1. TJC has come and gone!

2. How did we do?

3. Great!
This is fabulous news!!!
Kathy/JCR

4. Accreditation Based on
Impact on Patient Care 4 14

5. Our Action Plan Direct Impact – 45 days (1/28)
Indirect Impact – 60 days (2/12)
Measures of Success – 4 months
(April 2010)

6. 4 Direct Impact Life Safety – hallway Provision of Care –
medication instruction
Record of Care – post-op note
Waived Testing – Accucheck
test strip containers

7. 14 Indirect Impact Environment of Care – 2 Life Safety – 3
Human Resources – 1
Medication Management – 3
Medical Staff – 2
Record of Care – 2
National Patient Safety Goals - 1

8. Environment of Care
Testing water flow devices
Documentation of drain testing
Testing of fire extinguishers in
construction areas
Testing operation of rolling fire
shutters
Battery operated light required
in transfer switch location

9. Life Safety
Wall penetrations
Opening in sheet rock in
construction staging area
Labeling of “K” extinguishers

10. Human Resources
Primary source verification

11. Medication Management
Include Heparin in high risk drug
policy
Range orders
(review of order sets)
Incomplete medication order

12. National Patient Safety Goals
Analysis of fall reduction data

13. Medical Staff
Ongoing Professional Practice
Evaluation
Focused Professional Practice

14. Record of Care
Physician signing verbal orders
within 48 hours
Date and Time required on
ALL chart entries

15. TJC will be back. Constant readiness,
Taking appropriate care of the next patient will take care of the next survey!