JCI Compliance Checklist

2016
HOSPITAL
Compliance Assessment Checklist
Executive Editor: Katie Byrne
Project Manager: Lisa King
Associate Director, Publications: Helen M. Fry, MA
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Executive Director, Publications and Education: Catherine Chopp Hinckley, PhD
Joint Commission Reviewers: Heidi Beckstrom, John Herringer, Michelle Johnson, Stephen Knoll, Cynthia Leslie,
Lynette Rainey, Kathy Tolomeo, Cherie Ulaskas, Lisa Waldowski, John Wallin
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The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the
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stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the
highest quality and value.
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Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Part 1: Prompts to Assess Your Standards Compliance. . . . . . . . . . . . . . . . . . . . 1

Accreditation Participation Requirements (APR) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . 3
Environment of Care (EC) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Emergency Management (EM) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Human Resources (HR) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Infection Prevention and Control (IC) Compliance Prompts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Information Management (IM) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Leadership (LD) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Life Safety (LS) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Medication Management (MM) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Medical Staff (MS) Compliance Prompts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
National Patient Safety Goals (NPSG) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Nursing (NR) Compliance Prompts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Provision of Care, Treatment, and Services (PC) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . 39
Performance Improvement (PI) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Record of Care, Treatment, and Services (RC) Compliance Prompts. . . . . . . . . . . . . . . . . . . . . . . . 45
Rights and Responsibilities of the Individual (RI) Compliance Prompts . . . . . . . . . . . . . . . . . . . . 46
Transplant Safety (TS) Compliance Prompts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Waived Testing (WT) Compliance Prompts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Part 2: Compliance Assessment Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Accreditation Participation Requirements (APR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Environment of Care (EC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Emergency Management (EM). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Human Resources (HR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Infection Prevention and Control (IC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Information Management (IM). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Leadership (LD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Life Safety (LS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
2016 Hospital Compliance Assessment Checklist
Medication Management (MM). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Medical Staff (MS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
National Patient Safety Goals (NPSG). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Nursing (NR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Provision of Care, Treatment, and Services (PC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Performance Improvement (PI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
Record of Care, Treatment, and Services (RC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
Rights and Responsibilities of the Individual (RI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Transplant Safety (TS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
Waived Testing (WT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Part 3: Survey Logistics: Tracer Methodology

and Planning Worksheets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
Overview of Tracer Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Worksheet 3-1: Planning an Individual-Based System Tracer—Medication Management. . . . . . . 626
Worksheet 3-2: Planning an Individual-Based System Tracer—Infection Control. . . . . . . . . . . . . 628
Worksheet 3-3: Planning a System Tracer—Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . 631
Worksheet 3-4: Program-Specific Tracer—Suicide Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
Worksheet 3-5: Program-Specific Tracer—Laboratory Integration . . . . . . . . . . . . . . . . . . . . . . . . 635
Worksheet 3-6: Program-Specific Tracer—Patient Flow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
Conducting Mock Tracers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Tracing the Environment of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
Worksheet 3-7: Environment of Care—Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
Worksheet 3-8: Environment of Care—Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 648
Worksheet 3-9: Environment of Care—Hazardous Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . 649
Worksheet 3-10: Environment of Care—Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
Worksheet 3-11: Environment of Care—Medical/Laboratory Equipment. . . . . . . . . . . . . . . . . . 651
Worksheet 3-12: Environment of Care—Utilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652
Worksheet 3-13: Environment of Care—Construction and Other EC Considerations. . . . . . . . . 653
Worksheets to Facilitate Hospital Logistics Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654
Worksheet 3-14: Competence Assessment Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
Worksheet 3-15: Emergency Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
Worksheet 3-16: Facility Orientation—Life Safety Code Surveyor. . . . . . . . . . . . . . . . . . . . . . . . . 658
Worksheet 3-17: Life Safety Code Building Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659
Worksheet 3-18: Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
Worksheet 3-19: Medical Staff Credentialing and Privileging. . . . . . . . . . . . . . . . . . . . . . . . . . . . 661
Introduction
The Joint Commission accredits and certifies nearly 21,000 have considered to be historically challenging or high risk,
health care organizations and programs across the United or those that focus on risks related to the Focused Standards
States. Joint Commission accreditation and certification is Assessment (FSA).
