The Physician’s Role and the Joint Commission

Premier Pulse     August 2017
Marc Belcastro, DO, chief medical officer, Southern Region
Matthew Reeves, DO, MBA, chief medical officer, Atrium Medical Center

Atrium Medical Center just completed a Joint Commission inspection and Miami Valley Hospital will be visited between now and October. While it is important to be prepared, it is more important to remember WHY we work so hard to comply with the guidelines. The WHY is our desire and commitment to keep our patients safe, every day, every time. This level of consistency requires a dedication to habits and attention to detail.

From our audits and mock surveys, the following are areas for physicians to remain focused:

Environmental Safety is about awareness:

  1. Awareness of where the fire extinguishers are located
  2. Know RACE: Rescue, Alert, Contain, Evacuate/Extinguish
  3. Know PASS: Pull, Aim, Squeeze, Sweep (operating a fire extinguisher)


  1. Always log off EPIC when you leave a station, even for a brief period
  2. Take care with printed material

Documentation in procedural areas is where the Joint Commission has intense focus:

  1. Complete a history and physical and/or bridge note prior to a procedure so the entire care team is up-to-date on the patient’s current condition.
  2. Informed consent is a process that providers do well. It is important to document what we did. This is as simple as signing the consent OR making note in the EMR that documents our discussion.
  3. Own the time out and culture of safety in your operating room and/or procedural areas. Inform the entire staff that if they see something, to ask everyone to pause so that it can be addressed. Your leadership and encouragement will help them feel safe about speaking up.
  4. When your patient leaves the procedural area, does the receiving team have the details they need to monitor and care for your patient? This can be accomplished by either a quick post op note or the full post op report. This documentation must be available BEFORE the patient is moved so the receiving team has what they need. If a physician that was in the procedure accompanies the patient to that next level of care, a note is not needed. Simply document that a handoff was completed.
  5. If conscious sedation is used, document the pre-sedation assessment using the template so that all the required elements (such as the Mallampati score) are documented.

Medication Safety:

  1. Review the recent medical staff email and policy on therapeutic duplication
  2. Reconcile the medications so that patients, families and caregivers feel safe and confident regarding their medications
  3. Do not carry medications in your pocket
  4. Never fill a syringe that is unlabeled
  5. Dispose of medication syringes in the proper bins or waste the medication prior to disposing of the syringe

Infection Prevention:

  1. Surveyors observe the caregivers closely for hand hygiene
  2. Foam in and foam out of a room
  3. Use proper personal protective equipment during a procedure or entering an isolation room
  4. Dispose of sharps properly to avoid accidental sticks to yourself and others

Thank you for your care of our patients. The consistent documentation of our care, our safety culture, our communication, and collaboration for every patient through the entire continuum is how we are and should be measured. 

Back to the August 2017 issue of Premier Pulse

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