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Welcome to the BOJExtra! tools library where you can easily download electronic versions of the forms, policies, and staff training applications that are featured in the Briefings on The Joint Commission newsletter--plus bonus tools available for BOJ subscribers only online. You'll save a lot of time by not having to recreate tools from the print newsletter. The tools are arranged by topic using the chapter titles of the Joint Commission's Comprehensive Accreditation Manual for Hospitals. Whenever possible, we'll provide the tools in the popular Microsoft Word Document format, but occasionally there will be some in the Excel or PDF formats.

The library contains tools beginning with the June 2006 issue of Briefings on The Joint Commission and is updated each month.

Medication Reconciliation

Medication Reconciliation Policy and Procedure

This policy and procedure will help you comply with the JCAHO's National Patient Safety Goal for medication reconciliation (#8) and medication management standard MM.4.10.

Medicine Review form

This form is used by the James H. Quillen VA Medical Center in Mountain Home, TN. It explains to patients the importance of the medical review process and how patients can identify which medications they are taking.

Hand-off Communication

Interdisciplinary Patient Plan of Care: Patient Plan of Care Update

The form was developed by highlighting the key areas of the initial interdisciplinary care plan and it is uniform for all disciplines, so everyone is on the same page. It is used by Youville Hospital & Rehabilitation Center in Cambridge, MA, to help comply with the JCAHO's hand-off communication National Patient Safety Goal.

Ticket to ride

Use this tool to help with handoffs to transporters. It was developed by The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, to help ensure staff has the proper information on a patient prior to transfer.

Critical Test Results

Critical Test Result Form

This chart is a list of values that Mat-Su Regional Medical Center uses to define lab, radiology, and CP results as critical.

Sticker Label: Notification of Critical Test Value

A label for critical test values.

Other National Patient Safety Goals

Failure Mode and Effect Analysis: Suicide Prevention

A sample FMEA completed at Loma Linda University Behavioral Medicine Center, Redlands, CA.

Restraint and Seclusion model policy

A model policy for Restraint and Seclusion addressing National Patient Safety goals in this area.

Medication/Medical Errors

Authorized Access to Drugs and Biologicals

This policy covers authorized access to drugs and biologicals. Remember, the Joint Commission does not require locks with keys or combinations on emergency carts/crash carts, but it does require that carts be secure. "Secure" can mean locked (breakaway locks are acceptable) but it can also mean under constant surveillance (in the nurse's station, in a corridor, positioned so staff see it. The Joint Commission does not require someone to actually look at/watch the cart. Be sure to conduct a risk assessment to find the best method for your facility.

Use of verbal and telephone medication order audit tool

Use this tool to track and decrease medication verbal and telephone orders in urgent/emergent situations.

MM.8.10 Poster

Brooke Army Medical Center in San Antonio, TX, developed this poster to help staff comply with standard MM.8.10, medication management risk assessment.

Medicine Review form

Heparin safety fishbone

A fishbone detailing Heparin management. Created by Eileen Willey, RN, MSN, CPHQ, and Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA.

Heparin Administration FMEA

A Heparin Administration Failure Mode Effects Analysis. Created by Eileen Willey, RN, MSN, CPHQ, and Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA.

Joint Commission Survey Preparation/Staff Training

15 Staff Tips for a Successful JCAHO Survey

This list of JCAHO survey tips is distributed to staff at a 341-bed hospital. The tips are applicable at any type facility preparing for JCAHO survey, although you may want to adapt them to suit yours.

Checklist of data surveyors want when they arrive at your facility for survey

This checklist is adapted from a handout given to attendees during Joint Commission Resource Inc.’s Hospital Accreditation Essentials education program in Chicago in May 2006. Be sure to also consult your Survey Activities Guides for more information about these items and additional items surveyors will want to see when they arrive at your facility for survey.

Top 10 Patient Safety Questions and Answers All Staff Should Know

Fairlawn Rehabilitation Hospital in Worcester, MA, teaches these 10 questions, and answers, to all staff, so they can

JCAHO Survey Highlights, Questions and Focus Areas

These questions and focus areas were recorded by Florida Hospital DeLand staff who shadowed surveyors during patient and system tracers during a JCAHO survey at the Daytona, FL, area hospital.

’Smart Cookie’ Game Trains Staff in a Fun Way

To help train staff about JCAHO standards Peace Health Medical Center in Longview, WA, decided to create a game, called Smart Cookie, to teach staff while having fun. To play you need two staff. One is the "taster," and the other is the "tester." The tester pulls a cookie card out of the box (use the sample template here for ideas) and reads the question on the front. The taster guesses at the answer, which is located inside the folded card. If the answer is correct, the taster's name is written on the back of the card and dropped in a cookie jar for a raffle.

Survey Experience Slideshow

This slideshow was put together by Huntington Hospital in Pasadena, CA, to present survey results to staff.

Joint Commission Survey Score Card

Huntington Hospital in Pasadena, CA, developed this score card to track its constant readiness for a Joint Commission survey.

Patient Tracers/System Tracers

Care Location Tool

This sample tool is one of eight tracer tools used in The Mock Tracer Monitor, a resource developed by the accreditation experts at The Greeley Company, a division of HCPro Inc. It mirrors the type of tracer activity you can expect a surveyor to conduct during an actual survey.

Periodic Performance Review Management

Five Steps to Build a Plan of Action

To develop and implement of plan of action, first understand the issue and then ask the following five key sets of questions recommended by Jodi Eisenberg, CPMSM, CPHQ, program manager for accreditation and clinical compliance at Northwester Memorial Hospital in Chicago.

CMS Survey Management

Remember to do Pre-Surgery H&Ps

At St. Mary's Regional Medical Center in Russellville, AR, doctors remember to do pre-surgery H&Ps thanks to this simple form developed by the nursing staff.

Environment of Care/Life Safety Code

Compliance Checklist for EC.4.20

The fastest way to know if your hospital complies with the elements of performance for EC.4.20 (conduct drills to test emergency management), is to go over this checklist.

Sample Questions for Emergency Power Preparedness

Answering these questions, provided by a JCAHO surveyor, will help your organization gauge how successful it is at preventing and predicting potential emergency generator failures.

Sample hand hygiene compliance tracker form

Hand-hygiene compliance can be a challenge. At LifeCare Hospitals of San Antonio, 30 observations are done each month to assess compliance using this simple one-page tool.

Sample hand hygiene compliance, isolation protocol tracker form

This tool tracks compliance with not only hand-hygiene, but isolation protocol and gloves used with all patients. It is used at LifeCare Hospitals of San Antonio.

Life Safety Code building tour checklist

Use this handy, thorough checklist to record your building tour activities.

Sample EC/IC tracer checklist

This is a checklist of conditions to look for when conducting EC or IC tracers. Use this checklist to collect data relating to conditions in the environment. Unique identifiers allow for tracking and trending of specific occurrences and can help identify strategies for resolving them.

Meeting the Standards

2007 Policies and Procedures (LD.3.90)

This tool, deveoped by Elizabeth DiGiacomo-Geffers,RN, MPH, CNAA, BC
Di Giacomo-Geffers and Associates, acts as a matrix to help bring policies and procedures into compliance with LD.3.90.

Other

Accrediting Agency Options Worksheet

The amount of time and resources necessary to maintain JCAHO accreditation has many healthcare organizations weighing alternatives. This is a sample accrediting agency options worksheet for doing this exercise, developed by Woman’s Hospital in Baton Rouge, La.

Survey Coordinator Job Description

How do your responsibilities compare? Check out this sample job description for survey coordinator used at Rockford (IL) Memorial Hospital/Rockford Health System.

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