recognized nationwide as a symbol of quality that reflects
your hospital’s commitment to meeting certain performance The compliance prompts can help you to determine, among
standards. other things, whether or not you have the appropriate policies
and procedures in place, who is responsible for different
The Joint Commission accreditation process is data driven aspects of the care process, if time-related issues are being
and emphasizes continuous improvement and ongoing completed according to schedule, and if policies and proce-
standards compliance. In this way, the accreditation process dures are being effectively communicated to staff.
can be used as a systems improvement and management tool,
essentially becoming a by-product of quality improvement. Throughout this section, you will also find tips for successful
compliance. Keep in mind that these tips are not new accredi-
The 2016 Hospital Compliance Assessment Checklist is a self- tation requirements. They are intended to be used as compli-
assessment workbook designed to help you maintain continu- ance strategies and may help point you toward both internal
ous compliance. This easy-to-use workbook can be used both and external resources that can help you maintain continuous
by staff new to the hospital accreditation process and by expe- compliance. They also include strategies for conducting mock
rienced accreditation managers to assess standards compliance tracers, keeping documentation readily accessible, communi-
at whatever level is most comfortable. The book, with its cating among staff members, and more.
targeted assessment prompts, expansive compliance checklist,
and multiple worksheets, helps in the following ways: Part 2: Compliance Assessment Checklist
n Engages staff and leadership in accreditation activities with The compliance checklist in Part 2 is a self-assessment tool
simple questions, checklists, and tools that will allow you to easily assess your hospital’s compliance
n Helps you to plan for addressing deficiencies and sustain- with each and every standard and EP in the CAMH, includ-
ing improvements ing those used for deemed status purposes and Primary Care
n Improves your understanding of how to plan for and con- Medical Home certification. The checklist format will allow
duct a tracer you to note any actions needed, identify who is responsible
n Better prepares you for your next unannounced survey for implementing improvements, and track progress toward
n Reduces anxiety about the survey process, which will allow compliance. It also identifies which EPs require documen-
for a more relaxed and beneficial on-site survey tation and/or Measures of Success (MOS) if they are found
out of compliance during an actual survey. The compliance
The 2016 Hospital Compliance Assessment Checklist is divided checklist can be used as a planning tool for the Intracycle
into three parts: (1) high-level compliance prompts that allow Monitoring (ICM) process in the following ways:
you to see the big picture, but also include some very pointed n For full FSA: Use the compliance checklist to guide your
questions that may help you to get to the heart of your com- self-assessment over time so that you are ready to effec-
pliance issues; (2) a simple but detailed compliance checklist tively populate your FSA tool on your Joint Commission
that includes an assessment question for every single element Connect™ extranet site in the allotted time frame. You
of performance (EP) in the 2016 Comprehensive Accredita- can identify where Plans of Action are needed and if any
tion Manual for Hospitals (CAMH); and (3) tracer scenarios required MOS must be captured.
and survey worksheets. As a package, the hands-on contents n For Option 1: Use the compliance checklist to complete
found throughout this publication make it truly a continuous your actual assessment so you can attest to the completion
compliance workbook. of an FSA on your ICM profile.
n For Options 2 and 3: Use the compliance checklist as a
Part 1: Prompts to Assess Your quick self-assessment to anticipate standards compliance
Standards Compliance issues before an on-site FSA survey.
The compliance prompts are questions designed to help
prompt staff discussion about quality and compliance as Part 3: Tracer Methodology and Worksheets
addressed in each of the standards chapters in the CAMH. to Facilitate Survey Logistics Planning
Rather than addressing specific details of the requirements, In Part 3 you will find a detailed overview of tracer methodol-
the prompts are intended to help you focus on the broader ogy—a primer of sorts detailing the purpose and importance
view. The questions in this section target EPs that hospitals of this key aspect of The Joint Commission’s accreditation
v
survey process. This section discusses the various types of those policies and procedures. An incorrect answer to a tracer
tracers in detail, offers sample general tracer questions, and question should always receive comments or recommenda-
presents an extensive exploration of mock tracers. Conducting tions for follow-up. The worksheets include space for you to
mock tracers is a good method for assessing continuing survey record notes, discussion points, and areas of concern that you
readiness; this allows you to examine your current systems identify while conducting your mock tracers. This informa-
and processes, identify problematic trends, and implement tion can be used to highlight a good practice or to determine
changes as part of an ongoing improvement process. In issues that may require further follow-up.
essence, it helps you answer the questions posed in Parts 1
and 2 of this workbook. Finally, Part 3 wraps up with a series of survey preparation
worksheets based on the tracer types and on specific CAMH
This portion of the book discusses the steps for conducting chapter areas.
