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Joint Commission Exam Questions With
Correct Answers.
What high risk processes has your team analyzed? - Answer✔•Emergency Codes - how to
respond in Code Blue situations, how to respond to a fall, how to respond to an emergency
outside the building
•Knowing and understanding our responsibility in answering the Emergency phones (red pull
cords)
•Incidents relating to the Revolving doors
•Annual Flu Compliance
•Safety and Infection Control CBT Compliance
What performance improvement projects is your team working on? - Answer✔•Call
Abandonment rates in Orthopedics - implementation of the Appointment Center, analysis of FTE
needs, etc.
•MRI Scheduling for Orthopedic patients
•OT Hand Walk In Process
How do you ensure that you have the correct patient? - Answer✔We always confirm that we
have the correct patient by asking for two patient identifiers - patient name and DOB or MRN
What do we do for patients assessed for a STANDARD fall risk? - Answer✔Patients at standard
fall risk have universal precautions such as maintaining a safe room environment and assessing
patient safety with each patient encounter. This includes
intentional hourly rounding, educate the patient about fall risk and prevention during
hospitalization, familiarize patient with environment, have patient demonstrate call light
use, keep patients personal items within their reach, bed in lowest position and wheels locked,
non-slip footwear, night light or supplemental lighting and keeping floors clean, dry and clutter
free.
What is our organizational process improvement model? - Answer✔FOCUS PDCA
1|Page
Joint Commission Exam Questions With
Correct Answers.
What high risk processes has your team analyzed? - Answer✔•Emergency Codes - how to
respond in Code Blue situations, how to respond to a fall, how to respond to an emergency
outside the building
•Knowing and understanding our responsibility in answering the Emergency phones (red pull
cords)
•Incidents relating to the Revolving doors
•Annual Flu Compliance
•Safety and Infection Control CBT Compliance
What performance improvement projects is your team working on? - Answer✔•Call
Abandonment rates in Orthopedics - implementation of the Appointment Center, analysis of FTE
needs, etc.
•MRI Scheduling for Orthopedic patients
•OT Hand Walk In Process
How do you ensure that you have the correct patient? - Answer✔We always confirm that we
have the correct patient by asking for two patient identifiers - patient name and DOB or MRN
What do we do for patients assessed for a STANDARD fall risk? - Answer✔Patients at standard
fall risk have universal precautions such as maintaining a safe room environment and assessing
patient safety with each patient encounter. This includes
intentional hourly rounding, educate the patient about fall risk and prevention during
hospitalization, familiarize patient with environment, have patient demonstrate call light
use, keep patients personal items within their reach, bed in lowest position and wheels locked,
non-slip footwear, night light or supplemental lighting and keeping floors clean, dry and clutter
free.
What is our organizational process improvement model? - Answer✔FOCUS PDCA
1|Page
