The Joint Commision Basics
Which accrediting agency surveys hospitals every 3 years to ensure compliance with all standards and National Patient Goals?
A. OSHA B. The Joint Commission (TJC) C. FBI
How does BID-Plymouth define high quality care?
A. Patient centered B. Patient centered, evidence based and safely delivered care C. Employee centered
What is the process used to understand WHY a non-desired even occurred?
A. Sentinel Event Alert B. Rounding C. Root Cause Analysis
What methodology does BID-Plymouth use to eliminate waste in a process?
A. LEAN B. SBAR C. Outcome measures
What is AIDET?
A. Ask, Involve, Direct, Entertain, Thanks B. Aim, Inspire, Draft, Execute, Test C. Acknowledge, Introduce, Duration, Explanation, Thank you
What do all staff wear above their waist that includes their name and picture?
A. ID badge B. BID-Plymouth fleece coat C. Scrubs
What does washing hands with soap and water or alcohol based gel before and after each patient contact reduce the spread of?
A. Healthcare associated infections B. Fever C. Headache
Which office do you notify if you receive a summons or subpoena, or if there is a need to disclose an untoward event to a patient/family?
A. Medical Records B. Security C. Risk Management
What does PDSA stand for?
A. Plan-Do-Study-Act B. Public Display of Affection C. Please Don’t Sing Aloud
What is HCAHPS?
A. Hospital Consumer Assessment of HealthCare Providers and Systems B. Hospital Community Actions to Help People Survive C. Health Care Acquired Headache Post-Surgery
What legislation states that PHI (Protected Health Information) may only be used for purposes of treatment, payment and healthcare operations?
A. Affordable Care Act B. HIPAA C. Mass Health
What are the two patient identifiers used for patient care, treatment and services?
A. Name and room number B. Name and cell phone number C. Name and date of birth
Which state agency requires notification in the event of a fire, strike or patient injury such as a fall with fracture?
A. Department of Public Health (DPH) B. Food and Drug Administration (FDA) C. Department of Public Safety (DPS)
Who defines the value in any given process?
A. The CEO B. The Patient/Customer C. The Insurance Company
What is service recovery?
A. Help offered in the post anesthesia care unit (i.e. Recovery Room) B. A special service offered to patients C. An apology or other action in response to a service failure
Joint Commission surveyors use this methodology to analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple departments, and services rendered to the patient?
A. Geocaching Methodology B. Tracer Methodology C. LEAN Methodology
How do we track our quality and safety data across the organization?
A. Patient whiteboard B. Quality scorecard/dashboard C. HCAHPS survey
Which type of culture is non-punitive as it relates to adverse events?
A. Organizational Culture B. Just Culture C. Pop Culture
Who are the greatest experts at delivering care?
A. The New England Patriots B. Your mother C. Front line staff
What is wayfinding?
A. Signage with arrows B. Crosswalk in the parking lot C. Walking a visitor or family member to their destination to improve the patient experience
Who is involved in the Joint Commission Survey?
A. Everyone (staff, physicians, patients etc) B. Jennifer Aniston C. Only managers
What is a Hospital Acquired Condition (HAC)?
A. A rough cut B. An undesirable situation or condition that affects a patient in the hospital (falls with injury, catheter associated UTI, surgical site infection) C. Using a computer to gain unauthorized access to data in a system
What is the process to report near misses and actual events in order to help prevent future occurrences?
A. Post on Facebook B. An event report (Expanse) C. Compliance report
How do you ensure that a process is done the best way every time?
A. Do the process yourself B. Reprimand any person who makes a mistake C. Create and follow standard work
What is complaint resolution?
A. Explaining to a patient that it wasn’t your fault B. When a patient or family states they are unsatisfied C. Attempt to resolve the concern yourself, if unable to do so elevate to your supervisor/manager/ director