The Joint Commission (TJC) is the leading standards-setting and accrediting body in healthcare across the United States. For respiratory therapists (RTs), understanding the role of TJC is essential, as its standards directly influence patient care, safety, and the delivery of respiratory therapy services.
Accreditation by TJC is not only a mark of quality but also a requirement for many healthcare facilities that want to participate in federal healthcare programs such as Medicare and Medicaid.
What Is The Joint Commission?
The Joint Commission (TJC) is an independent, not-for-profit organization that accredits and certifies nearly 21,000 healthcare organizations and programs in the U.S. Its mission is to continuously improve healthcare for the public in collaboration with stakeholders by evaluating healthcare organizations and inspiring them to provide safe, effective, high-quality care.
TJC sets rigorous performance standards that focus on patient safety, clinical effectiveness, and organizational efficiency. Hospitals, clinics, and long-term care facilities undergo regular surveys and evaluations to maintain their accreditation. For healthcare professionals, including RTs, adherence to TJC standards is a critical part of daily practice.
Why Is The Joint Commission Important?
Earning and maintaining TJC accreditation demonstrates that a healthcare organization is committed to providing safe, high-quality care. Accreditation affects nearly every aspect of patient care—from how medical records are kept to how staff respond to emergencies. Importantly, it also impacts funding, as many insurers and government programs require TJC accreditation for participation.
For respiratory therapists, this means that the quality of respiratory care services is directly tied to TJC standards. Whether it involves ventilator management, infection control, or patient safety initiatives, RTs contribute to the measures that surveyors evaluate.
The Relevance to Respiratory Therapists
Respiratory therapists play an active role in helping healthcare facilities meet and exceed TJC requirements. Some key areas where RTs intersect with TJC include:
- Patient Safety: Ensuring proper infection control during procedures such as intubation, suctioning, or ventilator management.
- Clinical Documentation: Accurate charting of oxygen therapy, ventilator settings, and patient responses is critical to meeting performance measures.
- Core Measures: Many of TJC’s standards address conditions such as pneumonia, COPD, asthma, and ventilator-associated events—areas where RTs are directly involved in patient outcomes.
- Survey Participation: RTs often interact directly with TJC surveyors during on-site visits, providing evidence of compliance and demonstrating best practices.
The Role of Professional Organizations
The American Association for Respiratory Care (AARC) collaborates with TJC to ensure that respiratory therapy standards are well-represented. Through its Professional and Technical Advisory Committees (PTACs), the AARC provides input on accreditation standards that impact the field.
Additionally, TJC periodically seeks public comment on proposed standards, giving RTs a voice in shaping the policies that guide their profession.
The Joint Commission (TJC) Practice Questions
1. What is the primary role of The Joint Commission (TJC) in the U.S. healthcare system?
To set standards and accredit healthcare organizations, promoting safe, high-quality patient care.
2. How many healthcare organizations and programs are accredited or certified by TJC in the United States?
Nearly 21,000.
3. What type of organization is The Joint Commission?
An independent, not-for-profit organization.
4. What is the mission of The Joint Commission?
To continuously improve healthcare by evaluating organizations and inspiring them to provide safe, effective, high-quality care.
5. How often does The Joint Commission conduct on-site accreditation surveys?
Every 3 years.
6. What happens if a healthcare facility loses its Joint Commission accreditation?
It may lose funding, including reimbursement from Medicare and Medicaid.
7. Which organization works with TJC by appointing members to its Professional and Technical Advisory Committees (PTACs)?
The American Association for Respiratory Care (AARC).
8. What are PTACs, and what is their function?
They are advisory committees that provide expert input on TJC accreditation standards.
9. How does TJC measure healthcare quality?
Using core performance measures and evidence-based practice guidelines.
10. What is The Joint Commission’s vision statement?
That all people always experience the safest, highest quality, best-value healthcare across all settings.
11. When was The Joint Commission founded?
1951
12. When were hospital accreditation standards first published by The Joint Commission?
1953
13. What is a sentinel event?
An unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof.
14. What does the term “serious injury” include according to TJC?
Loss of limb or loss of function.
15. What does the phrase “or risk thereof” mean in relation to sentinel events?
A process variation with the potential for a serious adverse outcome if it recurs.
