Joint Commission Basics
Who will the surveyors primarily talk to?
The doctors, nurses and staff (You)
Use at least two patient identifiers when providing care, treatment, and services. Improve effectiveness of communication among caregivers, ex. Report critical results of tests and diagnostic procedures on time. Reduce the risk of health care–associated infections by following CDC hand hygiene guidelines. Reduce the risk of suicide. Improve health care equity. These are all examples of what?
2024 National Patient Safety Goals
What are ways to increase fire safety?
Keep hallways clear of clutter. Do not block exits, fire extinguishers or fire alarms.
How to answer surveyors?
Simply answer the question. Do not over-speak (if you are not asked) or mis-speak (if you do not know the answer).
Where should your ID be worn?
Above the waist.
The following are identified as what during the survey process?
1) Follow the experience of care for individuals through the entire health care process.
2) Evaluate the integration of related processes and the coordination and communication among disciplines and departments in those processes.
Individual and system "tracers"
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!
Handwashing
What do you do in case of a fire?
RACE
Rescue Alarm Confine Extinguish/Evacuate
What should you do if a surveyor approaches you?
Smile and introduce yourself. Remember, this is an open book test. YOU know your job the best.
Health Insurance Portability and Accountability Act states that Protected Health Information (PHI) may only be used for purposes of treatment, payment, healthcare operations is as identified as what?
HIPPA
What are the Patient's Full Name and MRN known as in regards to the national patient safety goals?
2 patient identifiers
How do you use a fire extinguisher?
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 at base of fire
What do you do if you are caring for a patient prior to speaking with a surveyor?
Patient/Guest Handoff
What do the Joint Commission Standards focus on?
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 I do if I have trouble answering a question or navigating the medical record?
Ask for help from colleagues or clarification of question from surveyor. 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.
How often The Joint Commission survey is conducted?
Approximately every 3 years.
What you should remember when being questioned by a surveyor?
Relax! Be confident, you know this stuff :) It's okay to say you don't know something as long as you let them know you will find out the answer. It's okay to ask your coworkers for help. This is an open book test!