Joint Commission Booklet

Survey 2024

Questions & Answers

INTRODUCTION

What is the Joint Commission survey?

The Joint Commission on Accreditation of Healthcare Organizations (JOINT COMMISSION) surveys healthcare organizations to ensure compliance with appropriate standards.

PATIENT-FOCUSED FUNCTIONS

• Rights and Responsibilities of individuals

• Provision of Care, Treatment and Services

• Medication Management

• Record of Care, Treatment & Services

• Infection Prevention and Control

ORGANIZATONAL FUNCTIONS

• Improving Organization Performance

• Leadership

• Management of Environment of Care

• Management of Human Resources

• Management of Information

• Emergency Management

What is Gosnold’s Mission Statement?

"To excel in addiction and mental health treatment, prevention, and management; to serve individuals and families affected by these illnesses and to promote lasting recovery. “

What is Gosnold’s Vision Statement?

• Deliver a full continuum of services, using best practices, evidenced-based care and leading clinical research which consistently demonstrate positive outcomes.

• Show respect, patience and compassion for our patients, their families and the communities we serve. Consistently present a positive attitude and professionalism to all people with whom we have contact.

• Show respect, patience and compassion for our patients, their families and the communities we serve. Consistently present a positive attitude and professionalism to all people with whom we have contact.

• Be the employer of choice for professionals who excel in the delivery of behavioral health care across the care spectrum. Recognizing and appreciating talent in our staff, encouraging growth and professional development and promoting an atmosphere of trust and teamwork throughout the organization.

• Uphold Gosnold’s rich and long-standing history of compassionate care, and understanding and anticipating our clients’ needs in order to provide the highest quality and most innovative care both locally and nationally to those seeking help.

What are Gosnold’s core values?

At the heart of Gosnold is a set of core values that permeates our customer services, patient care and staff interaction.

Innovation Integrity Collaboration

Accountability Respect Excellence

The Gosnold Philosophy

• Addiction and mental illness are chronic diseases that adversely affect individuals and families in all major life areas.

• A continuum of services should be available to patients and treatment should occur in the least restrictive setting consistent with presenting problems and diagnoses.

• Abstinence is necessary for lasting recovery from addiction, but anti-craving medications should be used as an evidence-based treatment.

• The recovery principles of self-help groups are of major importance and are recommended to patients and their families.

• Treatment should be provided by competent, qualified personnel in settings that are safe, healthy and accessible to patients and their families.

• Because whole families are affected, treatment should involve the family and other significant persons.

2024 Behavioral Health Care National Patient Safety Goals

The National Patient Safety Goals (NPSG) were established by the Joint Commission to help accredited organizations focus on patient safety. There are 10 safety goals for ambulatory centers. The health center monitors our compliance with these goals during our internal audits. It is expected that all staff understand and comply with the applicable goal to ensure our commitment to deliver safe services.

The 2024 goals are:

Identify patients correctly

Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

Use medicines safely

Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up to-date list of medicines every time they visit a doctor.

Prevent infection

Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

Identify individuals served safety risks

Reduce the risk for suicide.

Improve health care equity

Improving health care equity is a quality and patient safety priority. For example, health care disparities in the patient population are identified and a written plan describes ways to improve health care equity.

INFECTION CONTROL

What does the term universal precautions for infection control mean?

It means that all patients' blood, body fluids, and specimen are treated as if they were infected with a bloodborne pathogen, like Hepatitis or HIV.

Where is the Infection Control Plan located?

The pIan is found on SharePoint in the Plans folder in Quality.

What is the purpose of the Infection Control Plan?

The plan outlines all measures used to minimize exposure to blood borne and other pathogens in the workplace. Information included on:

• Universal precautions

• Personal protective equipment (gloves, gowns, eye/face protection)

• Work practice controls (hand sanitizing)

• Engineering controls (sharp containers, needle safety devices

• Response to blood borne pathogen exposure

How are patients informed about infection control?

All patients will receive information regarding prevention and control of infectious diseases, including, Hepatitis B, HIV and Sexually Transmitted Diseases. This information will be presented to the program participants during their treatment program.

How are staff involved in infection control?

Employees are required to perform hand sanitation upon arrival at work, before and after patient contact, after removal of gloves, after toileting, before eating, and before leaving the organization.

Where is there waterless antiseptic available?

In all patient care and specimen handling areas.

When would you wear gloves?

Gloves must be worn when there is a possibility of contact with blood or bodily fluids or when in contact with equipment contaminated with blood or bodily fluids. Upon completion of the task, gloves are removed and hands sanitized.