16. What are the five most common sentinel events reported to The Joint Commission?
1. Unintended retention of a foreign object, 2. Wrong patient, site, or procedure, 3. Operative/post-operative complication, 4. Delay in treatment, and 5. Suicide.
17. What is the Sentinel Event Advisory Group?
An interdisciplinary panel of patient safety experts that analyzes sentinel events and recommends safety improvements.
18. What is the purpose of the National Patient Safety Goals (NPSGs)?
To improve patient safety by addressing specific problems in healthcare and identifying ways to solve them.
19. What are the six key National Patient Safety Goals for hospitals?
Identify patients correctly, improve staff communication, use medications safely, prevent infection, identify patient safety risks, and prevent surgical mistakes.
20. What is the most frequent healthcare-associated infection (HAI)?
Catheter-Associated Urinary Tract Infection (CAUTI).
21. Define a medication error according to The Joint Commission.
A preventable event that may lead to inappropriate medication use or patient harm while the medication is under the control of the healthcare provider or patient.
22. What are the two most common root causes of sentinel medication errors?
1. Communication failure and 2. Lack of procedural compliance
23. What three areas were targeted by the Institute of Medicine (IOM) Future of Nursing Initiative?
Ensure safety and quality in clinical care, redesign nursing education, and redirect research funding.
24. What are the six domains of healthcare quality defined by The Joint Commission?
Safe, effective, patient-centered, timely, efficient, and equitable.
25. What phrases should be avoided when responding to a TJC surveyor’s question?
Avoid saying: “I think we mostly do it this way,” “we’re supposed to,” “on my shift we…,” or “I usually do…”
26. What should you say if a surveyor asks a question you cannot answer?
Remain calm and respond with, “I can get the answer for you” or “I know where to find it.”
27. What should you do if you don’t understand a question asked by a TJC surveyor?
Politely ask them to restate or clarify the question.
28. Why is TJC accreditation important for healthcare facilities?
Because it allows reimbursement from Medicare and Medicaid, and it represents a nationally recognized symbol of quality.
29. Are clinical and support services available to patients during nights and weekends?
Yes, either directly or through on-call coverage, including a 24/7 inpatient pharmacy.
30. What is the definition of a sentinel event according to TJC?
A patient safety event that results in death, permanent harm, or severe temporary harm, and is not primarily due to the patient’s illness.
31. Where can you find your facility’s Sentinel Event Policy?
In the Administrative Policy under “Management of Significant Safety Events.”
32. What is your role if a sentinel event occurs in your area?
You may be involved in the Root Cause Analysis process to help determine contributing factors and implement changes.
33. What is the most frequently cited root cause of sentinel events?
Human factors, such as staffing issues, inadequate training, fatigue, distraction, and supervision failures.
34. What does the fire safety acronym “RACE” stand for?
Remove, Activate, Contain, Evacuate.
35. Where should you move patients and staff in the event of a fire?
Horizontally beyond the nearest fire zone doors to a designated area of refuge.
36. Are you allowed to pass through closed fire doors during a fire alert?
No, not on the activated floor, the floor above, or the floor below until an all-clear is announced.
37. When would strobe lights flash in the main hospital?
Only when the Chicago Fire Department orders a relocation or evacuation, not during initial alarm activation.
38. What information is announced during a Code Red on the public address system?
The phrase “Code Red,” followed by the specific floor and zone.
39. How can you determine the zone location mentioned during a Code Red announcement?
By checking the evacuation route maps or fire zone signs posted above fire doors.
40. Where is the nearest stairwell in your area?
Location-specific—know this for your department (go check).
41. Where is the nearest fire extinguisher in your department?
Location-specific—identify and memorize this (go find it).
42. Where is the closest fire alarm pull station in your area?
Location-specific—know this for your workspace (go find it).
43. What is your department’s primary and secondary evacuation route?
Check evacuation maps posted near stairwells and elevators, and know both routes (go find them).
44. What details are typically shared by leadership after a fire drill?
Time, location, and results of the drill.
45. Is it ever acceptable to prop open fire doors or tape over door locks?
No—these actions compromise fire safety and are strictly prohibited.
46. Where is the nearest red emergency phone in your area?
Location-specific—ensure you know where it is (go find it).
47. Where can you find the phone directory for the red phone?
It is attached to the red phone.
