Target audience: Department managers within the organization. This tool should be used by managers to prepare their staff. The examples of compliance should be tailored to the organization.

The downloads in the STET Tracers category are to help hospitals prepare for Joint Commission surveys. They provide sample questions similar to those you might expect to receive from The Joint Commission, but are in no way actual Joint Commission tracers.

In this section, you...

An example of an Evidence of Standards Compliance (ESC) document 

Customize the answers to the practice at your institution. This tracer is intended to guide you in understanding the types of questions that may be asked by the surveyor. It cannot guarantee these will be the questions asked.

NPSG.06.01.01 requires hospitals and critical access hospitals...

CONTRACTED SERVICES: Customize the answers to the practice at your institution. This tracer is intended to guide you in understanding the types of questions that may be asked by the surveyor. It cannot guarantee these will be the questions asked.

Evidence of contractual agreements that...

Cleaning and Disinfecting of Equipment; Focus on Flash Sterilization in the Operating Room/Ambulatory Areas

This tracer should be revised to accommodate the questions/notes specific to the hospital. The questions are examples only and do not reflect exact questions asked by surveyors.

Improving medication safety, including labeling, preparation, and adminstration. 

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