.. include:: ../variables.rst .. _joint.commission: Joint Commission ================ .. note:: **Preview feature.** The Joint Commission section is shipping in preview while the data feeds and survey templates are validated with our pilot customers. The user interface, the labels on the Evidence Export, and the structure of the Tracer worklist may change before the feature exits preview. The Joint Commission section bundles the tools that |APPNAME| provides for facilities accredited by The Joint Commission (TJC) in the United States. It groups four pages built around hand-hygiene compliance (NPSG.07.01.01) and the performance-improvement standards (PI.01–PI.03): * :ref:`Survey Readiness` --- a single dashboard summarising the metrics surveyors typically ask for. * :ref:`Action Plans` --- formal Plan-Do-Study-Act (PDSA) tracking for moments or units that fall below target. * :ref:`Tracers` --- generates randomised observation worklists that mirror the surveyor tracer methodology. * :ref:`Evidence Export` --- assembles a printable evidence package an Infection Preventionist can hand to a surveyor. To open the section, go to :blue:`Joint Commission` in the sidebar and pick the page you need. .. _joint.commission.readiness: Survey Readiness ---------------- .. figure:: /images/lightmode/tjc-readiness.png :align: center |br| Survey Readiness consolidates the data surveyors most commonly ask for into a single page so you do not have to assemble it by hand. The page does not change underlying data --- it is a read-only view onto the same observations, action plans, tracer runs, and observer records that the rest of |APPNAME| already maintains. Page Header Actions ^^^^^^^^^^^^^^^^^^^ * ``All Facilities`` --- limit every card on the page to a single facility, or leave it on ``All Facilities`` to see the organisation-wide picture. * Refresh --- reload all four cards. Cards ^^^^^ * ``Trailing 12-Month Hand Hygiene Compliance`` --- a line chart of average compliance per month with a target line at 90%. Hover any point to see the exact percentage and the number of observations that produced it. The card carries the ``NPSG.07.01.01`` standard reference so you can cite it directly to a surveyor. * ``Observer Competency`` --- four count tiles (``Current``, ``Expiring 30d``, ``Expired``, ``Never certified``) and a roster table showing each observer's IRR (Inter-Rater Reliability) score, expiry date, and a status pill. Use this to confirm at a glance that your observer pool is current. * ``Open Action Plans`` --- five count tiles by status (``Draft``, ``Open``, ``In Progress``, ``Measuring``, ``Closed``) and a list of upcoming-due plans. Overdue plans are flagged red, plans due within the next seven days are flagged amber. Click any title to jump straight to the plan's editor. * ``Sample Adequacy by Unit`` --- an observation count per unit over the trailing 90 days, grouped by facility and flagged ``OK`` / ``Below 30`` / ``No data`` against the CDC/TJC guidance of at least thirty observations per unit per quarter. The threshold is configurable. Status Pills ^^^^^^^^^^^^ The status pill on every row of every table sits at the far left so you can scan the whole page top-to-bottom and spot any unit, observer, or action plan that needs attention. .. _joint.commission.action.plans: Action Plans ------------ .. figure:: /images/lightmode/tjc-actionplan-list.png :align: center |br| A Plan-Do-Study-Act (PDSA) action plan is the formal record of a corrective intervention. When a moment, unit, or facility falls below its target, you create an action plan to document the intervention, who owns it, when it is due, and how the result will be re-measured. Surveyors expect this kind of evidence under the ``PI.01.01.01`` --- ``PI.03.01.01`` standards. To open the list, go to :blue:`Joint Commission` | :blue:`Action Plans`. .. _joint.commission.action.plans.list: Action Plan List ^^^^^^^^^^^^^^^^ Stat chips at the top of the page show the count of plans in each of the five statuses: ``Draft``, ``Open``, ``In Progress``, ``Measuring``, and ``Closed``. Page Header Actions """"""""""""""""""" * ``New Action Plan`` --- opens the editor to create a new plan. Filtering """"""""" * ``Search action plans…`` --- matches text in the plan title. * ``All Statuses`` --- show