oint Commission International Accreditation Standards for Hospitals, 6th Edition, provides the basis for accreditation of hospitals throughout the world. Joint Commission International (JCI) standards define the performance expectations, structures, and functions that must be in place for a hospital to be accredited by JCI. The standards are divided into two main sections: 1) patient-centered care and 2) health care organization management.

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 ?