©2016 Trinity Health - Livonia, Mich. 1

Joint Commission Triennial Survey Readiness

2021 Colleague Presentation

©2016 Trinity Health - Livonia, Mich. 2

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Why is accreditation by Joint Commission important?

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Environment of Care

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Uncovered Cart Blanket Warmer Out of Range Damaged Utilities and Furnishings

Environment of Care

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Damaged Furnishings Paint Peeling

Corrosion

Pull Cord (must be accessible from the ground)

Environment of Care

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Chipped Laminateon Surfaces

Tears in Fabrics/Exposed Padding

Plugging one extension cord into another

Environment of Care

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Damage/Missing Ceiling Tiles

Environment of Care

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> 32 Gallons Combustible Material

Linen/Trash in Biohazard Waste

Sharp FoundIn Biomed Waste

Environment of Care

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Unlabeled, Mislabeled, and Repurposed Containers for Storing Solutions

Taping Latches and Propping Doors Open

What is “SDS” and where can it be found?

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SDS is “Safety Data Sheet”• Information sheet from the

manufacturer on chemicals

• Contains instructions on safe use & response actions in case of harmful exposures

Located in ZENworks Application

orReached by Hotline

(1-888-362-7416)

• “Spot the Dot” system: Dot indicates the month/year of the next scheduled medical equipment annual preventative maintenance (PM)

• 2021: • 2022:

• Black label indicates equipment does not require annual PM

Environment of Care: Medical Equipment Safety

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12 2Month DueYear Due

Month DueYear Due

Infection Control: What is the Contact Time for Germicidal Wipes?

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Infection Control: How do you prevent the spread of infections?

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Isolation Precautions:

• Contact (example: MRSA) – Gown & Gloves

• Airborne (example: TB) – N95 respirator, mask & gloves Negative pressure room

• Droplet (example: Flu) – Surgical mask & gloves

Hand Hygiene:

• Foam in, foam out with Alcohol Based Hand Rub (AHRB)

• Hand Hygiene before & after gloving

• If patient has C-diff, use Soap and Water

COVID-19 Pandemic: Staff are currently required to wear eye protection and medical grade mask

for all patient-facing interactions

Infection Control: What is wrong with these images?

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PolicySTAT: Coronavirus 2019 (COVID-19): Universal Masking Policy

Infection Control: What is an Isolation Caddy?

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What supplies do not go in an isolation caddy?

• Gloves

• Masks

• Purple-Top Wipes

Nursing Empties caddyDiscards any open items

Environmental Wipes caddy as they clean roomReturns cleaned caddy to clean utility

What supplies go into a clean isolation caddy?

• Gowns

• Stethoscope, Thermometer, BP cuff

• Bleach Wipes if patient has C-diff

• Correct isolation sign

Infection Control: High Level Disinfection

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• Place instruments in Open Position in puncture-proof container

• Spray instruments with Enzymatic Spray (such as PRE-Klenz)

• Seal puncture-proof container with lid. Assure seal is tight

• Assure appropriate Biohazard Label is affixed to puncture-proof container

• Transport to Sterile Processing Department Daily

Infection Control: Clean or Dirty Equipment

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Staff should be able to speak to their role in cleaning

process for patient care equipment

Before AfterHOW DO WE KNOW?

Infection Control: Expired Supplies

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Pay Attention To:

• Cabinets

• Drawers

• Caddies

• Carts

• Bins

• Seldom utilized

items

Infection Control

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Tape ResidueUnknown Substances

Unlaminated Paper and Tape

Infection Control

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Uncovered Linens

Plants and standing water attract insects

Infection Control

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Supplies on the Floor

Infection Control

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Corrugated Cardboard Shipping Box

Infection Control

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Missing 28-day Revised ExpirationO2 Meter Adapters post

patient dischargeFans

Provision of Care, Treatment, and Services

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Open ECG packs(Dry out and lose conductivity)

Opened food itemsPatient specific food items missing patient label and date placed in refrigerator/freezer

Life Safety: What do you do in the event of a fire?

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• Activate Code Red when you see

smoke/flames or smell smoke

• Dial 5555 (on campus)

• Dial 911 (off campus)

Life Safety: Who can shut off the oxygen valves in an emergency?

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Authorized to shut off valve in an emergency:• Clinical Lead (formerly known as "C3")• Respiratory Therapy Staff• Area Managers

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Combustible Material in Mechanical Rooms

HeatersToasters

Items within 18 inches of ceiling

Life Safety

Life Safety: EGRESS

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We should not block:• Exit Corridors• Mechanical Rooms• Panels• Fire Extinguishers• Shut Off Valves

Items in hallway must be mobile, remain on one side of corridor, and be moved

Life Safety: Oxygen Tanks

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Tighten thumbscrew

Are these empty tanks or partial tanks?

• Tanks are secured and segregated in racks based on

• Partial (> 500 psi) • Empty (< 500 psi)

• Locations should not store more tanks than their racks can hold

• Tanks are secured for transport in a carrier by tightening the thumbscrew

• Oxygen tanks are required to be removed from stretchers and placed in appropriate storage rack when stretchers are not in use

Improper

Storage

Medication Management

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Alarms Pill Splitter outside

Patient Specific Bin

Dirty Pill Crusher Multidose Vial Missing Beyond

Use (Revised Expiration) Date

Year missing on

Beyond Use date

Emergency Management

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Hospital utilizes emergency codes• Listed on back of badge buddy

Incident Command System• Used for large scale events

• Boardroom is Command Center

National Patient Safety Goals: How do you identify a patient?

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Always use 2 patient identifiers (name & date of birth)

Ask the patient to verbally state their name and birth

date when possible

Identify patient when:

• Administering medication or blood products

• Collecting blood samples or specimens

• Providing care, treatment, or services

National Patient Safety Goals: Restraints

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• Use restraint only as a last resort• Doctor’s order is required – each order may not exceed

24 hours• Perform and document ongoing assessment every 2

hours• Least restrictive method should be used to ensure safety

• Untied Mittens and Soft Limb restraints• Violent Behavior

• Twice as Tough (TAT) and Posey Cuffs

MITTENS ARE A RESTRAINT!

Rights and Responsibilities of the Individual

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Inform each patient, or patient’s representative, of the patient’s rights, in advance of

providing or discontinuing patient care. Notice of rights are provided:

• Before providing or stopping care, whenever possible

• To outpatients upon arrival and inpatients within 2 days of admission

• Explained in a language or manner that the patient, or the patient’s representative,

can understand

Do you know how to access Martti?• Inpatient unit iPads• Nursing Supervisor Office

Additional Translation Services• Certified Languages• Accommodating Ideas (onsite sign language)

Rights and Responsibilities of the Individual

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NoticeBrochure

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Always be on the Lookout!

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Survey Etiquette

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Surveyors partner with our organization to evaluate our processes and identify existing

best practice and observed opportunities. If they see an opportunity, they will cite it:

Know your Resources

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Handbook Department Posters Trinity Health Resources

Ask your Leaders!We are here to support You!

Accreditation Manager:

(954) 267-7025

Assignment!

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Must sign-in to receive credit for attendance

Locate the following in your work area

• Fire pull station

• Fire extinguisher

Department/unit specific information

• Quality improvement projects

• Patient safety initiatives