only plans in the chosen status, or all plans. * Refresh --- reload the list. Row Columns """"""""""" Each row shows: * ``Status`` --- a coloured pill matching the plan's current state. * ``Title`` --- click the title (or pick ``Edit`` from the row menu) to open the editor. * ``Facility`` --- the facility the plan applies to. * ``Owner`` --- the user assigned to drive the plan. * ``Due`` --- the due date. Plans past their due date show in red, plans due within seven days show in amber. * ``Actual`` --- the most recent re-measured result, as a percentage. * ``Target`` --- the target percentage the plan is working towards. Row Action Menu """"""""""""""" Click the three-dot icon at the end of any row: * ``Edit`` --- opens the :ref:`joint.commission.action.plans.editor`. * ``Delete`` --- permanently removes the plan after a confirmation prompt. .. _joint.commission.action.plans.editor: Action Plan Editor ^^^^^^^^^^^^^^^^^^ Click ``New Action Plan`` or pick ``Edit`` from a row's three-dot menu to open the editor. The editor uses five tabs --- one for the basic record and one each for the four PDSA phases. Basics """""" * ``Title`` --- the plan name. * ``Status`` --- the current PDSA stage. * ``Account`` --- shown only when you are signed in as a system administrator. Pick which corporation the plan belongs to; the other dropdowns then scope to that account. * ``Facility`` --- the facility the plan targets, or ``All Facilities`` for an account-wide plan. * ``Unit`` --- a specific unit within the chosen facility, or ``All Units``. * ``Moment`` --- pick one of the five moments to focus the plan, or leave it on ``All moments`` for an overall improvement. * ``Owner`` --- the user accountable for driving the plan to closure. * ``Start Date`` / ``Due Date`` / ``Re-measure`` --- the timeline. The re-measure date is when you intend to check whether the intervention worked. * ``Baseline %`` --- the compliance percentage that triggered the plan. * ``Target %`` --- the goal percentage. * ``Actual %`` --- the most recent re-measured value, updated as the plan progresses. * ``Problem Statement`` --- a short description of the gap between the baseline and the target. Plan / Do / Study / Act """"""""""""""""""""""" The remaining four tabs each hold a free-form text area for one phase of the cycle: * ``Plan`` --- the intervention, owners, resources, and how it will be communicated. * ``Do`` --- what was actually implemented, when, and any deviations from the plan. * ``Study`` --- analysis of the re-measurement vs. the baseline. Did the intervention move the metric? * ``Act`` --- adopt, adapt, or abandon. Document the decision and any standardisation or next-cycle changes. Click ``Submit`` to save the plan or ``Cancel`` to return to the list without saving. .. _joint.commission.tracers: Tracers ------- .. figure:: /images/lightmode/tjc-tracer-list.png :align: center |br| The Joint Commission tracer methodology asks surveyors to follow a patient (or a unit, role, or shift) through real care --- a randomised walk rather than a scheduled audit. The Tracers page lets you mirror that methodology by generating a randomised observation worklist for your own observers. A Tracer is the combination of two records: * a *template* that captures the rules (which facility, how many observations, which moments to include, an optional fixed seed); and * a *run*, which is a specific worklist generated from a template at a point in time. To open the page, go to :blue:`Joint Commission` | :blue:`Tracers`. .. _joint.commission.tracers.list: Tracer List ^^^^^^^^^^^ The page shows two tables stacked vertically. Templates """"""""" * ``New Template`` --- opens the editor to create a new template. * ``Search templates…`` --- matches text in the template name or description. Each row shows the template's name, facility, sample size, and a short description, plus two actions: * ``Generate Run`` --- runs the sampling algorithm and produces a fresh worklist, then opens the run viewer. * Three-dot menu --- ``Edit`` (open the editor) or ``Delete`` (remove the template along with all of its previous runs). Recent Runs """"""""""" Each row shows when the run was generated, which template produced it, the assigned observer, the number of items in the worklist, the