1. 6th
Edition
Joint Commission International
Accreditation
(JCIA) Survey
Most Common Question
Joven Botin Bilbao, RN, MAN
Accreditation and Clinical Nurse Educator (IMS)

2. IPSG
 Tell me how to identify patient Correctly?
 Tell me how to ensure the correct treatment is delivered to
correct unconscious or Uncommunicative patient or new
born?
 Tell me how to ensure the correct treatment is delivered to
unknown Patient?
 Tell me what you do if the doctors is not available to order
medication during an emergency?
 Tell me the process of receiving critical value result?

3.  Tell me how to communicate patient care?
 Do you have high alert medication in your hospital? What
are they?
 Show me the List of high alert medication/LASA? Or how
can you access the list of high alert medication and LASA?
 Tell me, Do you take any precaution measure to improve the
safety of high alert medication?
 Tell me, Do you keep concentrated electrolytes here ?
IPSG

4.  Tell me what do you do to ensure safe surgery or procedure
provided to your patient?
 Could you share me what is time out?
 Tell me when do you require surgical site marking for patient?
 Tell me more about sign-out?
 Show me the documentation of time-out and sign-out perform
to your patient?
 Show me how do you perform hand hygiene?
IPSG

5.  Tell me how do you know that these step are sufficient to
reduce risk of HEI?
 Tell me in which situation would you perform a hand
washing?
 Tell me the initiatives you have done in your department to
improve the rates of compliance of hand hygiene?
 What is the compliance rate of hand hygiene from last month
Audit?
 Tell me how do you ensure that the patient is safe from harm
due to patient fall?
IPSG

6.  Show me the intervention perform to prevent falls for your patient?
 Tell me when do you know that your patient are higher risk for fall?
 Tell me how do you reduce the risk of patient harm for patient on
fall risk?
 Tell me what would you do if you witness a patient fall?
 Tell me how do you prevent a patient harm from falls in Out
patient Settings ?
 Tell me where do you documents fall assessment and intervention in
OPD?
IPSG

7.  Who perform initial assessment?
 What is the time frame to complete the initial assessment?
 What is the minimum elements included in initial assessment?
 What is the validity on initial assessment for pre-operative
patient?
 Tell me about your nutritional assessment policy?
 What do you do if the patient/family express for financial
problem?
AOP

8. AOP
 Tell me about functional assessment?
 How do you do pain assessment?
 What do you do if patient has pain?
 What is your policy in pain management?
 Do you do pain reassessment?

9.  Tell me about functional assessment?
 How do you do pain assessment?
 What do you do if patient has pain?
 What is your policy in pain management?
 Do you do pain reassessment?
AOP

10. AOP
 How do you document pain assessment, treatment and re
assessment?
 Do you do point care testing?
 Do you have any certificate or competency on how to do
point of care testing?
 Do you know the turnaround time for lab investigation?
For stat/urgent? For routine? For preliminary result?

11. COP
 What is the care plan for this patient? How to reassess if
patient care plan are effective?
 Who are your high risk patient?
 What would you do after screening of patient with need
for nutritional needs?
 What is your policy in handling patient at end of life
care?
 How often do you check your crash cart? When your
crash cart are open during codes how long need to
completed and close by pharmacy?

12. COP
 What is the response process for resuscitation?
 Do you have policy on the use of restraints?
 Do you have policy on organ donation?
 What is your process in administering blood and
blood products?
 Tell me what do you check if patient admitted to
your unit?

13.  What is the criteria for admission in the hospital? Unit?
 What is the process of admitting patient
 What is the process in transferring patient to other unit
( intra hospital transfer)
 What information get transferred with patient during
transfer to other facility?
 How to handover patient during transfer to other facility?
ACC

14.  Who evaluate patient’s readiness for discharge?
 What does discharge summary contain?
 When is the discharge summary completed?
 What education and follow up instructions given to the
patient at discharge?
 What is the process if patient request for out on pass?
 What is the process for managing patient who notify staff that
they wish to discharge or leave against medical advice?
ACC

15.  How the patient and family involve in
anesthesia plan of care?
 Who is the responsible to give anesthesia to
high risk, pediatric and major operation?
 Tell me when would an informed consent
required
 Tell me how do you ensure the safety of the
patient during procedural or conscious
sedation?
ASC

16.  Tell me what is procedural sedation?
 Is your doctor are privilege to administer
conscious sedation?
 How do you ensure the safety of the patient just
receive conscious sedation?
 How do you know if the patient fit for discharge
after receiving conscious sedation?
 Tell me who can discharge the patient from
monitoring after conscious sedation?
ASC

17.  Tell me when do you know when the ambulatory
patient is ready to be discharge after conscious
sedation?
 How do you know that patient fits for discharge
from PACU?
 Do you have a process on how the post
anesthesia patient monitored outside recovery
room?
ASC

18.  Tell me who ensures and check you medication
storage or medication room ?
 How to make sure that medication are safe
from loss or theft?
 Tell me what are your high alert medication?
 How are medication requiring below 25 degrees
or below room temperature stored ?
 Where is your crash cart/e-Kit located ?
MMU

