©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
HIMS 3520: Joint Commission Exam
Questions With Correct Answers.
Joint Commission.... - Answer✔is an "accrediting" body
What is an accrediting body? - Answer✔External voluntary review that grants recognition to a
program of study or institution that meets certain predetermined standards
Can Joint Commission close your facility? - Answer✔No, it's a voluntary review, so they cant
close your facility
Pros of accreditation - Answer✔1) Looks good, respectable (gold seal of approval)
2)to treat CMS patients, AND get paid for treating them, you can avoid Medicare survey process
Cons of accreditation - Answer✔1) Expensive (10s of thousands of dollars)
Survey process is expensive
Purchasing standards = $$$$
2) Time-consuming preparation
Need to have people doing this
3) Stressful
Unannounced surveying
Why seek accreditation? - Answer✔1) Medicare certification/may fulfill other regulatory
requirements
2) Third-party payer recognition
(Some payers wont contract with you if you're not joint commission accredited )
1|Page
, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
3)Image/competitive edge
4)Improves risk management and education for enhanced patient care
-----Compiles large data
-----Learning process
5) Validates high quality
6)Liability insurance
----Better rate on liability insurance, like good grades on car insurance
7)Recruitment of physicians, clinicians and administrative staff/competition
Other Hospital Accrediting Bodies (4) - Answer✔1) Joint Commission (4400)
2)Health Facilities Accreditation Program (HFAP) (150)
----historically osteopathic hospitals usually
3)DNV GL Healthcare (450)
---Originally Norwegian company for underwriting risks in ships but now involved in healthcare
4)Center for Improvement in Healthcare Quality (CIHQ) (40)
---New
Why would you or would'nt you choose Joint commission over the others? - Answer✔-Others
are cheaper than JC
-JC advantage: oldest, name recognition, has more resources bc larger
Survey Process Steps - Answer✔1) Organization applies for survey
2)On-site survey conducted by team of surveyors such as physicians, nurses and health care
administrators
2|Page
, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
3)Joint Commission Central Office issues report of survey findings on Joint Commission
extranet
------If no RFIs (Requirements For Improvement), accreditation decision accompanies report,
Accreditation decision is publicly disclosed once made
-------If RFIs, no accreditation decision until evidence of standards compliance (ESC) report is
submitted
4) Accreditation is for three years (laboratories: 2 years)
How long is accreditation ? - Answer✔Accreditation is for three years (laboratories: 2 years)
Accreditation is not automatically renewed
Re-accreditation: reapply, participate in a survey, and demonstrate compliance with the standards
Joint Commission Central Office issues report of survey findings on Joint Commission
extranet..... 2 options - Answer✔1) If no RFIs (Requirements For Improvement), accreditation
decision accompanies report
---Accreditation decision is publicly disclosed once made
2) If RFIs, no accreditation decision until evidence of standards compliance (ESC) report is
submitted
What happened prior to 2006? - Answer✔facilities knew surveying would be July 10th , 11th,
12th
so everyone prepped, records were clean etc
When did unannounced surveys begin? - Answer✔January 2006
Why did unannounced surveys begin? - Answer✔To shift focus to operational systems and
patient care processes
3|Page
HIMS 3520: Joint Commission Exam
Questions With Correct Answers.
Joint Commission.... - Answer✔is an "accrediting" body
What is an accrediting body? - Answer✔External voluntary review that grants recognition to a
program of study or institution that meets certain predetermined standards
Can Joint Commission close your facility? - Answer✔No, it's a voluntary review, so they cant
close your facility
Pros of accreditation - Answer✔1) Looks good, respectable (gold seal of approval)
2)to treat CMS patients, AND get paid for treating them, you can avoid Medicare survey process
Cons of accreditation - Answer✔1) Expensive (10s of thousands of dollars)
Survey process is expensive
Purchasing standards = $$$$
2) Time-consuming preparation
Need to have people doing this
3) Stressful
Unannounced surveying
Why seek accreditation? - Answer✔1) Medicare certification/may fulfill other regulatory
requirements
2) Third-party payer recognition
(Some payers wont contract with you if you're not joint commission accredited )
1|Page
, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
3)Image/competitive edge
4)Improves risk management and education for enhanced patient care
-----Compiles large data
-----Learning process
5) Validates high quality
6)Liability insurance
----Better rate on liability insurance, like good grades on car insurance
7)Recruitment of physicians, clinicians and administrative staff/competition
Other Hospital Accrediting Bodies (4) - Answer✔1) Joint Commission (4400)
2)Health Facilities Accreditation Program (HFAP) (150)
----historically osteopathic hospitals usually
3)DNV GL Healthcare (450)
---Originally Norwegian company for underwriting risks in ships but now involved in healthcare
4)Center for Improvement in Healthcare Quality (CIHQ) (40)
---New
Why would you or would'nt you choose Joint commission over the others? - Answer✔-Others
are cheaper than JC
-JC advantage: oldest, name recognition, has more resources bc larger
Survey Process Steps - Answer✔1) Organization applies for survey
2)On-site survey conducted by team of surveyors such as physicians, nurses and health care
administrators
2|Page
, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
3)Joint Commission Central Office issues report of survey findings on Joint Commission
extranet
------If no RFIs (Requirements For Improvement), accreditation decision accompanies report,
Accreditation decision is publicly disclosed once made
-------If RFIs, no accreditation decision until evidence of standards compliance (ESC) report is
submitted
4) Accreditation is for three years (laboratories: 2 years)
How long is accreditation ? - Answer✔Accreditation is for three years (laboratories: 2 years)
Accreditation is not automatically renewed
Re-accreditation: reapply, participate in a survey, and demonstrate compliance with the standards
Joint Commission Central Office issues report of survey findings on Joint Commission
extranet..... 2 options - Answer✔1) If no RFIs (Requirements For Improvement), accreditation
decision accompanies report
---Accreditation decision is publicly disclosed once made
2) If RFIs, no accreditation decision until evidence of standards compliance (ESC) report is
submitted
What happened prior to 2006? - Answer✔facilities knew surveying would be July 10th , 11th,
12th
so everyone prepped, records were clean etc
When did unannounced surveys begin? - Answer✔January 2006
Why did unannounced surveys begin? - Answer✔To shift focus to operational systems and
patient care processes
3|Page
