2024

Joint Commission
Quick Reference
Guide

12/23

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 The Joint Commission Quick Reference
January 2024

Table of Contents

Norman Regional Health System Mission and Vision……………………………..2

Joint Commission Public Notice……………………………………………………………..2

The Joint Commission…………………………………………………………………………….3

Code J……………………………………………………………………………………………………3

Unit Sweep……………………………………………………………………………………………3

Survey Process………………………………………………………………………………………3

Talking with the Surveyor………………………………………………………………………4

Infection Prevention……………………………………………………………………………..4

PDSA …………………………………………………………………………………………………….5

Environment of Care/Emergency Management……………………………………..5

HIPAA and PHI…………………………………………………………………………………….…7

Employee Health…………………………………………………………………………………...8

Conflict/Disruptive Behavior………………………………………………………………….8

Other Information………………………………………………………………………………….9

Resource Numbers………………………………………………………………………………….9

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 Norman Regional Health System

Mission
To serve our community as the leader in health and wellness care.

Vision
To be the provider of choice to improve the health and well-being of our regional
communities.

Joint Commission Public Notice

If you have concerns about patient care or safety anywhere within the
Norman Regional Health System (NRHS) you are encouraged to call us to
share your concerns by contacting any of the following:
 Patient Liaison at 405-307-1060
 Patient Safety Hotline at 405-307-7899
 Concerns regarding patient privacy issues, call the Privacy Officer at
405-307-1405
 Concerns regarding ethical/legal issues, call the Compliance Hotline
at 1-877-267-1929
 Concerns regarding acute changes in patients’ medical condition, dial
“88” for the Medical Intervention Team (MIT).
If the concerns in question cannot be resolved at this level, you are
encouraged to contact the Joint Commission, our accrediting body. To
contact the Joint Commission:

Office of Quality and Patient Safety

The Joint Commission
One Renaissance Blvd
Oakbrook Terrace, IL 60181

Fax: 630-792-5636
Email: [email protected]

The Joint Commission will acknowledge requests in writing or by telephone

and will inform the organization of the request for any interview. The
organization will, in turn, notify the interviewee of the date, time, and place
of the meeting. For more information about the Joint Commission, go to
http://www.jointcommission.org
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The Joint Commission
The Joint Commission (TJC) is an independent, not-for-profit organization
that evaluates the quality and safety of care for thousands of health care
organizations in the United States and around the world. Organizations
accredited by TJC are deemed to be compliant with The Centers for Medicare
and Medicaid regulations – which allows the organization to be reimbursed
by Medicare and Medicaid.

Code J
 When the surveyors arrive, the operator will announce “CODE J” over
the hospital intercom, alerting employees to the presence of the
surveyors. This will allow us to put plans into action to make our
survey flow smoothly.
 What should you do when a “Code J” is announced? Follow your
manager’s instructions. Also, clinical departments should utilize the
“Day of Survey” cards to do a department sweep every day of survey.
 Ensure all employees are wearing their name badge on the upper
part of their torso.

Unit/Department Sweep – Day of Survey cards

On each day of survey, your manager, supervisor or charge nurse will
distribute “day of survey” cards with tasks to complete. These tasks pertain
to the environment of care – dealing with clutter, cleanliness, expired
supplies, blocked egress, etc. Based on TJC’s new scoring structure, each
element a surveyor finds out of compliance can result in a survey finding, so
it’s important that you double check by using the cards to assess your unit’s
readiness.

Survey Process
All surveys are unannounced. This means we have to constantly be ready!
The survey generally lasts 4 days. The majority of the survey will be done by
the tracer methodology.

Tracers are the method used by surveyors to evaluate the organization’s

compliance with relevant standards. Typically, they will select a patient, often
based on multiple or complex services and will use that patient’s medical

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record as a roadmap to review the care the patient has received. Surveyors
will interview staff and will speak with the patient as they look for TJC
standards compliance. Surveyors are also looking for consistency of
processes and compliance throughout departments in the entire
organization.

As surveyors are rounding, they will observe for hand hygiene, use of PPE,
medication administration, hand offs and time outs. The surveyors will cite
ANY missed opportunity for hand hygiene. They will review documentation
in the EMR with the staff person caring for the patient.

