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
- 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

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
- 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
- Stroke
- APOT
- D2EKG
- Triage D2Doc, LWBS

Authors:

Bradley Chappell