Joint Commission Basics
During the JC survey, the surveyors will talk primarily to: A. The Hospital Administrators B. The doctors, nurses and staff C. The patients D. The Houston Chronicle
B. YOU! B. The doctors, nurses, and staff.
Name one of the 2021 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 (reduce risk of suicide)
NPSG 7- Prevent mistakes in surgery
Who is Kings County's Chief Safety Officer?
Dr. John Wagner is Kings County's Chief Safety Officer. Juan Checo is Director of Hospital Police for Kings County.
What is "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 Behavioral Health.
Hand-washing, the use of alcohol gel, use of gloves, annual flu vaccine, COVID vaccine , wearing a mask, using contact precautions, using Personal Protective Equipment (PPE), cleaning and disinfecting equipment, counter tops, etc.
When using a disinfectant wipe, what is dwell time?
Dwell time, or contact time, is the amount of time disinfectants need to remain wet on surfaces to properly disinfect.
This is an important consideration when using cleaning supplies for fighting coronavirus and other germs.
Staff must review the instructions on the container to obtain the appropriate dwell time for the product (e.g., 3 minutes, 5 minutes). Not every product has the same dwell time.
What is HIPPA? Name one way protected health information is kept private in your department?
Health Insurance Portability and Accountability ACT. States the 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 documents with PHI and identifiers in locked areas, 3. keep computer passwords protected and ensure you log off/out when you walk away from computer that is in a shared space
How do you improve the accuracy of patient identification in your area?
Use at least two (2) - Patient's full name and date of birth
Review ID band
What do RACE and PASS acronyms stand for?
RACE: R - Remove/Rescue; A- Alarm; C- Confine/Contain; E- Evacuate/Extinguish
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 acronyms "TJC" stand for?
TJC = The Joint Commission
How does BHS identify patients at-risk for suicide ? Note: This is a Joint Commission Safety Goal
BHS identifies patients at – risk for suicide by screening patients with Columbia Suicide Severity Rating Scale. A Suicide Risk Assessment is conducted with the SAFE-T.
What is a Material Safety Data Sheet (MSDS) and where can you find a MSDS?
Material Safety Data Sheets (MSDS) provide instructions for safe use, information about hazards, and first-aid for misuse of all products used in the workplace. The sheets are available by clicking on your desktop icon (MSDS).
Ligature risks are considered a compromise to patients’ right to re-ceive care. True or False?
True. It is a patient’s right. The New State Patient Bill of Rights states that every patient must “receive considerate and respectful care in a clean and safe environment .“ BHS must provide appropriate patient assessment, have mitigation plans, and safety precautions ¡n place to ensure a patient’s safety.
How do you access interpreting services for a Creole speaking patient?
To access an interpreter over the phone, a staff member should use the CYRACOM phone interpreting service or dial x1500 from any hospital phone and follow the prompts.
To access an interpreter via video remote interpreter, a staff member may use the AMN Stratus device and follow the instructions on the instruction card. Arrangements for a face-to-face interpreter can be made by emailing requests@justinterpretation.com.
If the patient is Deaf, arrangements can be made by calling X 7418 to schedule a face-to-face sign language interpreter, or the AMN Stratus device may be used for access to an interpreter especially in emergent situations.
A native Creole speaking doctor, clinician, or nurse providing care to the patient may communicate medical information. A native Creole speaker (non-clinician) may communicate with a patient to provide instructions, and social conversations. However, a native Creole speaker (non-clinician) cannot translate clinical information for a MD, Nurse, clinician or treatment team. CYRACOM must be used. This applies to all languages. Document all interpreter usage in the patient’s medical record for every encounter, including the language requested and the interpreter’s credentials.