Quality and Risk

What is documented in an incident report?

Any event occurring on the premises which is not consistent with the routine operations of Gosnold or routine care of its patients.

What are examples of incidents?

Fall (with injury), adverse occurrences/reaction, equipment related, property/loss/damage, security issues, patient complaint, medication variance, suicide or suicide attempt, behavior disturbance.

Where do you document incidents?

All incidents are reported using the online platform Incident Tracker. The reports should be factual and concise. You can either find the Incident Tracker icon on your desktop or you can simply type in http://incidenttracker.gosnold.org/ into your web browser.

What is a sentinel event?

A sentinel event is an unanticipated occurrence involving death or serious physical or psychological injury. Serious injury includes loss of limb or limb functions.

What is a root cause analysis?

Root Cause Analysis is conducted when variation/failure of performance and/or sentinel event occur. It primarily focuses on systems and processes as a whole, and not on individual performance. Internal review is conducted to identify casual factors and changes that can be made in systems and processes. Risk reduction strategies and Action Plan is developed and implemented to prevent reoccurrences.

Good catch is defined as a circumstance that might have caused harm but was prevented from reaching the patient.

A near miss, is an unplanned event that has the potential to cause, but does not actually result in injury

Quality- Improving Organization Performance

What are the methods of performance improvement at Gosnold?

The organization utilizes multiple tools for performance improvement including but not limited to LEAN, PDSA, SWOT, GEMBA etc.

What are clinical outcome measures?

Clinical outcome measures are a set of indicators addressing diagnoses where performances improvement is likely to have a significant impact in the outcomes of specific patient populations.

What clinical outcomes does Gosnold collect data on?

Patient Satisfaction, Average length of stay, daily census, Incident reporting data, Medical Chart documentation Compliance

How is patient satisfaction measured?

Inpatient and group program services and measure patient experience of care at Discharge.

Outpatient services measure patient experience of care using a point-in time methodology (2x annually).

Data is available to program directors and leadership through dashboards that are available at all times. Supervisors share this information with their staff during group and individual supervision.

Safety

Gosnold’ s values include a commitment to establish and maintain a safe, accessible and aesthetically pleasing environment of care that enhances the dignity of individuals and ensures the safety of patients, staff and visitors. To ensure that Gosnold facilities and programs provide a safe environment the Gosnold has developed a comprehensive Safety Management Program designed to provide an environment free of hazards and to minimize the risk of human injury.

What security measures are used in your area?

• ID badges

• Locks

• Alarms

• Cameras

What do you do in the event of a fire?

Remember RACE and PASS for fire safety.

RESCUE anyone in immediate danger from the fire or smoke

ALARM call out "code red" and pull nearest fire alarm and dial 911

CONTAlN the fire. Close all doors that you are able to

EVACUATE the building and meet in designated area. DO NOT USE ELEVATORS

When it is safe to operate a fire extinguisher follow PASS

Pull the pin

Aim at the base

Squeeze trigger

Sweep

Where is the location of the nearest fire alarm?

As a general rule, pull stations are located approximately 5 feet from every exit.

Is smoking allowed inside the building?

No.

Where can you find the Gosnold emergency plan? The plans can be found on SharePoint.

Environment of care plan-utility management

Gosnold is committed to ensuring that patients receive care in facilities that are supported by adequate utility systems and with equipment that is maintained in proper working order. Although no life support systems are used, minor equipment is used for clinical care or diagnosis. This EOC plan is established to ensure that program equipment and utility (gas, electric, etc.) systems are operationally reliable and maintained in accordance with safety precautions.

Hazardous chemical and communication and storage program

Gosnold has developed a Hazardous Chemicals Communication and Storage Program to insure employee health and safety. Gosnold will provide information about chemical hazards and the control of hazards through a Hazardous Chemicals Communication and Storage Program that includes specifications for Container Labeling, Safety Data Sheets (SDS), Chemical Storage, and staff training. The responsibility for organizing and implementing the program will rest with the Director of Facilities.

Where is the hazard communication manual kept?

A Hazard communication manual (SDS/safety data sheets) will be located at each of Gosnold's facilities and accessible to employees. The manual contains all Gosnold applicable Safety Data Sheets (SDS), OSHA regulations (Hazard Communication Act), DPH 105CMR670.000 (Right to Know), Gosnold chemical list and a copy of this procedure.

What codes are used at Gosnold?

Code Red

Used for fire emergencies. Remember RACE and PASS when handling fire emergencies.