48. What is the purpose of the red phone?
To provide emergency communication during network or phone system outages.
49. What does the acronym “PASS” stand for when using a fire extinguisher?
Pull the pin, aim at the base of the fire, squeeze the handle, and sweep side to side.
50. How should you respond to a minor chemical spill that poses no harm?
Check the SDS, contain the area, clean it with a spill kit, notify EVS, and complete a SERS report.
51. How would you be notified of an internal or external emergency situation?
You would be informed by department leadership and possibly hear an overhead announcement via the public address system.
52. What does HIPAA stand for, and where can you find more information?
HIPAA stands for the Health Insurance Portability and Accountability Act, and its policies can be accessed in the Policies and Procedures database.
53. What might a TJC surveyor ask regarding instrument handling?
They may ask you to explain how instruments are wiped down, how they are transported, and how contaminated instruments are processed.
54. How and when should blood pressure cuffs be cleaned?
BP cuffs must be wiped down between patients using Purple Top Sani Wipes. Only CRITIKON cuffs are approved in clinical areas.
55. What are the key steps in sterile instrument processing?
You must wipe down the instrument, safely transport it, and follow protocol for decontamination and reprocessing.
56. When do opened EKG electrode packages expire, and what must be done?
Seven days after opening. The expiration date must be written on the outside of the package.
57. Who is allowed to access medication cabinets and drawers?
Only staff authorized to administer medications should have access to secure medication storage areas.
58. How should logs be maintained according to TJC standards?
Only the current month’s logs should be visible; past logs must be filed and retained for 3 years.
59. What is the requirement for pain reassessment documentation?
Pain must be reassessed and documented in EPIC using the Pain Reassessment Flowsheet.
60. How often should components of the emergency cart be checked?
EKG rhythm strip: Weekly; Suction canister: Daily; Canister L attachment: Present at all times; and Infant defibrillator pads: Must be present.
61. What is the “18-inch rule” in fire safety?
Items must be stored at least 18 inches below fire sprinkler heads to ensure proper sprinkler function during a fire.
62. What is wrong if items are stored too close to fire sprinkler heads?
It violates the 18-inch clearance rule, which may prevent the sprinklers from distributing water effectively during a fire.
63. How is informed consent obtained from a patient or guardian?
A provider must explain the risks and benefits, and the parent or legal guardian must sign the consent form.
64. When and how should you wear your ID badge?
Your badge must be worn at all times, with both your photo and name clearly visible.
65. How should patient complaints be addressed?
Attempt to resolve the issue at the point of care. If unresolved or complex, escalate it to the department manager.
66. What actions help protect patient privacy?
Use curtains or close doors during exams, access only necessary patient info, log off computers when leaving, do not share passwords, and dispose of PHI in secure shredding bins.
67. How do you request access to old medical records?
Contact the Medical Records department through your facility’s designated request system.
68. What is the process for transferring patient info to another facility during hospital admission?
A verbal report is given between providers, and a copy of the progress note and relevant lists (problem or medication) are sent with the patient.
69. What are the two required patient identifiers?
Name and date of birth—always confirmed before delivering care, treatment, or services.
70. How should instruments be transported after use to ensure safety and compliance?
Dirty instruments must be placed in labeled containers and taken directly to central processing following infection control protocols.
71. What should you do if you find an expired item in the clinical area?
Remove it from use immediately and notify the appropriate staff member or supervisor for replacement.
72. How long should logs and audit records be kept to comply with TJC regulations?
A minimum of 3 years.
73. Who is responsible for documenting pain reassessment after medication or intervention?
The clinical staff member who administered the intervention must reassess and document in the EMR.
74. When is it appropriate to access a patient’s health record?
Only if you are directly involved in their care or have a legitimate reason related to treatment, billing, or operations.
75. What should you do before leaving a computer station that contains PHI?
Always log off to protect patient information and maintain HIPAA compliance.
76. How should you handle the use of unacceptable or prohibited abbreviations in clinical documentation?
Refer to the posted list of unacceptable abbreviations (available in all exam rooms) and avoid using them under all circumstances.
77. What is the Universal Protocol, and when must it be used?
The Universal Protocol requires a “Time Out” before all invasive procedures to confirm the correct patient, procedure, site, supplies, equipment, and team members are present and in agreement.
