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Joint Commission Basics
Patient Safety
Fire Safety
Joint Commission Etiquette
Surprise!
100
The doctors, nurses and staff (YOU!)
Who will the surveyors primarily talk to?
100
Use at least two patient identifiers when providing care, treatment, and services. Improve effectiveness of communication among caregivers Report critical results of tests and diagnostic procedures on a timely basis. Reduce the harm associated with Clinical Alarms system Reduce the risk of health care–associated infections. Reduce the risk of falls Maintain and communicate accurate patient medication information. Conduct a preprocedure verification process
What are 2017 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
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.
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
Patient Verification/Order Verification Dosimeter usage
What are patient safety and quality items you focus on every day?
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
Oxygen tanks
What needs to be segregated between unopened and opened?
500
Within 36-39 months
How often The Joint Commission survey is conducted?
500
4 minutes and 2 minutes
What are the wet times for the two types of Sani-cloth wipes that we use to disinfect equipment? Purple and Orange Wet time is the length of time a surface must remain wet.
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 elopements of psychiatric patients?