mock tracers and features an example consisting of a tracer
scenario and a completed worksheet, plus a blank worksheet Acknowledgments
allowing you to record your own information during a mock We are indebted to our writer, Kitty Wilson, for her attention
tracer. The completed worksheet identifies potential tracer to detail in preparing this workbook. We are also grateful to
participants and contains sample tracer questions that can our reviewers and contributors from The Joint Commission
be used to determine whether or not certain policies and (see copyright page) for their time and insights.
procedures exist and if staff are aware of and are following
vi
Part 1:
Prompts to Assess Your
Standards Compliance
Prompts to Assess Your

Standards Compliance
The following worksheets contain questions to prompt staff Throughout you will also find brief tips offering helpful
discussion in your organization regarding compliance with compliance strategies. Note that these tips do not represent
challenging areas in each of the standards chapters of the new accreditation requirements. They are intended to provide
2016 Comprehensive Accreditation Manual for Hospitals. The helpful strategies for standards compliance.
questions target elements of performance (EPs) considered
historically challenging or high risk or those focusing on risk
areas related to the Focused Standards Assessment.
2
Part 1: Prompts to Assess Your Standards Compliance
Accreditation Participation Requirements (APR) Compliance Prompts
Who is responsible for keeping the electronic application for accreditation (E-App) up to date? Has your account executive been
notified of any changes within 30 days of the change occurring?
Who is responsible for keeping the electronic Statement of Conditions™ (SOC) and the Basic Building Information (BBI) up
to date? Has the Accreditation Coordinator been notified of any changes to either the SOC or BBI? Have you confirmed that it
is current and that all work identified in your Plan for Improvement (PFI) is completed or is on track for completion within six
months of the projected completion date?
Have any new locations or services been added recently? If so, has your E-App been updated? Has your account executive been
notified within 30 days of the time the change(s) occurred?
Has the ownership, control, or capacity of the organization changed recently? If so, has your account executive been notified?
And was this completed within 30 days of the time the change(s) occurred?
What process is in place to ensure that all accreditation information is kept current?
TIP: Consider conducting a “paper drill” to ensure that all required documents listed in the Survey Activity Guide (at
http://www.jointcommission.org/organization_survey_activity_guide/) are easily located, retrievable, and current.
Have responsibilities for completing the Focused Standards Assessment (FSA) tool been determined?
How have the program-specific risk areas been incorporated into your intracycle self-assessment process?
TIP: Be proactive in preparing for your Intracycle Monitoring touchpoint call by using your FSA tool and this work-
book as a management tool to track and document organizational findings on an ongoing basis.
3
Have you determined which option will be selected for submission of an FSA?
TIP: Ensure accurate and timely submission of information by planning ahead.
Are your ORYX® data stable or unstable? Are your data satisfactory?
TIP: If your organization is struggling with ORYX measures, consider visiting the Core Measure Solution Exchange®
via your secure Joint Commission Connect™ extranet site.
Where are official records or reports from licensing, examining, reviewing, or planning bodies stored?
TIP: Keep official records and reports of licensing, examining, reviewing, or planning bodies easily accessible, as
surveyors may ask to review such documents.
How do staff, patients, or the public report concerns to hospital management about quality or safety?
TIP: Confirm that there is a process in place to notify the public about how to contact hospital management and The
Joint Commission to report patient safety and quality-of-care concerns.
Do providers of care, treatment, and services know that concerns regarding the safety and/or quality of care provided in the
organization may be reported to The Joint Commission without the threat of retaliation from the organization? Is there evidence
showing that providers have received education about this?
TIP: Incorporate a method for staff to report concerns regarding safety or quality of care to The Joint Commission
without retaliatory action from the hospital.
4
Environment of Care (EC) Compliance Prompts
Is the environment of care committee composed of a multidisciplinary team that reports to the governing body?
Are there written management plans for the areas identified in Standard EC.01.01.01, EPs 3–8? Has the organization evaluated
each of these plans in the past 12 months in terms of objectives, scope, performance, and effectiveness?
Is there a risk assessment process for the environment of care? When a risk assessment is completed, is the process documented?
Are the implementation and results reported to the environment of care committee?
How is the safety of the outside grounds and equipment (that is, the physical environment) being monitored?
Is the smoking policy up to date and enforced as written?
Is there a documented and current inventory of all required hazardous materials and waste? Has the hospital documented the
inspection and monitoring of all required hazardous gases and vapors?
