Harbor: Joint Commission (JC) Readiness

General

  • 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
    • Joint Commission Readiness Pocket Guide


  • 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 after ~10 applications of foam; wash hands >15 seconds
      • Wash hands before and after glove use
      • 6th documented episode of non-compliance with hand hygiene can result in termination!
    • Wear PPE, but not in the halls; remove N95 outside the room
    • Isolation signage on room doors for patients with droplet/airborne precautions
      • Negative pressure room requires 1 hour of air exchange before re-use
    • 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: 30 second scrub, 3 min dry
      • Moist: 2 minute scrub, 3 min dry
    • 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


Physican Specifics

  • 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 within 48 hours)
    • 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; Insight App; DC instructions in preferred language
    • EMTALA form
    • Timely/accurate documentation
    • Pre-procedural timeout form - right patient, procedure, and site
      • Ketamine is "deep sedation"
    • Restraints - least restrictive to keep the patient and staff safe
      • Document face-to-face within 1 hour of application
    • 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 one of the doctors taking care of you"
      • Use patient's preferred language
      • Document SDOH needs (for billing as well)
    • Medications
      • Pain management - consider adjunctive treatments such as ice and heat packs; document patient's response to treatment
      • 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
      • As soon as reasonably possible:
        • Active labor of a pregnant patient
        • Acute altered mentation
        • Acute focal neurologic deficit
        • Acute respiratory distress requiring positive pressure ventilation
        • Acute resuscitation of hemodynamically unstable patients
        • Any acute life, limb, or vision-threatening condition
        • Cardiac arrest
        • Children under 2 years of age
        • Code Gold activations and/or patients presenting an acute threat to others
        • Concern for child abuse
        • Critical medical ALS ambulance runs
        • ESI 1 & 2 triage category patients
        • Falls in the emergency department with apparent injury
        • Neonatal resuscitation and/or neonates born out of asepsis (BOA)
        • Patients requesting to be seen by an attending physician
        • Trauma team level 1 and level 2 activations
        • Unexpected deterioration in the patient’s condition
      • Must discuss with attending prior to discharge:
        • Abdominal pain (age > 50)
        • Age under 18
        • Any patients requiring advanced imaging
        • All critical lab results
        • Blood product transfusion
        • Chest pain (age > 50)
        • Change of code status
        • Complications from blood product transfusion, medication administration, or procedures
        • Patients being discharged with abnormal vital signs
        • Pregnant patients with abdominal pain and/or vaginal bleeding
        • Patients attempting to elope and/or leave against medical advice (recognizing that patients may elope unannounced)
        • Change in previous disposition plan or significant change in clinical status/situation
      • 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.

JC Standards

    • Flow management: keep boarding time <4 hours
    • Transfer policy: based on capacity - MAC transfer center
    • Assessment and reassessment: MSE in timely manner, goal<30 min; reassessment: ESI2=2 hrs, ESI3=4hrs, ESI 4/5=8 hrs
    • Documentation of ongoing education to maintain competency
    • Annual Workplace Violence training, de-escalation training, reporting process
    • Hospital credentialing process, OPPE, FPPE criteria
    • Hospital Safety: identify & eliminate security risks
    • Maintain unobstructed exit paths
    • Medical record: document MDM & dispo


  • Fire
    • RACE - rescue, alarm, contain, extinguish
    • PASS - pull, aim, squeeze, sweep
    • ED fire extinguisher locations
    • ED O2 turnoff valves


  • Process Improvement Projects
    • Sepsis >75%
    • Stroke < 60 min
    • APOT <30 min with EMS diversion <20%
    • D2EKG < 10 min
    • Triage D2Doc < 10 min, LWBS < 2%
    • Hospital Throughput: case management on inpatient teams (decreased LOS ~1 day), earlier discharges and downgrades, reduce ED to ED transfers (direct to inpatient beds), consult TAT, EVS room TAT, 4th Attending in ED during peak hours, placement pathway, ED Obs, RLA pathways (Neuro, Cardiology), radiology acquisition and read times, direct admission pathways, expanded pathway to UCC, Gyn UCC, direct to clinic, ED to Specialty f/up
    • Staff Safety: Security Oversight Committee, Staff Assault Prevention Committee, AVADE 1 & 3, Golden Hand (propensity for violence screening tool), Complex Care Plans, High-utilizer Committee, Safety Sitters for SI, Securitas Escorts from Triage to Psych ED

