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Joint Commission Basics
Patient Safety/Quality
Fire Safety
Joint Commission Etiquette
Surprise!
100
The doctors, nurses and staff (YOU!)
Who will the surveyors primarily talk to?
100

GOAL 1: Identify Patients Correctly GOAL 2: Improve Staff Communication GOAL 3: Use Medicines Safely Goal 4: Use Alarms Safely Goal 5: Prevent Infection Goal 6: Identify Patient Safety Risks Goal 7: Prevent Mistakes in Surgery

What are National Patient Safety Goals?

100
30 Minutes
How long items may be left in hallways? Stretchers, wheelchairs, WOWs, etc
100
Simply answer the question.
How to answer surveyors? do not over-speak (if you are not asked) or mis-speak (if you do not know the answer).
100
Above the waist.
Where should your hospital ID be worn?
200

The surveyors select a patient and use the individual’s medical record as a roadmap to move through the hospital to assess and evaluate our compliance with TJC standards.

What are individual and system "tracers"?

200
Handwashing.
Name one way you reduce the risk of health-care associated infections in your department. Wash 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!
200
RACE
What do you do in case of a fire? Rescue Alarm Confine Extinguish/Evacuate
200
Smile and introduce yourself.
What should you do if a surveyor approaches you? Remember, this is an open book test. YOU know your job the best.
200
Pick it up!
What do I do if I see garbage on the floor?
300
Health Insurance Portability and Accountability Act states that Protected Health Information (PHI) may only be used for purposes of treatment, payment, healthcare operations.
What is HIPPA?
300
2 patient identifiers
What are the Patient's Full Name and MRN?
300
PASS
How do you use a fire extinguisher? 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 at base of fire
300
Patient Handoff
What do you do if you are caring for a patient prior to speaking with a surveyor?
300
Any clinical person having knowledge of the patient's medical condition.
Who is authorized to shut off the medical gas valves in the event of an emergency?
400

Patient rights and education, infection control, medication management, preventing medical errors, hospital staff verification of qualified and competent staff, emergency preparation performance data collection and its use towards improvement.

What do the Joint Commission Standards focus on?

400

Top Box Score of 45

What is the departments patient meal satisfaction target score!

400
Solid shelving
What is needed on the bottom shelf of any clean/non sterile storage location to prevent splashing when floor is cleaned?
400
Ask for help from colleagues or clarification of question from surveyor.
What do I do if I have trouble answering a question or navigating the medical record? They want to see how we work together. If you get flustered, take a deep breathe, smile and relax. If you see someone struggling, jump in to help! Have each others back.
400

These contain the chemical name, precautions that should be adhered to and side-effects of the chemical. They are accessible on the intranet and a binder in every department; the nursing department binder is located in the nursing office. 

What are SDS (Safety Data Sheets)

500
Within 36-39 months
How often The Joint Commission survey is conducted?
500

1 minute and Oasis 146

What is the wet time for the type of Sanitizer that we use to sanitize work surfaces and equipment? 

500

18"

How many inches or more of open space must be maintained from the ceiling so that sprinklers will work properly?

500
Medical Gas Valves and Fire Extinguishers/Pulls
What should I not place any equipment in front of?
500

Gray

What code refers to violence in the workplace and elopements of psychiatric patients?