Harbor: Joint Commission (JC) Readiness

• Updates: Survey Window October 2025 - March 2026
  • The JC eliminated 714 requirements
  • 14 Categories: Right Patient, Right Care; Culture of Safety; Emergency Management; Excellent Health Outcomes for All; Infection Prevention and Control; Pain Management; Patient Rights; Suicide Risk and Reductions; Safe Transplant Practices; Waved Testing; Workplace and Patient Safety; Staffing; Imaging Safety; Medication Management

• General tips:
  • Wear badge above the waist
  • Use 2 patient identifiers (name, MRN, DOB
  • Clear hallways (equipment/carts on one side, one side free) with access to fire extinguishers, medical gas shut-off valves, & exits
  • Only answer the question asked; if you are not sure, tell them where your would find the answer (or escalate to your supervisor)

• Infection Control
  • Wash your hands! Foam in, foam out; wear PPE (not in the halls)
  • Isolation signage on room doors
  • Think about HAP (when intubating/placing chest tube), CAUTI (minimize foleys)
  • Expiration dates on US gel
  • Wipes: purple 2 min wet time, grey (US), alcohol (Dragon), orange (bleach) 4 min wet time
  • Chloraprep TIMES
  • US - clean after use and just prior to use; dirty US probes to the transport box
  • Vacutainers to dirty utility room, EVS bags and dispos

• Doc Box
  • No open food (bottled water)
  • No meds (eye gtts)
  • Shred HIPAA material, F8 when not at computer

• Orders
  • Restraints q4 hours (still needed?)
  • No verbal orders
  • Parameters for titratable medications
  • Review home meds for interactions with new meds
  • No meds (including saline flush) in your pocket

• Documentation
  • PLIN for use of translators
  • EMTALA form
  • Patient/family education

• Process Improvement Projects
  • Sepsis
  • Stroke
  • APOT
  • D2EKG
  • Triage D2Doc, LWBS