Policy Links

  • Hospital
    • 109a - Designated Visitors
    • 140 - Decedent Viewing
    • 301 - AMA
    • 308a - Emergency Transfer Outs
    • 308c - Acceptance of ED to ED Transfers with EMC
    • 308d - Acceptance of ED to ED transfer without EMC
    • 312 - ED Admission Process
    • 332a (adult abuse), 332b (child abuse), 332c (intimate partner violence), 332d (elder abuse)
    • 355 - Procedural Sedation
    • 360a - consult times???
    • 370 - Admission and Transfer Guidelines (ED Physician Admitting Privileges)
    • 367B - MRI
    • 374a - MSE
    • 374b - ED Central Log
    • 604a - Consent/Definition of "Complex" Procedures
    • 612a - Reporting event - needlestick?
    • 620 - Consent for Patient with Limited Capacity
    • DHS 377 - Consent for Blood Alcohol Test (in police custody)


  • ED
    • 1 - Provision of Care
    • 3 - Clinic admissions
    • 4 - OOP Patients
    • 5 - Evaluation by Consulting Services
    • 6 - Flow of Patients between Psych ED and Medical ED
    • 7 - Scope of Assessment
    • 8 - Invasive Procedures
    • 9 - Respiratory Illness Protocol
    • 10 - Authorization for Treatment (consent)
    • 11 - Treatment of Minors without a Guardian (consent)
    • 12 - Consent for Blood Alcohol Test
    • 13 - AMA
    • 14 - Coroner's Cases
    • 15 - Death Notification
    • 16 - Discharge Process
    • 17 - Disability (work notes - 1 week max)
    • 18 -
    • 19 -
    • 20 - Transitions of Care (Admissions)
    • 21 - Medical-legal Specimens
    • 22 - Medication Refills
    • 23 - Visitation and Family Presence During Procedures
    • 24 - Paramedic Training
    • 25 - Reddinet
    • 26 - Pronouncement in the Field
    • 27 - Paramedic Radio Internship (MICN/Base Hospital Physician)
    • 28 - Animal Bites ... http://publichealth.lacounty.gov/vet/Forms.htm
    • 31 - Medications in Triage (Nursing Standardized Procedure)
    • 32 - Immunizations (documenting in PED)
    • 33 - Nursing Documentation
    • 40 - Notifying Patient's Private Provider
    • 45 - US-Guided Peripheral IV (Nursing Standardized Procedure)

Education Plan

  • TeamSTEPPS - OCN with 31-day Q&A
  • Newsletter Q&A Snippets
  • Rounding Room Reminders
  • Laminated card at computers
  • Faculty Questions for monthly CME raffle (must include clinical):
    • TalentWorks with questions
    • SurveyMonkey questions
    • Docusign questions
    • MS Forms

Morning of JC Visit

  • AOD will alert Physician Ops leadership and start a group TEAMS chat
    • Dr. Chappell to email departmental leadership informing them, assess same-day availability for on-site support
      • Send an all-staff email:
        • We would like to welcome the Joint Commission for their survey on ____ (dates). As you go about your daily patient care, please consider the following: keep your name badge visible, focus on patient safety (use 2 patient identifiers, wash your hands before and after each patient encounter, do not leave meds unlabeled/unattended, no verbal orders, document the need for restraints when utilized), document your use of interpreters, procedural timeouts and procedures, medication reconciliation prior to DC, reassessment of pain management interventions, for the residents and fellows be familiar with the "must discuss with attending" lists, be cognizant to keep PHI private (F8 when leaving your workstation), and complete all outstanding clinical documentation. If interviewed by a surveyor, stay positive, answer the question asked, and if you do not know, look on WikEM or your JC Readiness Guidebook. If you don't know, ask your supervisor!
    • Identify members of the Physician Ops Leadership team, nurse manager, and charge nurse to be present and available in the ED at all times.
      • AOD or Available Admin Physicians personally speak with nursing and physician teams at shift changes/Team STEPPS to set a positive tone and review key reminders (hand hygiene, patient ID above waist, escalation to supervisors, no food or drink in patient care spaces, signing out of computers when walking away, and safety practices) - check-list printed out for each workstation
    • Arrange immediate on-site ED walkthrough with AOD physician, nursing leadership, EVS, materials/supply leadership (Mario) to identify areas for rapid correction.
      • Remove all chairs/dividers/equipment from surge spaces. Surge into R8-12 + P8-11
      • Fire exits clear
      • Ensure nursing, triage, and doc box workstations are clean, organized, and free of clutter, food, PHI, medications (lidocaine bottles, tetracaine, etc)
      • Verify no open patient charts or screens are left unattended
      • Confirm policies, quality binders, and metric dashboards are readily available
      • Ensure all previously opened ultrasound gel bottles have expiration date listed (<28d from opening)
        • Open new ultrasound gel bottles, label each with “Opened [today’s date]” and an expiration date 28 days later.
      • Check gurneys: ensure all oxygen tanks are secured and stored appropriately and that they have oxygen in them
      • Logs and records: Confirm completion and accuracy of refrigerator temperature logs, crash cart checklists, eyewash station checks, and equipment inspection forms.
      • Ensure all crash carts were checked that morning and documented as such.
      • PPE carts stocked and readily available
      • Update KPI boards
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