Does the organization have accessible safety data sheets for all hazardous materials? Is there documentation of Department of
Transportation training (every three years) for all staff authorized to sign manifests for hazardous material and waste shipments?
Are all hazardous material and chemical containers (including secondary containers) labeled per the Occupational Safety and
Health Administration’s (OSHA’s) requirements?
5
Is all personal protective equipment that is required for handling, storing, transporting, using, and disposing of hazardous
materials available and maintained as required?
What is the organizational policy/procedure for monitoring radiation workers for radiation exposure?
What is the organization’s policy/procedure for routine storage and prompt disposal of trash?
TIP: During environmental rounds, evaluate for hazardous materials or waste that have not been previously identi-
fied. Also evaluate for policy compliance with managing such materials.
Is there a current, written fire response plan that describes the following?
n Specific roles of staff and licensed independent practitioners at and away from a fire’s point of origin
n When and how to sound and report fire alarms
n How to contain smoke and fire
n How to use a fire extinguisher
n How to evacuate to areas of refuge
When were fire drills conducted over the past year? Were critiques completed as planned?
Critique Completed
Fire Drill Date Quarter Shift (Y/N)
Health Care Occupancy (once per shift, per quarter)
Ambulatory Occupancy (once per shift, per quarter)
Business Occupancy (every 12 months from the date of the last drill)
6
Are fire safety equipment and fire safety building features maintained as required?
Current Date of
Applicable Inventory Testing Completion
Device (Y/N) (Y/N) Frequency Documented
Supervisory Signal Devices Quarterly
Water-Flow Devices Quarterly
Valve Tamper Switches 6 Months
Duct Detectors 12 Months
Electromechanical Releasing Devices 12 Months
Heat Detectors 12 Months
Manual Fire Alarm Boxes 12 Months
Smoke Detectors 12 Months
Visual Fire Alarm Devices 12 Months
Audible Fire Alarm Devices (including speakers) 12 Months
Fire Alarm Equipment for Notifying Off-Site Responders Quarterly
Fire Pump(s) Under No-Flow Conditions Weekly
Fire Pump(s) Under Flow 12 Months
Water-Storage Tank High- and Low-Water Level Alarms 6 Months
Water-Storage Tank Temperature Alarms Every Month
During Cold
Weather
Main Drains 12 Months
Water Supply Connections Quarterly
Standpipe Systems 5 Years
Kitchen Automatic Fire-Extinguishing Systems 6 Months
Carbon Dioxide and Other Gaseous Automatic Fire-Extinguishing Systems 12 Months
Portable Fire Extinguishers Inspection Monthly
Portable Fire Extinguishers Maintenance 12 Months
Standpipe Occupant Hoses 5 Years After
Installation/
3 Years
Thereafter
Fire and Smoke Dampers 1 Year After
Installation/
6 Years
Thereafter
Automatic Smoke-Detection Shutdown Devices for Air-Handling Equipment 12 Months
Sliding and Rolling Fire Door(s) 12 Months
7
Does all of the documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection
systems include the following?
n Name of the activity
n Date of the activity
n Required frequency of the activity
n Name, affiliation, and contact information of the person who performed the activity
n National Fire Protection Association (NFPA) standard(s) referenced for the activity
n Results of the activity
TIP: Similar to managing human resources records, develop a systematic process that proactively informs staff
when equipment maintenance is required prior to the due date. This will allow for adequate time to address the need
before that due date. This will be particularly useful if it is discovered that the equipment needs extensive repairs or
replacement.
Does the organization have a written inventory of all medical equipment? If the organization does not use Joint Commission
accreditation for deemed status purposes, does the organization have either a written inventory of all medical equipment or a writ-
ten inventory of selected equipment categorized by physical risk?
Does the inventory identify all high-risk medical equipment?
Does the inventory identify which medical equipment is maintained in accordance with manufacturer recommendations (includ-
ing all mandated medical equipment noted in Standard EC.02.04.01, EP 5)?
If applicable, does the inventory identify which medical equipment is maintained in an alternative equipment maintenance
(AEM) program? For medical equipment that is maintained in an AEM program, what documented written criteria was utilized
by a qualified individual(s) to determine that AEM program?
Is there a policy/procedure in place in order to meet the requirements of the Safe Medical Devices Act of 1990?
8
Are there written procedures to follow when medical equipment fails, including emergency clinical interventions and backup
equipment?
What quality control and maintenance activities are in place to maintain the quality of the diagnostic computed tomography
(CT), positron emission tomography (PET), magnetic resonance imaging (MRI), and nuclear medicine (NM) images produced?
