Question

You are on a Mock Joint Commission Survey Team for the hospital. The hospital will conduct an unannounced mock survey in the next 3 months. The team leader has asked you to bring suggestions of activities to include in the upcoming internal (mock) survey to share at the next meeting. You want to include activities that simulate a real Joint Commission on-site survey. You have several ideas from networking with your peers on the regional and state levels of your professional associations and by participating in AHIMA's CoP for Joint Commission Accreditation. Your next step is to visit the Joint Commission website at www.jointcommission.org (Links to an external site.)Links to an external site. and review the current survey process to gain a better understanding of what is being done during the on-site survey.

What suggestions would you include in the next mock survey conducted?

Develop a Mock survey plan for this organization by using information from the reading and at the Joint Commission's website. Be sure to include information on tracers, the National Patient Safety Goals, physician compliance with documentation standards, medication safety, etc.

Answer 1

Mock survey plans:

Healthcare associated infections- patient safety

Common ways in prevention of infection transmission

Identification of C-difficile and MRSA infected patients

Precautions to use with C-difficile patients

Precautions to use with MRSA patients

Procedure for donninng and removing gowns, gloves etc

Patient and health care practitioner preparation while going for a diagnostic evaluation

Infection control practices training

Fall prevention

Medication safety

Medication reconcilation

procedure for monitoring blood and blood products transfusion

procedure for monitoring IV fluids transfusion