Exam 1 Flashcards
TRUE/FALSE: Despite there being a number of procedures to correctly identify patients, wrong patient surgeries still occur
True
TRUE/FALSE: A safety plan has protocols in place to prevent patients from self-harm
True
TRUE/FALSE: Time out forms are only completed on outpatient surgery cases in ambulatory care settings
False
TRUE/FALSE: CMS surveys are necessary annually even though your facility is accredited by TJC
False
TRUE/FALSE: If your facility is accredited by the joint commission you have the gold star approval and deemed status
True
TRUE/FALSE: Accreditation by The Joint Commission is voluntary and the hospital pays no associated fees for participating in a survey
False
Cleanliness and storage of medical devices
Infection control
Standards in this area evaluate the number of patients who develop complications due to an intravenous catheter
Infection control
Evaluates the appropriateness of medication orders
Medication management
TJC have standards in this area that evaluate how and at what temperature IV meds are stored
Medication management
This area evaluates the facility compliance with inspection of fire extinguishers
Life safety
History and physical compliance would be monitored with this set of standards
Information management/record of care
Reviews the surgical consent for accurate completion and authentication
Information management/record of care
Inspects and conducts generator tests
Environment of care
Element of performance that evaluates verbal order authentication
Information management/record of care
Outlines the requirements for patient chart completion by the physician
Information management/record of care
Monitor for adverse drug events
Medication management
Standards in this area evaluates the infection rates associated with medical devices
Infection control
Sprinkler head functionality would be evaluated with this set of standards
Life safety
Tamper proof doors and windows would be reviewed with these joint commission standards
Environment of care
These standards validate that the hospital establishes and maintains a safe and functional facility
Environment of care
All of the following items are checked on a time out form except:
A. Patient Identity
B. Insurance type
C. Procedure site
D. Equipment needed
B. Insurance type
Failure to properly sterilize the equipment used in surgery would indicate:
A. High level disinfection
B. Bad manners
C. Immediate threat to life
D. Both A and C
C. Immediate threat to life
An accreditation cycle for TJC is:
A. 1 year or annually
B. Every 2 years
C. Triennial or every 3 years
D. Every 60 days
C. Triennial or every 3 years
Which of the following is not a true statement about The Joint Commission:
A. Results of your survey are available to the public
B. Length of the survey are based on the size of the facility and complexity of services
C. There is no fee for accreditation
D. Random unannounced surveys can occur at the
C. There is no fee for accreditation
Deemed status means:
A. Gold star approval
B. Automatic increase in reimbursement
C. Exempt from surveys by Medicare
D. Both A and C
D. Both A and C
An immediate threat to life can be awarded for which of the following situations:
A. Failure to properly identify a patient and perform the wrong procedure
B. Inappropriate disinfection of medical supplies
C. Lack of leadership oversight in the surgical area
D. All of the above
D. All of the above
All of the following are benefits to TJC accreditation except:
A. Enhancing physician recruitment
B. Improved liability insurance coverage
C. Validating quality care to your patients and their families
D. All are benefits
D. All are benefits
Mock surveys may be performed at your facility to evaluate compliance with the standards:
A. Coordinated internally by the facility quality improvement coordinator
B. By a parent company if your facility is owned by a corporation
C. If you pay a fee of $1500
D. Both A and B, and not C
D. Both A and B, and not C
RFI is defined as:
A. Recommendations for immediate transfer
B. Request for increase
C. Requirements for improvement
D. Return of fiscal intermediary
C. Requirements for improvement
Evidence of standards compliance involves:
A. Elements of performance
B. A, C, and D
C. Requirement for improvement
D. Survey analysis for evaluating risk
A. Elements of performance
True/False: Tracer mythology involves using visitors as specimens for appropriate activity
False
TRUE/FALSE: Human resources is never involved in a joint commission survey
False
TRUE/FALSE: Records of care standards only apply if the hospital has a census of 150 or more
False
TRUE/FALSE: Delinquent rates for 12 months are required by TJC
True
TRUE/FALSE: If you receive conditional accreditation, (accreditation with follow up survey) you have 60 days to send in a corrective action plan and demonstrate evidence of compliance
True
TRUE/FALSE: National patient safety goals are used by TJC to evaluate each facility for the elements of performance and evidence of standards compliance
True
TRUE/FALSE: Denial of accreditation means your facility can no longer has deemed status and cannot accept federal Avenue
True
TRUE/FALSE: A preliminary denial of accreditation is evidenced by a failure to resolve a requirement in the follow up survey
True
TRUE/FALSE: TJC usually requests 2 months of data from each department on their arrival to the facility for review
False
