JC Final Prep

The Joint Commission:
November 2010
Department of Pediatrics
National Naval Medical Center
Bethesda, Maryland
What is The Joint Commission (TJC)?
• “To continuously improve health care for the public, in collaboration
with other stakeholders, by evaluating health care organizations and
inspiring them to excel in providing safe and effective care of the
highest quality and value”
• Voluntary survey
• Evaluates:
– Compliance with Joint Commissions standards
– Compliance with National Patient Safety Goals
– Compliance with internally established standards and
National Capital Military Children’s Center
The Surveyors
• Life Safety Specialist: John
DiGirolomo, CHFM
• Physician: Marvin Kolb, MD,
• Field Rep: Wendel J.
Schmitt, FACHE
• John E. Eiland, RN, BSN, MS
National Capital Military Children’s Center
Tracer Methodology: The TJC tool
• The tracer methodology traces a number
of individuals through the organization’s
entire health care process.
• Opportunity to examine our
documentation, processes, hand-offs
• Can lead to examination of clinical activity
files, credentialing, infection control data
• They will interact with all levels of
providers: corpsman to attending staff
National Capital Military Children’s Center
Surveyor Truths
• Focused on Patient Safety
• Seeking evidence of compliance to elements of
• Seeking documented evidence of quality
• Assess for variation in processes
• Seek to identify the systems issues related to
the above
• Seek to provide consultation, education and
• Seek to learn
National Capital Military Children’s Center
Variation Responses
• Staff often answer questions with variation
described as part of the process. e.g., “I
usually…” “we often…” “If night shift does
it then…” “I guess…”
– Avoid this type of answer whenever
possible as it leads to the need for further
questioning to determine if the process is
• Use statements that describe less
variation e.g., “Our procedure is…” “An
assessment requires…” “We have
guidelines that…”
– Do not guess, fog, or evade.
National Capital Military Children’s Center
• Express that you feel anxious.
• Relax – You can’t blow the survey for your
• Take a deep breath.
• Seek clarification to get grounded.
– “Let me get the chart.”
• If you think you’ve answered the question, just stop.
The surveyor will ask you another question if they
need more information
• Engage the surveyors on best practices. They like to
share what they know to be best
National Capital Military Children’s Center
What you should be doing NOW
Review the 2010 JC Readiness Guide
Review NNMC Annual Plan
Review PI projects
Know the NPSG’s that affect your day to day
Complete all outstanding records by 10 Nov
Assure H&P’s are signed within 24 hours
Daily attending notes on chart
Advance Directives summarized in chart if
not available
National Capital Military Children’s Center
What you should be doing NOW
• Informed Consent with legible signature, name printed or
• Universal protocol for all procedures: confirm patient with
2 identifiers ,confirm site/side/procedure, and conduct a
time out. Document universal protocol was done.
• Wash your hands on the way in and out of all patient
• Scrub your current records for “Do not use”
• Be sure to have only 1 parameter on range orders, not
both dose and time!
National Capital Military Children’s Center
What you should be doing NOW
• Review all current inpatient charts.
• Check for errors that have been copied forward from
note to note
• Ensure care plan at the bottom of the notes are
• H & P to be cosigned within 24 hours.
• Initial consults should be signed by the staff and then
subsequent notes should say seen/discussed with and
the staff name.
• Be sure that all PHI/PII is secured, particularly at the end
of the day
• Remind staff of electronic patient safety reporting: “PSR”
icon on the intranet for errors and near misses
National Capital Military Children’s Center
NPSG in the Ambulatory Setting
• Identify patients correctly
– Use 2 patient identifiers
• Use medication safely
– Label all medications, date all multi-use vials
• Prevent infection
– Hand hygiene
• Check patient medications
– Med Reconciliation
– Give patients a list of medications
• Be sure Fire Doors are NOT propped open
National Capital Military Children’s Center
National Capital Military Children’s Center
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