the development and updating of NPSGs. Additionally, they help to identify patient safety issues and advises the Joint Commission how to address these issues.

What is the Patient Safety Advisory Group

500

In addition to obtaining information regarding outpatient medications patients are currently taking prior to admission, NPSG.03.06.01 also states that these actions should also be taken for patients admitted for greater than 24 hours.

What is 1) Reconcile home meds with those ordered for inpatient use and resolve any discrepencies 2) Provide patients and caretakers written information on the medications the patient should take when discharged 3) Explain the importance of managing medication information when the patient is discharged.

Miscellaneous

100

NPSG stands for

What is National Patient Safey Goal

200

According to the surgical care improvement project (SCIP) national hospital inpatient quality measure, prophlactic antibiotics should be administered within ___ of incision and discontinued within ___ following total knee arthroplasty

What is 1 hour and 24 hours respectively

300

In 2010, the Patient Safety Advisory Group recommended to establish a NPSG regarding this type of hospital acquired infection, however, it was not accepted

What is ventilator associate pneumonia (due to a lack of national consensus of definitation and means to identify and measure response)

400

This Joint Commission initiative integrates outcomes and other performance measurement data into the accredidation process and are intended to support the Joint Commission accredited organizations in their quality improvement efforts

What is ORYX

500

In 2012, these National Hospital Quality Measures were added (name 2)

What is 1) emergency department 2) tobacco treatment 3) immunization 4) substance use