Joint Commission Basics
These are the people that TJC surveyor's are most interested in interviewing.
Who are the doctors, nurses and staff (YOU!)?
This is the most effective way to prevent the spread of infection in a hospice setting
Proper hand hygiene
RACE is the acronym used in this type of situation.
What do you do in case of a fire? Rescue Alarm Confine Extinguish/Evacuate
During an interview with a TJC surveyor, I will do these things.
What is ONLY answer their specific question and not offer more than what was asked.
These should be worn above the waist and on at ALL TIMES when at work.
What is my ID badge?
The Joint Commission requires healthcare organizations to have a written plan for this type of continuous improvement.
What is Performance Improvement or Quality Improvement?
This is the way you reduce the risk of health-care associated infections. It may involve soap and water before and after each patient contact or an alcohol-based hand rub if there is no visible soiling and C. Diff is not suspected.
What is handwashing?
You use this acronym to guide the use of a fire extinguisher - include what each letter of the acronym represents. PASS
What is 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 you should do if a surveyor approaches you.
Smile and introduce yourself.
I will do this if I see something in the wrong place or where it doesn't belong.
What is pick it up and put it where it belongs
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 HIPAA?
We use these 2 patient identifiers to ensure we have the correct patient and/or the correct record.
What are the patient's name and date of birth?
In hospice residential facilities, all exits must remain this to comply with fire safety standards.
What is unobstructed and clearly marked?
Will be sure to complete this task should a surveyor ask to speak with me while I am in the middle of providing patient care.
What is Patient Handoff?
Hospice programs must have protocols to prevent and manage this common patient safety issue related to mobility and comfort.
What is fall prevention?
They care the "gatekeeper" for CMS and ensure that patient care is delivered in a safe manner, by qualified individuals, and in an environment that is safe for everyone. If they find concerns, an organization could be placed on conditional status which could jeopardize the organizations ability to operate.
Who is the Joint Commission?
Identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery. These represent a category that are driven by high volume mistakes made throughout health care institutions.
What are National Patient Safety Goals?
This document must be updated and readily available in healthcare organizations, outlining all fire safety procedures.
What is the Fire Safety Plan?
I can do this if I am not sure of what the surveyor is asking or am having trouble finding the answer.
What is "Can I ask that you word that question differently?" or "I will ask my manager."
(do not say I do not know)
These need to be segregated between full and partially used and placed in a holding rack
What are oxygen tanks?
The Joint Commission survey is conducted on a regular basis. This is the time frame for that survey.
What is every 36-39 months. (every three years)
Hospice programs are required to conduct this type of review after a sentinel event or unexpected patient outcome.
What is a Root Cause Analysis (RCA)?
Hospice staff must regularly check this equipment to ensure oxygen delivery systems are safe and functioning properly.
What is oxygen tanks, tubing, and regulators?
Demonstrating knowledge of this helps show surveyors that hospice staff understand compliance and patient care standards.
What are policies and procedures?
This is the most important rule when using oxygen in a hospice patient’s home to prevent fire hazards.
What is “No smoking or open flames near oxygen”?