The Joint Commission

By Joseph Bernardino posted 06-07-2019 16:32

Hi All.

My name is Joseph Bernardino and I am the Respiratory Care Manager at Marin General Hospital. We just had The Joint Commission Surveyors here, and i just wanted to inform the respiratory community as to what they focused on. The surveying is now 5 days longs as opposed to 3 days. There were three surveyors, one nurse, one M.D. and one biomedical engineer with extensive history  and experience. All three were kind, bright and knew what they were looking for. I sat with a surveyor for an hour and a half going through patient's charting that were on ventilators. She wanted to make sure that the orders correlated with the charting especially when there were order changes. Also, the time differences between when a order was placed and when the change was made. She looked for charting as to why a patient failed a spontaneous breathing trial as well. 
The surveyor looked at almost every oxygen storage we had to make sure that oxygen tanks were stored correctly between empty and full tanks. They asked about our cleaning procedure for bronchoscopes as well. For everything they asked for from respiratory, we did great and had no issues. 

This was my first round in management with TJC, and I have to say although stressful, it was a great learning experience to know where I needed to readjust my focus. And it helped that they were kind.
I hope this helps any of you in future and if you have any question please do not hesitate to ask. I am here to help raise the bar any way I can.

Joseph Bernardino, RCP | Manager of Respiratory

Marin General Hospital
250 Bon Air Road
Greenbrae, CA 94904
Office 415-925-7472 | Mobile 415-497-1032| Fax 415-925-7473|    

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11-21-2019 18:08

​Hi Joseph,
They will be arriving in January.  How deep did they look into your policies?  How deep did they look into a staff file, if any?  Helen

09-25-2019 11:22

Thanks for the information.
We will be seeing them early next year.

Not sure if during your visit there was any discussion about finger pulse ox's for spot checks?? Not even sure if your staff use them. However, I  am being told these are not permitted by Joint Commission. I am trying to get some more information.

Jackie Paulik RRT/RCP
Administrative Director
Mercy Medical Center