RE: Joint Commision Visit
Nauss,Karen A (Mount Auburn)
HI Everyone,
Drew at St E’s just had Joint Commission visit. Here are some of the things they looked at.
Thanks for sending this along. We all appreciate it.
Have a nice weekend.
Take Care,
Karen
Group, I thought I would send along a quick email about my Join Commission visit that I had here at Saint E’s last week. Hopefully this is helpful…
They showed up last Tuesday morning and stayed until about 2pm on Friday. There first visit to CPD was late in the day on Tuesday at about 3:00pm. I will work on getting you the names of the surveyors and will provide them at some point later this week.
The wheels on our racks where we store sterile instrument trays were inspected for rust. It was mentioned about not storing card board boxes even in a break down area where there were no sterile items kept. They questioned my staff on scope processing. One of my techs had to walk them through the whole process from when a flexible scope hits decon to when the scope is out of the System one E and transported to be hung in the scope cabinet. One of my other techs was questioned about knowing how an instrument washer cycle passes. He walked her through the testing aspect as well as the info that we keep in our log book. They asked about steam cycles, how we verify that a load successfully goes through a complete cycle. Where do we place the bowie Dick for testing and why. It was also asked about our process if an instrument comes through the washer with bio-burden on it. What steps would be taken and why. They were very big on what our processes were and why we do them. They asked to see one month of records for just one of our steam autoclaves, which they reviewed. This visit lasted about an hour and a half.
The second visit was on the very next day. All of our ceiling tiles were inspected, air flow, and making sure all soft good items were 18inches from the ceiling. This visit lasted only about 30 minutes.
Lastly, one of my techs files were randomly picked to have someone go through them. This was not a visit, rather a meeting that was held on the Friday. They went over all competencies, orientation, and certification verification. This lasted about 30 minutes.
CPD at Saint E’s had no findings! We passed with flying colors! It was said that my staff were very knowledgeable and precise with their answers. Hopefully this helpful for the group and good luck to all of you that have your visits coming up!
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