78. What are the proper steps for reporting critical test results?
Write down the results, read them back to the caller for confirmation, immediately notify the provider, and document the entire process accurately.
79. Are departments responsible for maintaining personnel files on contracted workers?
Yes, departments must maintain appropriate documentation and personnel files for contracted staff.
80. How can you stay informed about new or updated policies and procedures relevant to your role?
Updates may be communicated via global emails, unit postings, educators, department leadership, SharePoint sites, or required online courses.
81. What should you do if you are exposed to blood or body fluids?
Notify your manager, follow the Blood and Body Fluid Exposure Management policy, and complete a SERS report immediately.
82. What are Standard Precautions, and why are they important?
They are infection prevention practices used for all patients to prevent the spread of infectious agents, including hand hygiene, PPE, sharps safety, and equipment cleaning.
83. When is it necessary to perform hand hygiene in a clinical setting?
Hand hygiene should be done when entering and exiting patient rooms, before and after glove use, when moving between body sites, and after any potentially contaminating activity.
84. Where are food and beverages permitted in clinical environments?
Food and drinks are prohibited in patient care areas, including laboratories. They must be stored and consumed only in designated break rooms.
85. What are some infection prevention practices you should follow for patient and personal safety?
Hand hygiene, appropriate PPE use, cleaning equipment, safe sharps disposal, up-to-date vaccinations, and staying home when ill are all essential prevention measures.
86. What resources are available if you have questions about infection prevention or surveillance?
Consult the “Bug Book” on SharePoint, refer to Infection Prevention & Control policies, or contact the Infection Prevention department via 24/7 pager.
87. How can you determine the required contact time for a disinfecting product to be effective?
Check the manufacturer’s label for the specified drying or contact time before wiping or reusing the surface.
88. What should you do if you’re unsure how to apply a policy or guideline related to your department?
Ask your supervisor, check SharePoint or the unit’s intranet, and review the official policy manual or training materials for clarification.
89. What is the importance of reading back critical test results during a phone report?
It ensures accuracy and prevents miscommunication of vital patient data by verifying the information with the caller.
90. Why must all personnel be present in the room during a “Time Out” procedure?
To confirm shared understanding and eliminate potential errors before an invasive procedure begins.
91. How often should prohibited abbreviations be reviewed in the clinical setting?
They should be reviewed regularly and reinforced during staff training and competency assessments.
92. What documentation is required after exposure to bloodborne pathogens?
A SERS report must be completed, and follow-up procedures outlined in the IP&C policy must be initiated promptly.
93. Why are Standard Precautions applied to all patients, regardless of diagnosis?
Because any patient may harbor infectious agents, even without symptoms, making universal precautions essential to infection control.
94. How do Standard Precautions differ from Transmission-Based Precautions?
Standard Precautions apply to all patients, while Transmission-Based Precautions are additional measures used for patients with known or suspected infections.
95. What is the purpose of performing hand hygiene after removing gloves?
Gloves may have microscopic tears or contamination during removal, so hand hygiene eliminates residual pathogens.
96. What is the consequence of improper storage of food or drinks in clinical areas?
It can result in contamination and violation of infection control standards, posing risks to staff and patients.
97. Why is PPE essential even when the patient does not appear to be infectious?
Because infectious agents may still be present in blood, body fluids, or non-intact skin, even in asymptomatic patients.
98. What should you do if you suspect a fellow staff member is violating infection control protocols?
Report it to your supervisor or the Infection Prevention & Control team for follow-up and corrective action.
99. What is the benefit of using the “Bug Book” as an infection control resource?
It offers quick reference for organism-specific precautions, treatment guidelines, and best practices for containment.
100. What should you verify before using a disinfectant wipe on clinical equipment?
Check the label for appropriate usage, drying time, and compatibility with the surface to ensure effective disinfection.
Final Thoughts
The Joint Commission (TJC) plays a central role in shaping the quality and safety of healthcare in the United States. For respiratory therapists, understanding TJC’s mission, standards, and survey processes is essential, as their daily work contributes directly to an organization’s compliance and accreditation status.
By aligning with TJC standards, RTs not only help their facilities achieve excellence but also elevate the quality of care for patients who depend on respiratory support.
Written by:
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
- Wadhwa R, Boehning AP. The Joint Commission. [Updated 2023 Mar 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.