Talking with the Surveyor

If one of your patients is selected for a tracer, you will be interviewed by the
Joint Commission surveyor. The surveyor will ask you questions about the
patient’s care and will review the medical record with you. Some points to
remember:
 Don’t make yourself scarce! Be personable and helpful to the
surveyor.
 Make sure you are comfortable looking for documentation in the
patient’s EMR.
 Be confident. Think about the question, take your time, ask for
clarification if you are not sure what the surveyor is asking and
answer to the best of your ability.
 Answer with clear statements – yes/no, always/never, etc. Avoid
statements that convey being unsure such as maybe, sometimes or
hopefully. Answer the specific question – just the facts!
 Be honest if you do not know the answer. It is appropriate to state
that whenever you are unsure about what to do you always use the
resources available (consult with charge nurse or manager, review
the policy in Policy Manager, reference the Nursing Reference Center
in the EMR [globe icon], etc.)

Infection Prevention
Points to remember:
 Hand hygiene
o when entering a patient’s room,
o before having direct contact with patients
o before donning gloves
o before any procedure

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 o after contact with the patient’s skin, body fluids, wounds, etc
o after contact with equipment in the immediate vicinity of the
patient
o after removing gloves
o upon leaving the patient’s room
 Staff providing any care for patients cannot have fingernails longer
than ¼ inch, and cannot wear artificial nails, overlays or gels.
 Know the contact times for the cleaning/disinfecting solutions you
use:
o Dispatch (red top): contact/wet time – 2 minutes (3 minutes
contact/wet time for C-diff)
o PDI Super Sani-cloth (purple top): contact/wet time – 2
minutes
o Sani-cloth AF3 (gray top): contact/wet time – 3 minutes
o Virex 256 (spray bottle): contact/wet time – 10 minutes
 Remember, no PPE in the hall – including gloves, gowns, masks (even
hanging around your neck) or shoe covers!
 NOTE! Contact (or wet) time means that the item being cleaned with
the cleaning agent must stay wet the entire contact time. It is not to
be dried off before the contact time is up, and staff are not to fan it
to try to get it to dry more quickly.

PDSA
 NRHS utilizes the PDSA method for accelerating performance
improvement. The steps include:
o Plan – plan the trial or observation, including a plan for
collecting data
o Do - try out the trial on a small scale
o Study – set aside time to analyze the data and study the
results
o Act – refine the change based on what was learned from trial

Environment of Care/Emergency Preparedness

 Keep hallways clear and uncluttered – items not in use cannot be left
in hallways more than 30 minutes.
 In the case of FIRE, follow the response principles of R.A.C.E.
o Rescue: the patient, person, or visitor in the endangered fire
area.

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 o Alarm: pull the nearest Fire Alarm Pull station, dial “88” and give
name, location, and remain calm.
o Contain the fire: close all doors and windows to prevent spread
of fire.
o Extinguish (if safe): If it is not safe, close the door, place a pillow
outside the door & wait for the Fire Department.
 Pull stations are located near each fire stairwell on the patient care
units. A fire extinguisher is located near the pull-box or in the fire
hose cabinet. Every employee needs to know these locations in
relation to their work area.
 Use P.A.S.S. to remember how to use a fire extinguisher:
o Pull the safety pin
o Aim the nozzle at the base of the fire
o Squeeze the handle to discharge agent
o Sweep side to side
 Piped oxygen is turned off by Charge Nurse/Supervisor or designee,
after all oxygen dependent patients have been provided with
portable oxygen or relocated to areas where they can be served.
Under direction of Supervisor on duty, Engineering Services or the
Fire Department can shut off the medical gas valves, unless unit
specific policy applies. (See Environment of Care Code Red policy EC
8142-201 and Fire Plan policy EC8143-508.)
 Know the location of the nearest exit, fire alarm pull station, and fire
extinguisher!
 Small chemical spill: Follow the C.L.E.A.N. principles: (EC8143-302)
o Contain the spill
o Leave the area
o Emergency eyewash, shower, medical care
o Access SDS (Safety Data Sheet)
o Notify Emergency Response Team at “88”
 Large chemical spill: (EC8143-302)
o Sound verbal alarm and evacuate area
o Call “88” for STAT assistance
o Move employees out of affected area
 “SDS” stands for Safety Data Sheet. A SDS contains important
information regarding what to do if someone is exposed to a
hazardous material or chemical. SDS can be accessed on MyLink
under Resource tab, Helpful Tools, Safety Data Sheet.
 Emergency Codes at NRHS (on badge buddy):
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 o Code Red - Fire
o Code Black – Severe Weather
o Code Yellow – Disaster Plan
o Code Orange – Chemical/Biological Plan
o Code Pink – Infant/Child Abduction
o Code White – Armed Intruder
o Code Blue – Adult Resuscitation
o Code Broselow – Pediatric Resuscitation
o Code 99 – Need OB Physician
o Code Green – Emergency Evacuation

