®
CJCP
Certified
Joint Commission Professional™
I
n January 2013, Joint Commission Resources (JCR) launched its credential for accreditation professionals—Certified Joint
Commission Professional (CJCP®). Upcoming testing dates will occur in July and October in 2015.
To help candidates prepare for the CJCP examination and understand what to expect, this column features sample questions similar to those that appear on the examination. The answer key on page 10 provides the context for the correct answer. All of the CJCP examination questions are multiple choice, offering three possible choices from which you should
pick the BEST answer. Also, the examination does not have any true/false questions or include any answers that are “All of the above” or “None of the above.” Please note the questions that follow are NOT actual examination questions; they are simply indicative of the types of questions a candidate may see on the exam. For more information on CJCP, or other products to help you prepare for the exam such as live events, workbooks, or online education learning modules, visit w w w.jcrinc.com
/cjcp-certification/. You may also e-mail questions directly to cjcp@jcrinc.com.
The intent of the “Patient Safety Systems” (PS) chapter— added to the Comprehensive Accreditation Manual for Hospitals for January 2015—is to provide health care organizations with a proactive approach to design or redesign a patient-centered system that aims to improve quality of care and patient safety, an approach that aligns with The Joint Commission’s mission and its standards.
The PS chapter is intended to help inform and educate hospitals about the importance and structure of an
integrated patient safety system. Although this chapter does not include new accreditation requirements, it describes how existing requirements can be applied to achieve improved patient safety. It is also intended to help all health care workers understand the relationship between Joint Commission accreditation and patient safety.
The Joint Commission encourages hospitals to view a patient safety event as which of the following?
An opportunity for learning and improvement
An Immediate Threat to Health or Safety
A situation requiring disciplinary action for the staff involved
The role of hospital leaders in creating an effective patient safety system includes which of the following?
Active participation in the development of a comprehensive systematic analysis of sentinel events
Identifying which staff were responsible for causing a patient safety event
Removing intimidating behavior that might prevent safe behaviors
A run chart is an effective tool for which of the following?
Identifying variations within a system
Identifying causes of variation within a system
Predicting whether a process will function as expected
Which of the following is not required of leaders according to Joint Commission standards?
Leaders provide staff with the time, resources, and opportunities to participate in improvement efforts as part of daily work.
Leaders celebrate and recognize improvements.
Leaders use data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
(See Answer Key on page 10.)
CJCP
(continued from page 9)
The correct answer is a. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. Types of patient safety events include adverse events, sentinel events, close calls, no-harm events, and hazardous conditions. In a learning organization, patient safety events are seen as opportunities for learning and improvement. Therefore, leaders in learning organizations adopt a transparent, nonpunitive approach to reporting so that the staff can report to learn and the organization can collectively learn from patient safety events. To become a learning organization, a hospital must
have a fair and just safety culture, a strong reporting system, and a commitment to put those data to work by driving improvement. Some patient safety events may involve an Immediate Threat to Health or Safety and, in cases of clear negligence or violation, may require some disciplinary action, but that is not necessarily the case.
The correct answer is c. Removing intimidating behavior that might prevent safe behaviors. Leadership
r
LD.03.01.01 equires leaders to
in comprehensive systematic analysis—providing support, resources, approval of proposed corrective actions, dissemination of information, and so forth— they do not need to be involved in the day-to-day operations of the team performing the analysis.
Answer b is incorrect because no Joint Commission standards require leaders to identify individuals responsible for patient safety events. In the vast majority of cases, multiple systems-related factors contribute to the event.
The correct answer is a. A run chart is an effective tool for identifying variations in a system. Other tools, such as a statistical process control chart, are more effective for finding the causes of variation. A capability chart is an effective method of predicting whether a process will function as expected.
The correct answer is b. Leaders celebrate and recognize improvements. Recognizing and celebrating improvements is a best practice that can help motivate staff to participate in improvement activities and to report potential problems. However, Joint Commission standards do not require this. Standard LD.03.01.01, EP 3 requires that leadership provides staff with the time, resources, and opportunities to articipate in improvement efforts as part of daily
(LD) Standard
create and maintain a culture of safety and quality throughout the hospital. Element of Performance (EP) 4 requires leaders to develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety. EP 5 requires leaders to create and implement a process for managing behaviors that undermine a culture of safety. Answer a is incorrect because, while leaders have a role
p
work. Standard LD.03.02.01 requires that the hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality. TS