Code Blue

Used for medical emergencies. Call 911. Charge nursing and/or other CPR certified staff gather medical supplies and bring them to the location of the emergency.

Rapid Response

Immediate medical attention.

Code Purple

Used for a behavioral crisis. This code would require staff assistance for physical altercations, threatening behavior, patient showing signs of escalation or patient verbalizing intent to harm self or others.

Active Shooter

Upon discovery of an active shooter situation, as soon as possible and when safe to do so, notify law enforcement (911) and provide announcement of an "Active Shooter" over the telephone paging system using the emergency paging system over our telephones. Dial (#00). You should also provide your location, if possible.

Human Resources

If you have an ethical, cultural or religious conflict regarding the care of a patient what would you do?

Communicate the conflict to your supervisor. The supervisor, along with others in authority, will make a reasonable effort to accommodate the conflict without adversely affecting patient care. Under no circumstance can the care of the patient be compromised.

What mandatory in-service (Relias) trainings do you receive each year?

• Fire Safety (RACE) Infection Control

• Emergency Preparedness

• Cultural Competency

• Security

• Patient Rights & Responsibilities

• Sexual Harassment

• Incident Reporting

• HIPAA

• Identifying victims of abuse or neglect and mandatory reporting

How is staff oriented to Gosnold?

Gosnold strives to provide all new staff members (payroll employees, independent contractors, interns and volunteers) with an orientation to the organization, its mission, the clinical programs and the policies and procedures that govern daily operation. Accordingly, all new staff shall undergo an orientation by the Human Resources Department and by the program in which they will be working.

How is staff oriented to their department?

• Worksite specific orientation is overseen by the manager and other knowledgeable co-workers.

• Job descriptions are reviewed along with position-specific standards.

• Training manuals are available as a resource.

• Job specific competencies are detailed for employees.

When did you receive your last performance review?

Annual performance reviews occur all at one time for employees and are completed during an Annual Performance Event. Gosnold's annual performance review period for this event is May 1st through April 30th. All employees hired in the previous calendar year will be included in the event.

New employees receive 3-month evaluations at the end of their introductory period.

How are your skills and competencies monitored and updated on the job?

• Worksite specific orientation

• Regular scheduled and mandatory in-services

• Self-learning through articles

• Participating on Committees

• Annual performances reviews

• Staff meetings

• Inservice trainings on clinical procedures

Management of Information

What kind of information is confidential?

Any information about the patient's condition, care, treatment, or personal data (for example, his/her address) is confidential and can only be discussed with those directly responsible for the patient's care and treatment.

Certain types of employee and business information are also confidential.

What are some examples of how staff ensure patient confidentiality?

• Staff does not discuss a patient's care or treatment with anyone other than those directly involved in the care or treatment.

• Employees are assigned levels of computer security depending upon job title, as well as individual passwords; sharing computer passwords is strictly forbidden.

• Employees are required to "exit" the patient's screen before walking away from the computer.

• Patient information is never disclosed without the patient's knowledge and consent, unless there is a legal obligation or duty to disclose information.

• Requests from external sources for patient information are directed to the Medical Records Department.

• The Community Relations/Development Department handles any requests for patient information from the media.

• Patient information is never disclosed outside the medical center, or in public or semi-public areas such as staff lounges, elevators, hallways and restrooms.

Patient’s Rights and Responsibilities

How are patients informed about their rights and responsibilities?

Patients are informed of their rights at orientation sessions, through information packets and via the patient bill of rights. These rights are also displayed prominently in-patient admission areas and patient communication boards in all Gosnold facilities.

How are the patient complaints handled at Gosnold?

If a patient wishes to lodge a complaint about the treatment they have received from a Gosnold employee or representative, or about any aspect of the program, its services, or their rights as a patient, that patient may file a formal complaint or grievance through three mechanisms:

1) Direct submission to Gosnold staff or management using the advocacy form.

2) Patient Advocacy Line

3) Report to a regulatory, licensing or accrediting organization.

Admission to Gosnold

Admission to any Gosnold program requires a determination that the patient is in need of the services offered and that no clinical condition exists which would preclude admission. To make this determination, persons requesting admission are interviewed, either in person or by telephone, in a pre-admissions screening interview. Persons who meet pre-admission criteria are scheduled for an on-site assessment. Admission decisions are based on individualized assessments using reasonable medical and clinical judgment.

What should staff do if the patient does not speak English?

Gosnold has a language line for patients whose language needs are not covered by the staff.