number that have been completed, and a status pill (``Open``, ``In Progress``, ``Complete``). Three-dot menu actions: * ``View`` --- opens the :ref:`joint.commission.tracers.run`. * ``Delete`` --- removes the run and its worklist items. .. _joint.commission.tracers.template: Tracer Template Editor ^^^^^^^^^^^^^^^^^^^^^^ .. figure:: /images/lightmode/tjc-tracer-template.png :align: center |br| * ``Name`` --- a label for the template (for example *Quarterly ICU Tracer*). * ``Description`` --- optional notes describing when and how the template is used. * ``Facility`` --- the facility the tracer covers, or ``All Facilities``. * ``Sample size`` --- the number of observations the run should generate (default 30). * ``Moments to include`` --- check one or more of the five moments to restrict the worklist. Leave them all unchecked to include every moment. * ``Randomization seed`` --- leave at ``0`` to use the current timestamp (every run is fresh and unique). Set a fixed value to reproduce the same worklist every time --- useful when you want a second observer to repeat the exact same shadow tracer. Click ``Submit`` to save the template or ``Cancel`` to return to the list without saving. .. _joint.commission.tracers.run: Tracer Run Viewer ^^^^^^^^^^^^^^^^^ Open a run by clicking its row in *Recent Runs* or by pressing ``Generate Run`` on a template. The page header shows ``Print`` and ``Back`` buttons. A summary card at the top lists the template, facility, generation date, assigned observer, current status, and the seed used. Below it is the worklist table itself --- one row per observation target, each with a sequence number, a unit, a suggested moment, an "observed" checkbox, a date column, and a free-form notes column. Click ``Print`` to send the worklist to your browser's print dialog. The print stylesheet hides the sidebar and header so the printed output is just the summary card and the table --- the format your observers actually carry into the field. .. _joint.commission.evidence: Evidence Export --------------- .. figure:: /images/lightmode/tjc-evidence.png :align: center |br| Evidence Export builds a single, printable document that bundles everything a surveyor typically asks to see: methodology, compliance trend, sample adequacy, action plans, observer competency, recent tracers, and a sign-off block. The document is rendered in your browser; saving it as PDF goes through the browser's print dialog. To open the page, go to :blue:`Joint Commission` | :blue:`Evidence Export`. Wizard Controls ^^^^^^^^^^^^^^^ * ``Facility`` --- limit the package to a single facility, or leave it on ``All Facilities`` for an organisation-wide bundle. * ``Period`` --- ``Trailing 12 months`` (the TJC default), six months, or three months. * ``Prepared By`` --- pick the user signing the package. The list shows users in your account; system administrators see admin users for every corporation, grouped by company name. * ``Generate Package`` --- assembles the document and replaces the wizard with the printable view. * ``Save as PDF`` --- appears after the package is generated. Opens the browser print dialog; pick *Save as PDF* to file the package. Document Sections ^^^^^^^^^^^^^^^^^ The generated document contains seven sections, in order: #. **Cover** --- product name, facility, period, prepared-by name, today's date, and a reference to ``NPSG.07.01.01`` and ``PI.01–03``. #. **Observation Methodology** --- a narrative describing the five-moment framework, observer training and recertification, the randomised tracer methodology, the compliance formula, and the PDSA workflow. #. **Compliance Trend** --- the trailing-period line chart and a monthly breakdown table. #. **Sample Adequacy by Unit** --- units grouped by facility, with a status pill and an observation count. #. **Performance Improvement (PDSA Action Plans)** --- the full action plan list with status, target, actual, and due date. #. **Observer Competency Roster** --- every observer's IRR score, last-certification date, expiry, and a status pill. #. **Recent Tracer Runs** --- the five most recent runs with status, template, observer, item counts, and observed counts. #. **Attestation** --- a sign-off block with two signature lines (Prepared By and Reviewed By) for the printed document.