HIM 370 Exam 1 Questions and Answers Already Passed
Reasons facilities want to be accredited by TJC? - Answers Community standing increases reputation;
Medicare/MCOs-managed care organizations require for contract;
Physician recruitment of specialties;
Gold star seal of success
if accredited by TJC the facility is - Answers exempt from annual "white glove" CMS certification survey;
considered Deemed Status
1. Strengthening your facilities image in the community; patient will have more confidence in healthcare
delivery system & will seek out statement
2. Validates the quality of care provided to our patients & their families
3. Assist with organizing & strengthening the facility improvement efforts
4 Improved the liability insurance coverage for your facility & reduce the risk associated with care
provided
5. Enhancement of staff recruitment & retention - Answers Goals of TJC
Strengthening your facilities image in the community; patient will have more confidence in healthcare
delivery system & will seek out statement - Answers Goal of TJC
. Validates the quality of care provided to our patients & their families - Answers Goal of TJC
Assist with organizing & strengthening the facility improvement efforts - Answers Goals of TJC
Improved the liability insurance coverage for your facility & reduce the risk associated with care
provided - Answers Goals of TJC
Enhancement of staff recruitment & retention - Answers Goals of TJC
Types of facilities who may be accredited by TJC - Answers General acute care; Children's hospitals;
Critical access facilities; Long term acute care; Oncology; Psychiatric; Rehabilitation; Specialty
Step ____: Learn more about the standards through working with TJC (TJC will provide the facility with a
representative/liaison to work with the facility once your fees are paid - Answers Step 1 to get
accredited by TJC
Step __: Review the requirements, tracer methodology, safer analysis (survey analysis for evaluation of
risk) - Answers Step 2 to get accredited by TJC
, Step ___: to get accredited by TJC -Assess your readiness; self-evaluation of facility against the standards
(elements of performance); the self-evaluation is usually performed by members of the management or
an outside vendor (mock survey) - Answers Step 3 to get accredited by TJC
Step ___: Apply & pay the $ fees (deposit) fees are based on the size of the facility & volume of
admission/average daily census; outline a ready date within 12 months of submitting application -
Answers Step 4 to get accredited by TJC
Step ___: Prepare for onsite survey/ plan description for opening conference/who will escort
surveyors/conduct mock surveys by outside corporation & must have at least 4 months of key
performance data - Answers Step 5 to get accredited by TJC
Step ____: Address any identified gap areas/ establish a timeline to implement any improvements so
that you are in compliance with all the standards by the time of your onsite survey - Answers Step 6 to
get accredited by TJC
Step ___: Participate in the actual TJC survey, trained & qualified surveyors will perform an invasive
review of charts/policies/governing board minutes/medical executive committee minutes &
credentialing procedures - Answers Step 7 to get accredited by TJC
Step 8 to get accredited by TJC - - Answers 8 Complete post survey follow up, address all
recommendations for improvement, submit evidence of compliance within 60 days of end of survey
Step ____: Celebrate/publicize our gold seal on all of our brochures/billboards/social media & web site -
Answers Step 9 to get accredited by TJC
Step ____: Maintain readiness - Answers Step 10 to get accredited by TJC
2 categories of standards - Answers Patient Focused & Organizational Focused
Infection preventions & control;
Medical management;
Provision of treatment - Answers Sections of patient focused
_____ focused: Infection Prevention & Control monitors infections from - Answers - Patient
- implanted devices I.E. joints/ stents/ mesh/ implants
- foley catheters I.E. clinically acquired UTI CAUTI
_____ focused: Infection Prevention & Control oversee -
Immediate threat to life/ health/ safety if -
Implications: - Answers - patient
Reasons facilities want to be accredited by TJC? - Answers Community standing increases reputation;
Medicare/MCOs-managed care organizations require for contract;
Physician recruitment of specialties;
Gold star seal of success
if accredited by TJC the facility is - Answers exempt from annual "white glove" CMS certification survey;
considered Deemed Status
1. Strengthening your facilities image in the community; patient will have more confidence in healthcare
delivery system & will seek out statement
2. Validates the quality of care provided to our patients & their families
3. Assist with organizing & strengthening the facility improvement efforts
4 Improved the liability insurance coverage for your facility & reduce the risk associated with care
provided
5. Enhancement of staff recruitment & retention - Answers Goals of TJC
Strengthening your facilities image in the community; patient will have more confidence in healthcare
delivery system & will seek out statement - Answers Goal of TJC
. Validates the quality of care provided to our patients & their families - Answers Goal of TJC
Assist with organizing & strengthening the facility improvement efforts - Answers Goals of TJC
Improved the liability insurance coverage for your facility & reduce the risk associated with care
provided - Answers Goals of TJC
Enhancement of staff recruitment & retention - Answers Goals of TJC
Types of facilities who may be accredited by TJC - Answers General acute care; Children's hospitals;
Critical access facilities; Long term acute care; Oncology; Psychiatric; Rehabilitation; Specialty
Step ____: Learn more about the standards through working with TJC (TJC will provide the facility with a
representative/liaison to work with the facility once your fees are paid - Answers Step 1 to get
accredited by TJC
Step __: Review the requirements, tracer methodology, safer analysis (survey analysis for evaluation of
risk) - Answers Step 2 to get accredited by TJC
, Step ___: to get accredited by TJC -Assess your readiness; self-evaluation of facility against the standards
(elements of performance); the self-evaluation is usually performed by members of the management or
an outside vendor (mock survey) - Answers Step 3 to get accredited by TJC
Step ___: Apply & pay the $ fees (deposit) fees are based on the size of the facility & volume of
admission/average daily census; outline a ready date within 12 months of submitting application -
Answers Step 4 to get accredited by TJC
Step ___: Prepare for onsite survey/ plan description for opening conference/who will escort
surveyors/conduct mock surveys by outside corporation & must have at least 4 months of key
performance data - Answers Step 5 to get accredited by TJC
Step ____: Address any identified gap areas/ establish a timeline to implement any improvements so
that you are in compliance with all the standards by the time of your onsite survey - Answers Step 6 to
get accredited by TJC
Step ___: Participate in the actual TJC survey, trained & qualified surveyors will perform an invasive
review of charts/policies/governing board minutes/medical executive committee minutes &
credentialing procedures - Answers Step 7 to get accredited by TJC
Step 8 to get accredited by TJC - - Answers 8 Complete post survey follow up, address all
recommendations for improvement, submit evidence of compliance within 60 days of end of survey
Step ____: Celebrate/publicize our gold seal on all of our brochures/billboards/social media & web site -
Answers Step 9 to get accredited by TJC
Step ____: Maintain readiness - Answers Step 10 to get accredited by TJC
2 categories of standards - Answers Patient Focused & Organizational Focused
Infection preventions & control;
Medical management;
Provision of treatment - Answers Sections of patient focused
_____ focused: Infection Prevention & Control monitors infections from - Answers - Patient
- implanted devices I.E. joints/ stents/ mesh/ implants
- foley catheters I.E. clinically acquired UTI CAUTI
_____ focused: Infection Prevention & Control oversee -
Immediate threat to life/ health/ safety if -
Implications: - Answers - patient
