Harbor: Joint Commission (JC) Readiness: Difference between revisions

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** The JC eliminated 714 requirements
** 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'''
** 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:
* General tips:
** Wear badge above the waist
** Wear badge above the waist
** Use 2 patient identifiers (name, MRN, DOB
** 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
** 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 escalate to your supervisor)  
** Only answer the question asked;  '''if you are not sure, tell them where your would find the answer (or ask your supervisor)'''
 


*Infection Control
*Infection Control
** Wash your hands!  Foam in, foam out; wear PPE (not in the halls)
** '''Wash your hands!''' Foam in, foam out; wash hands >15 seconds
** Isolation signage on room doors
*** '''Wash hands before and after glove use'''
** Think about HAP (when intubating/placing chest tube), CAUTI (minimize foleys)
** 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)
** Expiration dates on US gel (28 days after opening)
** Wipes:  purple 2 min wet time, grey (US), alcohol (Dragon), orange (bleach) 4 min wet time
** Wipes:  purple 2 min wet time, grey 3 min wet time (US), alcohol (Dragon), orange (bleach) 4 min wet time
** Chloraprep TIMES
** Chloraprep Times (scrub, not circles)
*** Dry
*** Moist
** US - clean after use and just prior to use; dirty US probes to the transport box
** 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
** Vacutainers to dirty utility room, EVS bags and dispos


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


* Orders
* Orders
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* Documentation
* Documentation
** PLIN for use of translators
** PLIN for use of interpreters - 68440 for in-person interpreter
** EMTALA form
** EMTALA form
** '''Timely/accurate documentation'''
** Patient/family education
** Patient/family education


* Patient Care Transitions
 
** SBAR
* 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
 


* Process Improvement Projects
* Process Improvement Projects

Revision as of 18:31, 30 September 2025

  • 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)


  • 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
    • 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
    • Patient/family education


  • 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


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