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Joint Commission JACHO TJC

Nurses   (146 Views | 2 Replies)

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Hi everyone, I am an ambulatory LPN in a very fast paced Internal Medicine office.  We are under our hospital standards.  We are up for a mock survey this week for JACHO and are in the window for the real deal.  For some reason I feel like our office is being picked on as they have been doing biweekly checks for potential JACHO visit by our education team.  Every single week they have some new insane rule and I am curious what goes on at other ambulatory offices when it comes to meeting standards.  Currently I feel like we are being punked.  We have to have our sinks marked "clean sink" (to prove we don't pour urine down it).  We have to mark 12 inches between the sink and the urinalysis machine even though the outlet is right next to the sink.  We had outlet covers on all outlets but we have now been written up for having outlet covers and they have all since been removed.  We have to clean our blood pressure cuffs between each patient for a full 2 minutes then we have to bag the cuffs in ziploc bags at all times when not actively taking a BP.  We cannot have medical scissors, tape measurers, or any other mutli patient item in a room unless it is in a ziploc bag and marked clean.  We cannot have table liners in our bed drawers.  The EKG machine cannot have one single bit of adhesive found on it from the leads or automatic write up.  Our wheelchairs have to have a tag on them that says clean when not in use.  This is just a few items of the many many many rules that keep getting thrown at us every other week.  I have gone to other offices within the same company and NONE of this stuff is being done at other facilities.  We got written up for having a desk fan because it was only a 2 prong not a 3 prong plug EVEN though our U/A machine is only 2 PRONG.  I am super frustrated and very curious of other practices experiences, when we ask we are told "It's a JACHO rule". 

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Jedrnurse has 25 years experience as a BSN, RN and specializes in school nurse.

1,575 Posts; 14,461 Profile Views

Management often wields the "because of TJC rules" club as a shut-everybody-up response, similar to people abusing the idea of HIPAA when they want to avoid the work of gathering/prepping/sharing medical records.

"TJC rules" can also be a knee-jerk reaction to a situation out of fear that a facility will be dinged. 

Ask for the citation of the rule in question.

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Davey Do has 41 years experience and specializes in Psych, CD, HH, Admin, LTC, OR, ER, Med Surge.

17 Followers; 1 Article; 6,686 Posts; 82,784 Profile Views

7 hours ago, lpn164 said:

 We are up for a mock survey this week for JACHO and are in the window for the real deal.  

Back in '93 and '03, the facilities I worked for as a nursing supervisor sent me to seminars for me to learn how to prepare for accreditation surveys.

One thing I remember a speaker saying is that most facilities tend to overcompensate in their endeavor to meet standards.

I have found, lpn164, that even if everything is perfect, accreditation surveyors will find something wrong or needs to be done differently. Surveyors need to identify problems in order to justify their existence. 

Sorry. And good luck!

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