1. Information For Physicians
The Joint Commission 2012
Information For Physicians

2. The TJC Survey Interview physicians and review documentation in the MR
Review documents (data, minutes, medical records) and credentials files
Review: fire safety, emergency management and other environmental issues
Remember to Wear your ID

3. Issues and Vulnerabilities
Authentication of entries in the medical record (name, date, time)
H&P within 30 days before or 24 hrs after admission
Prior to procedure requiring anesthesia
Update to H&P within 24 hrs of admission: patient must be examined to determine if there are changes
Must have the words patient examined in the update.
Reviewed and countersigned by attending physician

4. Issues and Vulnerabilities
Use of verbal/telephone orders should be very limited.
Per Med Staff Rules they MUST be cosigned within 48 hours and any member of the physician team can sign off another member of the team’s orders.
Universal Protocol
MUST be followed for invasive or operative procedures in any location including at the bedside or in clinic.
Perform pre-procedure verification
Perform Time Out prior to all operative and/or invasive procedures. Don’t forget to document the time out.
Mark surgical site as required.

5. Issues and Vulnerabilities NPSGs
Complete medication reconciliation for all patients. (National Patient Safety Goal – see revised Medication Reconciliation Policy)
Label all medications and medication syringes/containers with drug name, strength, diluents or quantity, and expiration date. (National Patient Safety Goal to Improve Medication Safety)

6. Issues and Vulnerabilities
Prevent MDROS (Multidrug-Resistant Organisms)
Includes patient education, hand hygiene, etc. Also know the MDRO surveillance data for your area.
Anticoagulation Safety
Use approved protocols for the initiation and maintenance of anticoagulant therapy.
Know the Anticoagulation Policy and the data to support effective practices
Central line bundle; daily documentation of line necessity
Includes patient education, use of a catheter checklist, and removing nonessential lines. Also, know the CLABSI infection rate data for our area.

7. Issues and Vulnerablilities
Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).
Improve the quality of pain management
Restraints:
Providers ordering restraints must have knowledge of the UTMB Restraint Policy. A link to the UTMB Restraint Policy is on the Epic restraint order.
Restraint must be ordered using the appropriate Epic restraint order and can never be ordered PRN.