TJC Basics
During the TJC survey, the surveyors will talk primarily to: A. The hospital leadership B. The doctors, nurses and frontline team members C. The patients D. The California State Journal
What is B? The doctors, nurses and frontline team members
This is a broad requirement established by TJC that outlines expectations for quality and safety in healthcare organizations
What is a standard?
Employee badges should be worn _____ ___ _____
What is above the waist with only approved stickers on the badge (Flu shot, etc.)?
A hospital TJC survey lasts for ____ days
What is 4 days?
Name one of the top 10 most cited standards
What is....Handling of hazardous materials; uniform use of diagnosis codes, procedure codes and abbreviations; reducing risk of infections associated with medical supplies and devices; providing a safe physical facility; resuscitation services available; process to identify pts are risk of suicide & self harm; medication properly stored; safe prescribing; process to evaluate quality and safety of patient care by each medical staff member; process to improve safety of high-alert medications
It is when TJC evaluates compliance with standards related to care, treatment and services provided to a patient (The surveyor will follow the path of a selected patient through the organization)
What is individual tracers (Patient tracers)?
This is the name of the individual who guides the surveyor and help facilitate the introduction to unit/area leaders during the survey
Who is the survey navigator?
If an active shooter is announced overhead, I should . . .
What is run, hide, and/or fight?
The number of years an organization is accredited for after a successful TJC survey.
What is 3 years?
Dr. X is starting his shift and walks down the hall. Starbucks in hand, and waves "hi" to the nurses, PCPs. He rounds the corner, going through the propped open fire door to stand in front of the board. He notes that there are 2 patients with the same initials on the board. He dumps his empty coffee cup in the trash, and logs into Epic. Where's TJC violation?
What is only special fire doors may remain open? Doors may not be propped open.
These are the areas in which KFH OAK/RCH has received Joint Commission accreditation
What are the hospital, home care and laboratory?
I am an individual who is well versed in TJC regulatory standards and can assist with questions in my area
What is a content expert/subject matter expert? (ARL member)
When there is a fire, team members should RACE and PASS. What do the mnemonics stand?
R- Rescue/Remove people from smoke/fire, A- Alarm - pull fire alarm and call, C- Contain the fire (close doors) E- Extinguish the fire when it is safe to do so or Evacuate,
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
True or False: Because we are TJC accredited we do not have to worry about CMS requirements or surveys
What is False?
This is the area or group you can reach out to for TJC readiness plans and questions
Who are the Accreditation and Regulatory Readiness Specialists, the Director of AR&L, the Quality and Patient Safety Director and our Chief Quality Officer?
A _______ __________ is the very first thing that happens during a Joint Commission survey
What is an opening conference?
This is a specific criterion or measure that is used to evaluate compliance with a TJC standard
What is a measurable element or element of performance?
True or False: It is acceptable to have items in the areas beneath sinks on the surveyable units
What is False?
This simple method is considered one of the most effective ways to stop the spread of hospital acquired infections in the hospital.
What is hand washing/hand hygiene?
What card should you have behind your badge?
What is the KP East Bay Service Area Emergency Code and Phone extension Codes?
KFH OAK/RCH is expecting to have their survey completed before _______.
What is December 31st, 2025?
A person who records surveyor questions and key issues throughout the survey process
What is a survey scribe?
True or False: It is facilities responsibility for keeping the environment of care safe for patients, families and team members.
What is false? All team members are responsible!!
The TJC's accreditation process involves rigorous evaluation of healthcare organizations to ensure they meet specific performance standards related to _____ and______.
What is quality and safety
When asked a question you do not know the answer to by a TJC surveyor, these phrases/methods will allow you to obtain an answer for them at a later time.
What is....
I would ask my leader, I would look up the answer on PolicyTech, I would look at the policy?