Information on upcoming Joint Commission survey

To help prepare for the upcoming full Joint Commission survey, please review the following updated policies and hand-outs.

  • The ADMIN 0145 Patient Identification (Intranet link) policy has been updated to better explain the process for conducting patient identification using two identifiers both in the inpatient and outpatient settings.  Please review and discuss the policy and the attached flyers within your departments.
  • The ADMIN 0162 Sentinel Event (Intranet link) policy has been updated to include Joint Commission’s addition of a non-patient occurrence into the definition of a sentinel event.  All staff need to be familiar with this addition as follows:

Sentinel Events Not Involving a Patient:

  1. Rape, assault leading to death or permanent loss of function, or homicide of a staff member, licensed independent practitioner, visitor or vendor while on-site at the health care organization is considered a sentinel event because of the safety and security concerns for everyone involved, including patients.
  2. If an immediate police response is needed, contact police by dialing 911. On the UNCH campus, Hospitals Police will respond to a 911 call. Off-campus, local police will respond.
  3. Hospitals Police will notify the Legal and Risk Management Department once safety and security are assured. After hours, Hospitals Police will contact the Director On-Call, who will notify a member of the Legal and Risk Management Department.
  4. Hospitals Police will conduct a root cause analysis of the non-patient sentinel event in consultation with Risk Management. A root cause analysis report will be completed and follow-up action plans will be developed within 45 days of the occurrence of the sentinel event.

For information about identifying inpatients click here and outpatients here.