Association for Utah Community Health

The Joint Commission's mission is "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."

Eight community health center organziations in Utah are currently accredited by the Joint Commision.  AUCH supports The Joint Commission mission by supporting member health centers through the process of becoming Joint Commission accredited.

Resources

Joint Commission Home Page

Posted: Nov 17, 11 - CDC Free Online Training Module for Waived Testing - Centers for Disease Control and Prevention (CDC), Division of Laboratory Science and Standards is now offering a free online laboratory training module entitled "READY? SET? TEST! Patient Testing is Important. Get the right results."

Currently Accredited Health Centers in Utah

Top Joint Commission Findings in Utah Health Centers
(please check back as this information is updated as health centers have Joint Commission surveys)

Infection Control Policies- infection control policies should be personalized to your health center.  Think about where your staff, patients and visitors could come in contact with something that could give them an infection and then ensure that your policy specifically addresses each of those areas.

Critical Lab Values- all critical lab values must be given to the provider in a timely manner.  Ensure that policies reflect the process for getting critical lab values to providers in the amount of time designated in the policy.  If you are using an electronic medical record or other electronic means of alerting providers to critical lab values make sure that providers are not only receiving the alert in their "in-box" but that they also know about the lab values to prevent harm to the patients.  Electronic messages may not be the most effective way to get a message to a provider.

Oxygen Tank Storage- all oxygen tanks should be secured to prevent falling.  This includes small and large oxygen tanks alike.  Oxygen tanks that have recently been delivered to the health center should be secured and stored and not left in a hall way where falls could occur.

Instrument Sterilizer (Autoclave)- if your health center has an autoclave machine the machine must be tested on a weekly basis to ensure that spores are being killed at an acceptable rate to prevent infection.

Refrigerator and freezer temperature control tests- a health centers must have a method for ensuring that inside temperatures are monitored on weekends.  Options include having someone come in to the clinic on weekends to read and document the temperatures or purchasing an alarm that will alert designated staff if the temperature is out of range.

Hand washing- ensure that all staff are properly washing their hands before and after putting on and taking off gloves as well as at other times as indicated by other activities.  Hand washing competency should be checked in two ways by the health center.  Ideas for checking competency with hand washing include: designating a person to check on hand washing of all staff on a regular basis, asking patients about hand washing on patient satisfaction surveys, having staff complete a written competency test on a regular basis.

Lab values- to ensure that proper documentation and follow-up on labs takes place all labs should be recorded in the patient chart along with the normal range for the test.

Medications- medications should be securely stored behind a locked door.  Make sure that all medications including topical anesthetics are on your formulary.  When patients are transferring care (even to your own dentist) a complete medication list should be provided to the next provider or the patient to give to the next provider.  Update medication allergies at each visit to ensure that patients are not prescribed something that could harm them.  Your health center should keep a list of look alike- sound alike medications and ensure that the proper medication is being prescribed if the medication is on the list.

Sample Medications- there are several rules to follow when handling sample medications to ensure that patient safety in maintained. 

1. Ensure that expired medications are disposed of. 
2. When providing sample medications to a patient write the order for the medications in the patient chart and keep a log of patients receiving medications, dates and lot numbers so that you can easily contact them if a medication lot number is recalled.  
3. Sample medications can be stored and given out through an on site pharmacy, however the pharmacy must be open when sample medications are given out in order for this method to work.  If sample medications are often given to patients when the pharmacy is not open, sample medications should be stored separately from the pharmacy.
4. When patients receive sample medications they must be given both verbal and written materials on the medication.  Written materials must be more than the package insert provided by the manufacturing company.

Patient Satisfaction Surveys- patients should be given the opportunity to provide feedback to the health center.  Questions on the survey should include asking for the patients perception of patient safety and effectiveness of pain management.

Time Out- before any procedure a “time out” should take place where a check to ensure the correct procedure is about to be done.  Also, this is an opportunity for patient education and acknowledgement that the correct procedure will be performed should take place. 

Hints for staff- preparing staff for a Joint Commission survey is a constant task.  Educate new employees to say “I don’ know, let me find someone that does” rather than lying or guessing.  Also, ensure there is a paper trail and that everything is documented.

If your health center is willing to share some findings that you have had on a recent Joint Commission survey to help other Utah health centers learn, please contact This e-mail address is being protected from spambots. You need JavaScript enabled to view it with all pertinent information.