Does a medical physicist annually measure the radiation dose for the CT imaging system for the adult brain, adult
abdomen, pediatric brain, and pediatric abdomen? Has the medical physicist verified that the radiation dose is within 20% of the
volume computed tomography dose index (CTDIvol)?
Does the organization conduct an annual performance evaluation of all CT, MRI, NM, and PET imaging equipment?
Before the initial use of medical equipment, is there a policy/procedure in place that requires the organization to perform safety,
operational, and functional checks? If the organization uses Joint Commission accreditation for deemed status purposes, does the
organization also perform safety, operational, and functional checks after major repair or upgrades of medical equipment?
Is there documentation that all inspections, test, and maintenance of both high-risk and non–high-risk equipment identified on
the medical equipment inventory has been completed as defined by the organization?
Is there documentation for the performance testing and maintenance of all sterilizers?
Is there documentation of equipment maintenance and chemical and biological testing of water used in hemodialysis?
9
For organizations that use Joint Commission accreditation for deemed status purposes, is there documentation that qualified
hospital staff inspect, test, and calibrate nuclear medicine equipment annually?
Does the organization have a written inventory of all operating components of utility systems? If the organization does not use
Joint Commission accreditation for deemed status purposes, does it have a written inventory of either all operating components of
utility systems or selected equipment based on risks for infection, occupant needs, and systems critical to patient care?
Does the inventory identify all high-risk utility operating components?
Does the inventory identify which utility operating components are maintained in accordance with manufacturer recommenda-
tions (including all mandated medical equipment noted in Standard EC.02.04.01, EP 5)?
If applicable, does the inventory identify which utility operating components are maintained in an AEM program? For utility
operating components that are maintained in an AEM program, what documented written criteria was utilized by a qualified
individual(s) to determine that AEM program?
For organizations that do not use Joint Commission accreditation for deemed status purposes, is there a policy/procedure that
requires the organization to evaluate new types of utility components before initial use to determine whether the operating compo-
nent(s) needs to be included in the inventory?
Is there documentation that identifies in writing the activities and associated frequencies for maintaining, inspecting, and testing
all utility operating components on inventory, and is the organization meeting those activities and frequencies?
10
Is there a policy/procedure in place that verifies the labeling of utility system controls to facilitate partial or complete emergency
shutdowns?
Does the organization have written procedures for all of the various utility system disruptions? Do these procedures address
shutting off the malfunctioning system, notifying staff in affected areas, performing emergency clinical interventions, and
obtaining emergency repair services?
Is there a policy/procedure in place that requires the organization to perform tests before the initial use of utility components?
If the organization uses Joint Commission accreditation for deemed status purposes, does the organization also perform tests of
utility components after major repairs or upgrades?
When evaluating utility system disruptions, is the organization following the written procedures?
Is there a policy/procedure that addresses how the organization minimizes biological agents in cooling towers, domestic hot- and
cold-water systems, and other aerosolizing water systems?
Is there a policy/procedure in place that defines how the organization maintains appropriate air-pressure relations, air-exchange
rates, and filtration in areas designed to control airborne contaminants? How often is the organization inspecting these critical
areas to ensure they are being maintained appropriately, and is there any need to modify those inspections due to trending data of
noncompliance?
Does the organization have current documentation that maps the distribution of its utility systems?
11
Are the following systems connected to emergency power?

n Alarm systems required by the Life Safety Code*
n Exit route and exit sign illumination required by the Life Safety Code
n Emergency communication systems required by the Life Safety Code
n Elevators (at least one for nonambulatory patients)
n Equipment that could cause patient harm when it fails, including the following:
o Life-support systems
o Blood, bone, and tissue storage systems
o Medical air compressors
o Medical and surgical vacuum systems
n Areas in which loss of power could result in patient harm (for guidance refer to NFPA 99, 1999 edition), including the
following:
o Intensive care
o Emergency rooms
o Operating rooms
o Recovery rooms
o Obstetrical delivery rooms
o Nurseries
o Urgent care areas
Have the life-support, infection-control, and non–life-support utility systems been inspected, tested, and maintained based on
organization policy requirements?
Is there documentation of at least monthly functional tests of battery-powered lights required for egress for a minimum duration
of 30 seconds and 12-month functional tests for a duration of 1½ hours? (Organizations can elect to replace all of the batteries
instead of conducting the 12-month functional test; however, the organization must additionally perform a random test of 10% of
the batteries for 1½ hours.)