19.  Who is responsible to check your crash cart and how
often?
 How to make sure that crash cart are maintain for
completeness?
 How to compute pediatric medication dosage during
emergency code?
 How to differentiate sound alike medication?
 What you will do if the medication control or narcotics
drugs?
 What is the process of administration of
control/narcotics medication from floor stock?
MMU

20.  Do you have a process to finding out what
medication is taking by newly admitted patient?
 Do you allow patient to used own medication
brought from home?
 Do you allow patient to self administer
medication?
 What is your process of getting medication in the
night or the pharmacy is closed?
 How is parenteral nutrition are stored in your
unit?
MMU

21.  What constitute complete medication order?
 Who review medication order? What is the
process of medication appropriateness review ?
 Do you accept verbal and telephone order for
high alert medication and narcotics?
 Where you can access the complete list of
medication allowed in the hospital?
 Do you pre[are IV admixture in this unit?
where do you prepare? Can you show how to
prepare?
MMU

22.  What is your policy for multi dose medication?
 What precaution do you observe when
administration of medication?
 What do you understand about free flow
mechanism? Do you set limit to your infusion
pump?
 What do you do if the medication are recalled?
MMU

23.  What is medication error? What do you
do if there is medication error?
 What is a near miss?
 What do you do if the patient having
drug adverse Reaction?
 How drug allergies and adverse reaction
reported?
MMU

24.  Tell me what do you know about infection
control?
 Tell me how to prevent the spread of infection in
your institution?
 Tell me, what do you do if you are required to
assist a procedure for an infectious patient?
 How do you know if the negative pressure room
is working?
 What would you do if the negative pressure will
mal function and you have patient inside
negative pressure room?
PCI

25.  What would you do if your were pricked with
used needle or had a blood/body fluids
exposure?
 Tell me what happen after the needle stick
injury when the staff return from Health clinic?
 What will you do if you witness blood or body
fluids spill?
 How do you know if the items are good to be
used?
 How do you clean your equipment?
PCI

26.  Do you have job description?
 How the hospital/ department prepare you to
perform the work you are doing?
 Tell me about you hospital orientation/
probationary program?
 Tell me What is your key competency to work in
this unit?
 Tell me who need to be
BLS,ACLS,PALS,NRP,ALSO certified? And how
frequent is being done?
SQE

27.  Tell me how do you maintain or advance your skills and
knowledge to meet the patient needs and/ or continuing
education requirements?
 How to maintain the staff clinical knowledge and skills are
consistent with the patients needs?
 Is there any staff health and safety programme for you as
employee?
 Do you have counselling and follow- up treatment for staff
who are second victim or involve in adverse or sentinel
event?
SQE

28.  Does the nursing staff participate in Quality
improvement program? Or do you have any
improvement program in you unit? What is your
role or participation?
 Do you receive education or training about your
roles in providing a safe and effective patient care
facility?
SQE

29.  Who is the responsible for quality and patient
safety in the hospital?
 Do you have KPI data? Where you can get the
data? Do you know here to find it?
 What do you do if your department did not reach
the target measures?
 Do you do bench marking? Can you explain
further about bench marking?
QPS

30.  What aspect of patient care has you unit
improved in last 6 or 12 months ? what do you
intent to improve for next 6 or 12 months?
 How do you manage the adverse incident
happen to your unit? What is root cause?
 How are the staff involve in quality decision and
the resulting quality activities?
 What is culture of safety? How do you promote
such culture?
QPS

31.  Tell me who does the patient and family
education?
 Tell me who assess the patient and family
education, language, learning capacity and
barriers?
 How do you conduct family and patient
education?
 How do you assess patient and family ability and
willingness to learn?
 Show me where do you documents PFE?
PFE

32.  Tell me what did you understand patient rights
and responsibilities?
 Tell me how the hospital address the patient
religious and spirituals needs?
 How are the patient protected from assault?
 How the DNR order issued?
 What will you do if you are having ethical
dilemma in taking care of patients?
PFR

33.  Tell me the process should a patient/ family
have any complaints or conflict?
 Tell me the procedure require informed
consent?
 Tell me the process of obtaining informed
consent?
 What do you do if the patient speaking/
reading English or Arabic?
 Do you use family member as Interpreter?
PFR

34.  Tell me the process of consent taking if patient
is incapable of giving informed consent?
 Tell me the validity of the consent?
 Tell me the care you provided for vulnerable
patient?
 Tell me how the hospital safeguard the patient’s
belongings?
PFR

35.  Tell me what happen if the patient request for
their medical records?
 How to ensure that the authorized person
enters patient records?
 How do you protect patient confidential
information?
 How is the abbreviation being monitored?
 How are you inform in an event of system
downtime?
MOI

36. FMS
 Tell me, What would you do in the event of fire?
 Tell me, what would you do when a non- ambulant patient
caught fire?
 What come next after you recued patient?
 How do you know that the fire extinguisher is suitable to
your department?
 Tell me how do you know it is suitable to evacuate patient
from your unit?

37. FMS
 Show me where would you go in the event of fire?
 Tell me the last fire drill in your hospital?
 How do you prevent the fire from spreading?
 How are your new staff prepared in the event of fire
outbreak?
 What happen if you see someone smoking in the hospital?
 What happen in an event of power trip ?