HIPAA and PHI

 HIPAA - The Health Insurance Portability and Accountability Act of
1996 is comprehensive legislation that ensures access to quality
health care coverage for people between jobs, protects private
health care information, creates a uniform standard for dispersing
personal information and prevents abuse, fraud and waste in
government-funded programs – Medicare, Medicaid, etc. It’s three
components are:
o Protection for the privacy of Protected Health Information
(PHI)
o Protection for the security of PHI
o Standardization of electronic data
 PHI - information about a patient held by health care providers and
health plans. PHI includes, but is not limited to: medical record
numbers; patients’ demographic information; images of patients;
and billing information. It is any information that can lead to the
identity of a patient or to a reasonable assumption as to the identity
of the patient.
 Your role:
o Ensure no PHI is shared with anyone other than staff who
need to know it during the course of their duties and only
the amount of PHI that the staff person needs
o Ensure no PHI in any patient care area is visible to the public
o Double check that you have the correct address before
mailing, faxing or scanning any PHI to another entity
o Never, ever access your PHI, friends or family PHI, coworkers,
VIPs or famous people’s PHI in the EMR or in paper format
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 o Always follow policy OP9100-915 – Prohibition of Using
Cellular Text and/or Picture Messaging and Alphanumeric
Pagers to Transmit HIPAA-Related Patient Information or
Confidential Information.

Employee Health
 Reporting:
o Call the “OUCH” line at 307-1482 and report the injury to
your manager or supervisor. Security will assist you and the
manager in completing the incident form and other follow-
up notification(s).
o During office hours work related injuries and illnesses are
directed to the Employee Health office for evaluation and
referral for treatment. When the Employee Health office is
closed, the employee is evaluated by the House Supervisor.
o Potential exposure to blood or other body fluids is followed
up by the Employee Health Nurse

Conflict/Disruptive Behavior
Intimidating or disruptive behaviors have a negative impact on patient safety.
Intimidating or disruptive behaviors by co-workers should be reported to
your supervisor when it occurs. If the situation is not resolved or recurs, you
should report your concerns to your department head or Human Resources
for further review.

If a physician or advance health care provider is the causing the intimidating

or disruptive behaviors:
 The patient care provider contacts their immediate supervisor (or
House Supervisor after hours) who speaks with the physician or
advanced health care provider.
 If unresolved, the Clinical Director brings the matter to the attention
of the Chair of the department where the physician or advanced
health care provider has clinical privileges.

Other
 Know how to access policies on the intranet. (Go to MyLink, Quick
Links, Policy Manager)

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  Know how to access physician privileging information:
o Go to MyLink -> Resources->Physicians -> Physician Privileges
o MIDAS will open and you can access information by physician or
privilege
 Be able to talk about specific competencies required for your area.
 Know what performance improvement and patient safety initiatives
your area is working on – and know how you are doing with these.
 Make sure all isolation rooms and dirty utility rooms are in negative
pressure
 Make sure everyone knows where the key to the patient bathrooms
is and can retrieve it quickly
 Make sure no medical gas valves are blocked by equipment
 Make sure full and empty oxygen tanks are stored separately

Quick Reference Numbers

Kent Endersby, Accreditation Program Manager 73040
Sara Barba, Manager for Accreditation and Centers of Excellence 73048

Gwen Harrington Infection Prevention Specialist Porter Campus 71401

Julie McCurley Smith Infection Prevention Manager HealthPlex 51401
Lea Ann Stephens Infection Prevention Specialist 55048
Brittany Tucker Infection Prevention Specialist 71881
Shane Cohea, Director, Safety and Security 71480
Rebecca Mathes, Safety and Emergency Preparedness Specialist 71587
Marilyn Graham, Interim Compliance and Privacy Officer 71064
Jenny Anderson, Director, Patient Safety, Quality & PI, MSO 71381

Medical Intervention Team (MIT) 88

Patient Safety Hotline307.7899 307.7899
Compliance Hotline 1.877.267.1929
Adverse Drug Reaction Hotline 73333
Ouch Line 307-1482
On campus Emergency Assistance 88
Off campus Emergency Assistance 911

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