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
- Wash your hands! Foam in, foam out; wash hands after ~10 applications of foam; wash hands >15 seconds
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.
- As soon as reasonably possible:
- Introductions
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 30-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
- 30 Questions - Joint Commission Daily Tips
- Closed-Loop Communication
- Give an example of closed-loop communication and explain why this is important.
- When receiving or giving orders, make sure to communicate back specifics or clarify specific medications, doses, sites of intervention, which side of the body, etc.
- Ensures clarity, accuracy, and accountability in information exchange. Minimizing misunderstandings, reduces errors, and enhances teamwork - ensure safety of our patients.
- Give an example of closed-loop communication and explain why this is important.
- Hand Hygiene
- When should hands be washed?
- Hands should be washed before and after entering a patient room/patient contact using hand sanitizer or washing your hands
- Speak up when you see others not doing this!
- When should soap and water be used vs. hand sanitizer?
- Soap and water for when hands are visibly soiled with dirt, blood, or body fluids, or when caring for a patient with diarrhea or vomiting, or with a known or suspected C. difficile (C. diff) infection
- Patient Identification
- Name two patient identifiers you can use when confirming you are speaking with the correct patient
- Use at least two patient identifiers for all patients each time you interact with them. These can include full name, MRN, DOB. Check the patient’s wristband to confirm.
- Patient’s room number or medical condition do not count as patient identifiers.
- Say “Please tell me your name and date of birth” instead of asking them “Are you Mr. Jones.”
- Staff Identification
- ID badges must be worn, visible to patients, above the waist.
- Identify yourself to patients by telling them your name and your role
- Preferred Language
- Identify the patient’s oral and written communication needs
- In-person and telephone interpreters are available at all times
- Document use of interpreters
- Give patient education and discharge instructions in the patient’s preferred language.
- Patient Reassessment
- When should patients be reassessed? (after changes in status such as vitals, pain, condition; after medication administration, prior to discharge or transfer).
- Patient reassessment should be documented each time.
- Isolation Precautions & PPE
- Identify and cohort/isolate patients as needed who have high-risk conditions based on level of isolation they may need (eg droplet, airborne, standard)
- Where can you find PPE? PPE are in yellow carts
- Annual mask fit compliance efforts exist.
- Signage lists minimum required PPE
- Don and doff PPE appropriately at entrances to patient care spaces.
- Critical Results
- Critical results should be communicated to the RN and physician/APP taking care of a patient.
- Closed-Loop Communication
Read back the test result to the individual reporting using closed-loop communication and including confirmation of patient identifiers.
Document your acknowledgment of this result in your patient care note and take actions to resolve it.
Reassess your patient.
Medication Administration
What do we need to confirm before medication administration?
Patient’s identity using at least two identifiers
Right medication
Right dose
Right route
Site of medication administration
Contraindications (medication reconciliation, interactions with other meds)
Parameters for giving, holding meds
Working IV (for IV administration)
Ask for clarification if needed!
Check for response, document administration appropriately
Alarms and Notifications
Be aware of unit default settings (eg pumps, tele monitors, bed alarms)
Promptly respond to all clinical alarms
Documentation
Documentation for every patient upon triage, provider eval, nurse eval.
Reassessment documentation for changes in patient status (eg clinical deterioration, improvement after intervention, etc).
Discharge documentation of crucial information, such as current clinical condition, safety for discharge, plan for getting home/facility, strict return precautions, tolerating oral intake, ambulatory/functional status.
All procedures require documentation to be completed, including the site, side, time-out completed when necessary, any complications, any blood loss, medications given, and vital signs.
All H&P/provider notes must be completed and signed by an attending physician within 24 hours, please complete by end of shift.
Procedural Sedation
Not “chemical sedation,” not “conscious sedation”
Requires time-out done and documented
Safe medication administration, constant monitoring
Be aware of reversal agents and possible side effects
Airway equipment at bedside as needed with prior evaluation of airway in case of need for intervention
Patient must be monitored after giving sedation and ensure return to baseline before disposition.
If requiring prolonged sedation, consider escalation to OR/anesthesia.
Procedure Safety
Requires time-out done and documented
Informed consent conversation, consent form signed and in chart. Correct site, medications as needed, indications, at baseline/reassessed prior to disposition.
Document all aspects of the procedure.
Behavioral Challenge Intervention
Behavioral redirection and interventions are prioritized, then consider utility of medications for anxiolysis or restraints for safety of patients and staff.
Make this decision as a team, document your reasons for doing so and indications to remove restraints as needed.
Gold hand icon in the EMR for patient violence risk identification.
