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Downstate Times

The Newsletter for SUNY Downstate
University Hospital of Brooklyn

Joint Commission: Preparation Is Key

Getting prepared for a Joint Commission visit is year-round exercise. Here are some quick tips for constant preparation:

  1. Know the positive outcomes for your unit or department. Have you successfully enacted a project to reduce noise or improve care? Be able to talk about your accomplishments with pride.
  2. Remember: we are all a team, not a silo. Everyone who spends time on your unit should know its policies and best practices.
  3. Practice rigorous handwashing routines at all times: wash hands before and after every patient contact— gloves are not a substitute!
  4. Make sure your patients know who you are: Identify yourself and back this up by wearing your ID cards.
  5. Be vigilant to avoid potential HIPPA violations: Don't leave a computer file open where others can view a patient's record; if you see an open chart, close it; WOWs (workstations on wheels) must be locked when not in use.
  6. Don't leave controlled drugs unattended, no matter who asks for access (even a Joint Commission surveyor!). Make sure that crash carts and WOWs are kept where they can be observed, and that they are locked and put away when not in use.
  7. Similarly, make sure that vaccines and other meds kept on units are up to date. Clean up expired meds. Make sure that all forms you use are the most recent, approved version.
  8. Check that all equipment, including patient call bells, work; if they don't, submit work orders to get them fixed.
  9. Make sure that all orders have name, time, and date.
  10. ALWAYS check ID bands; don't rely on verbal IDs for patient confirmation.
  11. Remember that corridors need to be clear. Return stretchers and other items in the hallways to where they belong.
  12. Linen cart covers must always be kept zipped down.

Do you have other tips on how to have a successful Joint Commission survey? If so, please send them to DownstateTimes@downstate.edu.