The use of actual patients and processes as the framework for asscessing standards compliance
Tracer Methodology
Unannounced Survey
Announced Survey
Accreditation Process
Join Communion surveys are unannounced and can occur ____ after the previous unannounced survey
3 to 6 months
6 to 18 months
18 to 39 months
24 to 48 months
A root cause analysis focuses primarily on
Systems and processes
Individual Performance
Equipment Malfunction
Standards Compliance
An RFI is a
Recommendation for Improvement
Requirement For Improvement
Regulation For Improvement
Registration For Improvement
Any unexpected occurrence involving death or serious physical of psychological injury
Failure Mode Effects Analysis
Root Cause Analysis
Sentinel Event
Tracer
A process for identifying the basic and causal factors that underline variation in performance, including the occurrence or possible occurrence of a sentinel event is
Performance Improvement
Hospitals seek Joint Commission accreditation for all the reasons below EXCEPT
To strengthen community confidence in the quality and safety of care
To lower their operating costs by becoming eligible for discounts
To improve risk management and strengthen patient safety efforts
To provide Medicare certification and recognition by insurers
The Joint Commission survey team can include one or more health care professionals, including all of the following except
A physician
A nurse
A hospital administrator
A maintenance engineer
An initiative established by the Joint Commission to help accredited organizations address specific areas of concern regarding patient safety
National Patient Safety Goals
On-Site Survey Process
The Joint Commission has been accrediting hospitals for
less than 25 years
More than 50 years
More than 75 years
More than 100 years
