Harbor: 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

• 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