©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
The Joint Commission Exam Questions With
Correct Answers.
What are some phrases to avoid when you are answering a surveyors question? - Answer✔Avoid
saying "I think we mostly do it this way", "we're supposed to", "on my shift we ....", "I usually
do..."
What should you do if a surveyor asks you a question that you can not answer? - Answer✔Stay
calm. Say, "I can get the answer" or "I know where to find it".
What should you do if you are not sure that you understand a surveyor's question? -
Answer✔Ask them to please restate and clarify it for you.
Do you know why TJC accreditation is important to us? - Answer✔Because the JC surveys us on
behalf of the federal governments Centers for Medicare and Medicaid Services, accreditation
allows us to receive Medicare and Medicaid reimbursement for our patients. Parents & insurance
companies consider it a "seal of quality approval".
Are all clinical and support services available to hospitalized patients on weekends, evenings and
nights? - Answer✔Yes these services are directly available or available by call-in page; we also
have a 24/7 Inpatient-Pharmacy.
Do you know what a Sentinel Event is? - Answer✔A sentinel event is a patient safety event (not
primarily related to the natural course of the patient's illness or underlying condition) that
reaches a patient and results in any of the following: death, permanent harm, severe temporary
harm.
Sentinel events require immediate investigation and response.
Where is our Sentinel Event Policy? What might your involvement be if an event occurs? -
Answer✔This is an Administrative Policy (Management of Significant Safety Events). If I was
involved in a sentinel event, I would participate in the Root Cause Analysis process.
What is the most frequently cited category of the root cause of sentinel events? -
Answer✔Human Factors is the most frequently cited category (Staffing levels, staffing skill mix,
staff orientation, in-service education, competency assessment, staff supervision, resident
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, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
supervision, medical staff credentialing/privileging, medical staff peer review, other (e.g.,
rushing, fatigue, distraction, complacency, bias)
What does the acronym "RACE" stand for? - Answer✔Remove Activate Contain Evacuate
Where would you move your patients/visitors/staff in the event of actual fire? -
Answer✔Movement would be done horizontally and beyond the nearest fire zone doors to a safe
area of refuge.
When a fire alert is given and the fire doors automatically close, are you allowed to go through
the closed doors? - Answer✔No, we cannot go through a closed fire door on the activation floor,
the floor above or the floor below the activation until code Green "all clear" is given.
In the main hospital, when would you see a strobe light flashing? - Answer✔When the Chicago
Fire Department gives an order to relocate or evacuate. The strobe light does not flash with the
initial activation of the fire alarm.
What information is given over the public address system when a Code Red is called? -
Answer✔CODE RED Floor number Zone
Where would you find the information to help you identify the "zone" that is mentioned when a
CODE RED is announced on the public address system? - Answer✔On the evacuation route
maps near the stairwells or with the fire door zone signage above the doors.
Where is the nearest stairwell in your area? - Answer✔This is area-specific. Be sure that you
know this for your department.
Where is your nearest fire extinguisher? - Answer✔Department-specific: know where in your
area/department (GO FIND IT).
Where is the nearest fire alarm pull station in your area? - Answer✔Department-specific. Know
where in your area/department (GO FIND IT).
What is the primary evacuation route you would use if you needed to evacuate staff and
patients/families from your department? What is the secondary evacuation route you would use
if your primary route is blocked by smoke or fire? - Answer✔Department-specific: Know the
route for your area (use the evacuation maps near the stairwells and elevators) (GO FIND IT).
What information do you receive from your department leaders following a fire drill? -
Answer✔Time of drill
Location of drill
Outcome/results of drill
Is it ever acceptable for fire doors to be held open with ties, wedges, or other objects or to tape
over the door lock/latch? - Answer✔No.
2|Page
The Joint Commission Exam Questions With
Correct Answers.
What are some phrases to avoid when you are answering a surveyors question? - Answer✔Avoid
saying "I think we mostly do it this way", "we're supposed to", "on my shift we ....", "I usually
do..."
What should you do if a surveyor asks you a question that you can not answer? - Answer✔Stay
calm. Say, "I can get the answer" or "I know where to find it".
What should you do if you are not sure that you understand a surveyor's question? -
Answer✔Ask them to please restate and clarify it for you.
Do you know why TJC accreditation is important to us? - Answer✔Because the JC surveys us on
behalf of the federal governments Centers for Medicare and Medicaid Services, accreditation
allows us to receive Medicare and Medicaid reimbursement for our patients. Parents & insurance
companies consider it a "seal of quality approval".
Are all clinical and support services available to hospitalized patients on weekends, evenings and
nights? - Answer✔Yes these services are directly available or available by call-in page; we also
have a 24/7 Inpatient-Pharmacy.
Do you know what a Sentinel Event is? - Answer✔A sentinel event is a patient safety event (not
primarily related to the natural course of the patient's illness or underlying condition) that
reaches a patient and results in any of the following: death, permanent harm, severe temporary
harm.
Sentinel events require immediate investigation and response.
Where is our Sentinel Event Policy? What might your involvement be if an event occurs? -
Answer✔This is an Administrative Policy (Management of Significant Safety Events). If I was
involved in a sentinel event, I would participate in the Root Cause Analysis process.
What is the most frequently cited category of the root cause of sentinel events? -
Answer✔Human Factors is the most frequently cited category (Staffing levels, staffing skill mix,
staff orientation, in-service education, competency assessment, staff supervision, resident
1|Page
, ©BRIGHSTARS 2024/2025 ALL RIGHTS RESERVED.
supervision, medical staff credentialing/privileging, medical staff peer review, other (e.g.,
rushing, fatigue, distraction, complacency, bias)
What does the acronym "RACE" stand for? - Answer✔Remove Activate Contain Evacuate
Where would you move your patients/visitors/staff in the event of actual fire? -
Answer✔Movement would be done horizontally and beyond the nearest fire zone doors to a safe
area of refuge.
When a fire alert is given and the fire doors automatically close, are you allowed to go through
the closed doors? - Answer✔No, we cannot go through a closed fire door on the activation floor,
the floor above or the floor below the activation until code Green "all clear" is given.
In the main hospital, when would you see a strobe light flashing? - Answer✔When the Chicago
Fire Department gives an order to relocate or evacuate. The strobe light does not flash with the
initial activation of the fire alarm.
What information is given over the public address system when a Code Red is called? -
Answer✔CODE RED Floor number Zone
Where would you find the information to help you identify the "zone" that is mentioned when a
CODE RED is announced on the public address system? - Answer✔On the evacuation route
maps near the stairwells or with the fire door zone signage above the doors.
Where is the nearest stairwell in your area? - Answer✔This is area-specific. Be sure that you
know this for your department.
Where is your nearest fire extinguisher? - Answer✔Department-specific: know where in your
area/department (GO FIND IT).
Where is the nearest fire alarm pull station in your area? - Answer✔Department-specific. Know
where in your area/department (GO FIND IT).
What is the primary evacuation route you would use if you needed to evacuate staff and
patients/families from your department? What is the secondary evacuation route you would use
if your primary route is blocked by smoke or fire? - Answer✔Department-specific: Know the
route for your area (use the evacuation maps near the stairwells and elevators) (GO FIND IT).
What information do you receive from your department leaders following a fire drill? -
Answer✔Time of drill
Location of drill
Outcome/results of drill
Is it ever acceptable for fire doors to be held open with ties, wedges, or other objects or to tape
over the door lock/latch? - Answer✔No.
2|Page