Restraints
Behavioral redirection and interventions are prioritized, then consider utility of medications for anxiolysis or restraints for safety of patients and staff.
Make this decision as a team, document your reasons for doing so and indications to remove restraints as needed.
Face-to-face assessment within 1 hour for restraints/seclusion for violent behavior and for non-violent behavior within 24 hours including rationale, response to intervention, need to initiate, continue or terminate restraint use, type of restraint, and alternatives considered before restraint use.
Identifying High-Risk Patient Conditions
We use wristbands and other alert systems for conditions such as fall risk, allergies, limb alerts,
Discuss With Attending Policies
Each department has its own policies, can find this on the Harbor Intranet page
List 3 conditions that you would discuss with an attending (eg change in status/pt becomes unstable, sepsis, STEMI, AMA/eloping, violence).
Adverse Events
What do you do if there is an adverse event or patient safety issue?
SI reporting software
Report to your supervisor
Disclosure of event to patient/patient’s family.
Report only the facts
Equipment Cleaning
Environmental services does daily cleaning, but we all have a responsibility to keep our areas clean.
Remove excess materials and clutter from all areas as needed.
Biohazard materials should be disposed of in red bins, sharps in sharps containers.
Pain Management
What are our current policies on pain management and reassessment in the ED?
Give pain meds and document reassessment.
Start with OTC meds before considering opiate medications unless otherwise indicated
Ensure timely evaluation of pain and intervention.
Patient Care Spaces
All patients deserve access to evaluation by members of their care team in privacy. Consider asking family members to leave the room. Move patients into separate areas if in a shared patient space for their evaluation
Ensure safety of care spaces (eg contamination/cleanliness, lighting)
Surge space (XH) activated in times of higher patient volumes
Workplace Violence
What is the pathway for reporting incidents of workplace violence?
What training do all staff members receive regarding workplace violence?
What strategies can we take to keep ourselves safe? (eg letting others know where you are, doors left open, stay near exits, watch for weapons).
Golden hand icon in the EMR for patient violence identification and placed outside the patient’s room.
Security
Where are the panic buttons in the emergency department?
At each of the nursing stations
Who are the security staff on site?
Securitas, Sheriffs
What do you do if there is a security threat (eg active shooter)?
Environmental Cleanliness
All patient care spaces and shared spaces (eg rounding room, doc boxes, nursing stations, triage rooms, waiting rooms) cleaned regularly
Can escalate to environmental services supervisors with any issues in real-time
TeleTracking system for room turnover and requests for prompt cleaning.
Fire Safety
RACE (Rescue-Alarm-Contain-Extinguish)
PASS (Pull-Aim-Squeeze-Sweep)
Call x113
Keep hallways clear, close doors including fire doors
Where are the nearest fire extinguishers and pull stations?
Evacuate – closest patients in danger first, then amb, non-amb/wheelchair, then bed bound patients)
Patient Education
Patients should be informed of their results by the APP or physician before discharge and before receiving discharge papers from their nurse.
Results should be given to patient upon request.
All incidental findings and plans for follow-up should be discussed with patients and documented as such.
Give patient education, results, and discharge instructions in the patient’s preferred language.
Patients should receive information about their condition and follow-up/next steps.
Food and Drink
Food and drink are not allowed in patient care areas.
MD doc boxes and rounding rooms are considered non-patient care areas
Hands should be washed before entering patient care areas as well as these non-patient care areas.
Any equipment (eg otoscopes) brought into these spaces should be cleaned with antibacterial wipes before being brought into doc boxes and rounding rooms.
5s must be completed each shift, with food and drink from prior shifts discarded or brought elsewhere.
Supervision and Organizational Structure
Discuss your reporting structure on shift (RNs to OCNs/charge nurses, APPs and physicians to attendings and operational and residency leadership).
Discuss the escalation pathway for challenges on shift.
When in doubt, there’s an organizational policy. Where can you find these policies? WikEM Harbor Main, Harbor Intranet, speak with supervisors.
Surge and Mass Casualty Incidents
Policies in place to handle mass casualty incidents, relying upon MICN and admin on duty to activate at specific thresholds, using staff and space more efficiently.
Surge team in place to handle higher peaks in patient volumes
Surge space (XH) activated in times of higher patient volumes
Emergency Preparedness
Location of downtime forms
How to access the Emergency Operational Plan
Where are the eyewash stations?
What is a code pink? What do you do if there is a code pink?
Code pink is Infant-child abduction
Call x111 and x64450. Provide location, age of patient and description of the patient.
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!
- Send an all-staff email:
- 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
- Dr. Chappell to email departmental leadership informing them, assess same-day availability for on-site support