Harbor: Joint Commission (JC) Readiness

• Updates: Survey Window October 2025 - March 2026
  • The JC eliminated 714 requirements
  • 14 Categories: Right Patient, Right Care; Culture of Safety; Emergency Management; Excellent Health Outcomes for All; Infection Prevention and Control; Pain Management; Patient Rights; Suicide Risk and Reductions; Safe Transplant Practices; Waved Testing; Workplace and Patient Safety; Staffing; Imaging Safety; Medication Management

• General tips:
  • Wear badge above the waist
  • Use 2 patient identifiers (name, MRN, DOB) - "Please tell me your name & DOB" & cross-check armband
  • Clear hallways (equipment/carts on one side, one side free) with access to fire extinguishers, medical gas shut-off valves, & exits
  • Only answer the question asked; if you are not sure, tell them where your would find the answer (or ask your supervisor)
  • No eating in patient care areas (go to the rounding room for food, closed drinks ok in doc box)
    • What is the actual OSHA requirement
  • High risk patients: LEP, SUD, fall risk, SI screening

• Infection Control
  • Wash your hands! Foam in, foam out; wash hands >15 seconds
    • Wash hands before and after glove use
  • Wear PPE, but not in the halls; remove N95 outside the room
  • Isolation signage on room doors for patients with droplet/airborne precautions
  • Review MDRO alerts and micro susceptibilities
  • Infection prevention:
    • HAP/VAP - do not pre-open trays or scopes, keep tube covered prior to intubating/placing chest tube, HOB 30-45 degrees
    • CAUTI - minimize foleys
    • CLABSI - minimize use of femoral lines, green alcohol caps on all IV's, scrub IV hub with alcohol wipe 5 seconds prior to use
  • Expiration dates on US gel (28 days after opening)
  • Wipes: purple 2 min wet time, grey 3 min wet time (US), alcohol (Dragon), orange (bleach) 4 min wet time
  • Chloraprep Times (scrub, not circles)
    • Dry
    • Moist
  • US - clean after use and just prior to use; dirty US probes to the transport box
  • Vacutainers to dirty utility room, EVS bags and dispos

• Doc Box
  • No open food (bottled water)
  • No meds (eye gtts); can't have them in your pockets, no rogue saline flushes
  • Shred HIPAA material, F8 when not at computer

• Orders
  • Restraints q4 hours (still needed?)
  • No verbal orders (only in extreme emergency or sterile procedure; verbal repeat back; must sign
  • Parameters for titratable medications
  • Review home meds for interactions with new meds
  • No meds (including saline flush) in your pocket

• Documentation
  • PLIN for use of interpreters - 68440 for in-person interpreter
  • EMTALA form
  • Timely/accurate documentation
  • Med reconciliation prior to discharge
  • Patient/family education
  • Report adverse events through SI system

• Communication
  • Introductions
    • Visible badge, no extras on your badge, "I am on of the doctors taking care of you"
    • Use patient's preferred language
    • Document SDOH needs (for billing as well)
  • Medications
    • Do not use any unlabeled medications (codes, sedations)
    • Review home meds for interactions with things you are ordering or prescribing
    • Review titration parameters for gtts
  • Patient Care Transitions
    • SBAR
  • Mandatory Discuss with attending list:
    • AED:
      • Invasive procedures, including intubation, cricothyrotomy, central venous access, transvenous pacer, tube thoracostomy
      • Critically ill patient, unexpected decompensation, or time sensitive diagnoses
      • Patient leaving against medical advice
      • Disruptive patient, including Code Gold, threat to self, staff, or other patients, elopements
      • Fall in Emergency Department with apparent injury
      • Trauma Team Activation (TTA) Level 1, TTA Level 2
    • PED
      • Pediatric medical cardiac arrest / death: the fellow should notify Patricia Padlipsky, MD, Director of the Pediatric Emergency Department, within 24 hours of the death. The fellow is encouraged to notify one of the adult ED on-site attendings during the resuscitation if notification will not impact the fellow’s ability to conduct the resuscitation.
      • Pediatric traumatic cardiac arrest / death: the fellow will co-manage the patient with the trauma surgery service attending. This will serve as attending notification.
      • If a pregnant woman is actively delivering the fellow must activate the OB Batch pager and notify one of the adult ED on-site attendings to aid in managing the care of the mother, while the fellow manages the care of the neonate.
      • On the extremely rare occasion that the fellow is performing a cricothyrotomy, needle cricothyrotomy, or pericardiocentesis without a trauma surgery attending present, the fellow must notify one of the adult ED on-site attendings.

• Process Improvement Projects
  • Sepsis
  • Stroke
  • APOT
  • D2EKG
  • Triage D2Doc, LWBS