Look specifically at competency policies, emergency preparedness standards, and other important measures. Review your human resource files to make sure orientation was completed within the appropriate time frame for all staff and that competencies were completed and maintained. Make sure you don't have outdated samples or floor stock medications, and be able to track back to the patient in case of recall of sample drugs. All temperature, crash cart, sterilizer, and other logs should be up to date with action taken when out of range for a particular area. Our facility has an ongoing Joint Commission task force that meets quarterly, and we also conduct satellite clinic staff meetings where we review standards to assess our readiness.
Clinic staff includes nursing, lab technicians, receptionists, and billing managers.
We also review and update, as necessary, departmental policies and procedures. Our parent facility conducts training sessions with outside consultants to assess our entire facility readiness with department heads and key individuals. We have multidisciplinary teams in place to address changes in the chapters of the Joint Commission manual and to oversee the annual review of pertinent documents, policies, and procedures. The HIM team meets on an ad hoc basis to address implementation of new or revised standards. Our next survey is scheduled for 2002 and to be sure we're ready, we're having a corporate team come in this spring to conduct a mock survey for us.