©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
Joint Commission Survey Exam Questions
With Correct Answers.
What does the Joint Commission on Accreditation of Healthcare Organizations do? -
Answer✔Evaluates and accredits nearly 15,000 health care organizations and programs in the
U.S.
Independent, not-for-profit
"State-of-the-art" standards
Conducts on-site surveys by a survey team at least once every three years (Labs surveyed every
two years)
What type of organizations does the Joint Commission provide evaluation and accreditation
services to? - Answer✔*General, psychiatric, children's and rehabilitation hospitals
*Critical access hospitals - Durable Medical Equipment (oxygen tanks, wheelchairs, etc.)
*Medical equipment services, hospice services and other home care organizations
*Nursing homes and other long term care organizations
*Behavioral Health care organizations, addiction services
*Rehabilitation centers, group practices, office-based surgeries and other ambulatory care
providers
*Independent or freestanding laboratories
What are the benefits of Joint Commission accreditation and certification? - Answer✔-
Strengthens community confidence in the quality and safety of care, treatment and services
-Provides deeming authority for Medicare certification
-Provides professional advice and counsel, thereby enhancing staff education
-May reduce liability insurance costs
-Provides a competitive edge in the marketplace
-Improves risk management and risk reduction (ex. managing infection control)
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, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
-Helps organize and strengthen patient safety efforts
-Provides education on good practices to improve business operations
-Enhances staff recruitment and development
-Recognized by insurers and other third parties
-Standards address organization's level of performance in key areas such as patient treatment and
infection control.
-Performance expectations for activities that affect patient safety
-Focus on organization's outcomes and Performance Improvement measures & how they try to
do better
-Patient infection control
-Readmission rates
What should you do if you are preparing for a hospital survey? - Answer✔Know the standards
Examine current processes
Improve areas that are not currently in compliance
Comprehensive Accreditation Manual for Hospitals (CAMH)
Attend seminars to understand standards
Network with colleagues
Do a mock survey before you have a survey for critical feedback (for improvement &
recommendations)
How many patient identifiers should you use? - Answer✔Use at least 2 ways to identify patients
Patients name & patients DOB
Use medications safely - Answer✔Before a procedure, label medicines that are not labeled.
Take extra care with patients who take medicine to thin their blood.
Record and pass along correct information about a patient's medicines, across the continuum
(recon the changes of the medications
Time out procedure - Answer✔must be done during procedure. Specific risk protocol that covers
array of things and ensures that the group is doing correct things for the client. Medication, site
of incision, removal of instruments, etc.
What are the AREAS OF FOCUS of the Joint Commission Survey/ AKA THE MAIN FOCUS?
- Answer✔*Ethics, Rights and Responsibilities: Patient rights, confidentiality, privacy,
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Joint Commission Survey Exam Questions
With Correct Answers.
What does the Joint Commission on Accreditation of Healthcare Organizations do? -
Answer✔Evaluates and accredits nearly 15,000 health care organizations and programs in the
U.S.
Independent, not-for-profit
"State-of-the-art" standards
Conducts on-site surveys by a survey team at least once every three years (Labs surveyed every
two years)
What type of organizations does the Joint Commission provide evaluation and accreditation
services to? - Answer✔*General, psychiatric, children's and rehabilitation hospitals
*Critical access hospitals - Durable Medical Equipment (oxygen tanks, wheelchairs, etc.)
*Medical equipment services, hospice services and other home care organizations
*Nursing homes and other long term care organizations
*Behavioral Health care organizations, addiction services
*Rehabilitation centers, group practices, office-based surgeries and other ambulatory care
providers
*Independent or freestanding laboratories
What are the benefits of Joint Commission accreditation and certification? - Answer✔-
Strengthens community confidence in the quality and safety of care, treatment and services
-Provides deeming authority for Medicare certification
-Provides professional advice and counsel, thereby enhancing staff education
-May reduce liability insurance costs
-Provides a competitive edge in the marketplace
-Improves risk management and risk reduction (ex. managing infection control)
1|Page
, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
-Helps organize and strengthen patient safety efforts
-Provides education on good practices to improve business operations
-Enhances staff recruitment and development
-Recognized by insurers and other third parties
-Standards address organization's level of performance in key areas such as patient treatment and
infection control.
-Performance expectations for activities that affect patient safety
-Focus on organization's outcomes and Performance Improvement measures & how they try to
do better
-Patient infection control
-Readmission rates
What should you do if you are preparing for a hospital survey? - Answer✔Know the standards
Examine current processes
Improve areas that are not currently in compliance
Comprehensive Accreditation Manual for Hospitals (CAMH)
Attend seminars to understand standards
Network with colleagues
Do a mock survey before you have a survey for critical feedback (for improvement &
recommendations)
How many patient identifiers should you use? - Answer✔Use at least 2 ways to identify patients
Patients name & patients DOB
Use medications safely - Answer✔Before a procedure, label medicines that are not labeled.
Take extra care with patients who take medicine to thin their blood.
Record and pass along correct information about a patient's medicines, across the continuum
(recon the changes of the medications
Time out procedure - Answer✔must be done during procedure. Specific risk protocol that covers
array of things and ensures that the group is doing correct things for the client. Medication, site
of incision, removal of instruments, etc.
What are the AREAS OF FOCUS of the Joint Commission Survey/ AKA THE MAIN FOCUS?
- Answer✔*Ethics, Rights and Responsibilities: Patient rights, confidentiality, privacy,
2|Page
