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TJC Survey

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The Joint Commission Survey can be a stressful time for hospitals. The ultimate goal of course is to maintain compliance and readiness in all areas, so any time a surveyor walks into your facility, you are ready. From the pharmacy’s perspective, this is comparatively easier to do if you have an engaged team. However, when it comes to medication management outside the pharmacy, it’s harder to ensure complete compliance. A common finding is in the area of IV drips – did the nurse follow the order when it comes to titration and documentation of all necessary vitals and scores? 

Other trends I am seeing on this go round in California is a solid interest in Antibiotic Stewardship. Surveyors will want to hear all about your program. They seem to also want to hear about your glycemic program. Directly within the pharmacy, they have taken a more detailed interest in the sterile compounding room. When my hospital was surveyed, the surveyor gave me a TJC Surveyor Guidance Checklist for On Site Activity the day prior so I could be prepared. The checklist included the assessment item, guidance on compliance, and the Joint Commission Standard regulation number. It gave me time to prepare, and in my preparation I realized I needed an inservice on how to read TSS reports. It really should not be that complicated! The Facilities Director ended up being invaluable to me on that survey day, and he saved the day with the surveyor. A reminder, all surfaces of the hood (ISO Class 5 PEC) need to be cleaned (disinfected) at the beginning of each shift, at least every 30 minutes when compounding or before each lot, after each spill, and when surface contamination is suspected. 

“Preparation doesn’t assure victory, it assures confidence.”
Amit Kalantri, Wealth of Words

Our References

Terri is absolutely phenomenal. She is an incredibly knowledgeable pharmacy resource. As the medication safety officer, the quality initiatives she implemented not only impacted the patients at our medical center but also reached into the community. Terri is a genuine professional who upholds accountability while creating community among her team members. She is a great listener to identify friction points and has actionable ideas to implement improvements.

T. Eagle. MBA, MLS(ASCP), CLS Lab Operations Manager

Terri is an expert at prospective risk identification -Failure, Mode and Effects Analysis (FMEA). Terri participated in CHPSO Patient Safety Safe Tables and was part of the Hospital Quality Institute’s Regional Quality and Patient Safety Leader Network.
She is an excellent public speaker and communicates well with public and professional audiences. I look forward to her continued work in medication safety.

Regional Quality Network at HQI

Terri has done a tremendous job with the controlled substance diversion program. She has had such a positive impact and has really made the hospital a safer place.

Tri-City Medical Center
Nurse Manager

We would not be where we are with the improvements we have made with opioid prescribing if it were not for Terri driving the process.

Tri-City Emergency Medical Group
Chief Physician

In addition to understanding the ins and outs of the [controlled substance use] process completely, she is very proactive in coming to me with provider issues that she detects. She truly balances the administrative duties and the regulatory components demand with a keen sense of what my practitioners do and what their needs are on the ground. Terri is instrumental in working with my department, balancing patient care, cooperation, ability, and integrity to get the job done.

UCSD Medical Center
Chief Anesthesiologist

Terri is knowledgeable and effective in pharmacy leadership. She has the ability to be able to anticipate and prepare for the future. Her ability to utilize resources effectively in this changing environment is a strong asset. She can adapt, evolve, mentor and still never say “no” when asked to assist. She exhibits great abilities to be flexible and is a “self starter”. She has a pleasant yet effective demeanor that commands results.

Candace Fong, Pharm D
System Director of Pharmacy and Medication Safety Common Spirit Health

Terri has always impressed me as being very smart. resourceful, creative, and easy to work with. Terri’s commitment to medication safety permeated our organization, raising the awareness of this important issue throughout all levels of the institution. Terri has always been engaged, cooperative, and generous with her time.

Cary Mells, MD
Chairman of the Department of Emergency Medicine Tri-City Medical Center

Terri has done more for the Pharmacy in her few months as Interim Pharmacy Director than any other Director has done during my 12 years here.

Anita Kennedy, MBA
VP of Ancillary Services Methodist Hospital

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Address: 950 Boardwalk Suite 305, San Marcos, CA 92078

  • 760.705.4078
  • tvidals@rxpert.solutions