Is there documentation of required testing of quarterly functional tests of stored emergency power supply systems (SEPSS)?
Is there documentation of required emergency generator testing (including each of the automatic transfer switches)?
* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.
12
Is there a policy/procedure requiring the organization (if an emergency power system test fails) to implement measures to protect
patients, visitors, and staff until necessary repairs or corrections are completed and to retest the system afterwards?
Does the organization have a policy/procedure that defines how it will inspect, test, and maintain critical components of piped
medical gas systems? Does this policy require the testing of piped medical gas and vacuum systems for purity, correct gas, and
proper pressure when these systems are installed, modified, or repaired?
How does the organization ensure that all main supply valves and area shutoff valves for piped medical gas and vacuum systems are
accessible and clearly identified as to what the valves control?
Is there a policy/procedure that requires a preconstruction risk assessment when planning for demolition, construction, or renova-
tion? Does it assess air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect
care, treatment, and services?
Who evaluates preconstruction risk assessments to ensure that actions were taken based on the assessment during demolition,
construction, or renovation?
How is the organization ensuring staff and licensed independent practitioners’ competency to describe or demonstrate methods for
eliminating and minimizing physical risks, actions to take in an incident, and reporting of incidents in the environment of care?
Is data being collected for all the prescribed environmental topics? What is the plan for analyzing environmental data? Does it
occur as planned?
How and when does the hospital analyze environment of care data, and who participates in the analysis?
13
TIP: Review the environment of care data being collected. Confirm that these data are capturing the relevant high-
risk issues and continue to be current with facility changes and improvements.
For patient care areas, are environmental tours completed every six months? For nonpatient care areas, are environmental tours
completed every 12 months?
14
Emergency Management (EM) Compliance Prompts
When was the most recent annual review of risks, hazards, and potential emergencies—as defined in the hazard vulnerability
analysis (HVA)—completed?
During the annual review, did the organization review the objectives and scope of its Emergency Operations Plan (EOP) and
update it accordingly?
Does the EOP address the prioritized risks and all the prescribed requirements for managing those risks?
Has the EOP been exercised within the defined time frame of twice a year at each site? Have these exercises been evaluated, and
have deficiencies and opportunities for improvement been identified, documented, and communicated to the team responsible for
monitoring environment of care issues and to senior hospital leadership?
After deficiencies and opportunities for improvement have been addressed by the organization, did the organization modify the
EOP? Did subsequent exercises reflect the modifications?
Does the organization have a documented inventory of on-site resources and assets that may be needed during an emergency,
including (but not limited to) personal protective equipment, water, and fuel as well as medical, surgical, and medication-related
resources and assets? Is this inventory reviewed annually?
TIP: Modify the EOP testing scenarios to evaluate the integrity and dynamics of the plan. For example, identify key
leaders as victims of the emergency to render them unable to provide support.
TIP: Use a systematic process or template to evaluate the exercises to ensure that they are evaluated comprehen-
sively and consistently. Do emergency exercises identify opportunities for improvement? If not, confirm whether the
vigor of the test meets your expectations.
15
Human Resources (HR) Compliance Prompts
Have all licenses and certifications been checked with primary sources upon hire and again prior to expiration?
Have all new hires completed orientation?
Have competencies been defined for all staff?
Are initial and subsequent competencies up to date for all staff?
What is the process for maintaining human resources records (for example, health screenings, competencies, performance
evaluations)?
Have performance evaluations been completed within the time frames defined by organization policy?
TIP: Create a manual or electronic tracking system that identifies the dates of license expiration and dates of reprivi-
leging to ensure that the status of the licenses is verified.
16
Infection Prevention and Control (IC) Compliance Prompts
Does the individual with clinical authority over the infection prevention and control (IC) program have the required expertise?
Have adequate resources been allocated to support the IC program (specifically, infection control practitioners, access to clinical
information, and the necessary supplies and equipment)?
Have you identified and prioritized infection control risk? Have measurable goals been established for each of the identified risks?
Have goals been established for limiting exposure to pathogens? Have goals been established for limiting the transmission of
infections associated with procedures and equipment, devices, and supplies?
Is the infection control plan reviewed annually, with each goal assessed and a determination made as to whether or not to carry it
over to the next year?
Does your risk analysis clearly include the care, treatment, and services provided and the information obtained from surveillance
data?
Are surveillance activities documented?
TIP: Review some charts of patients with infections to ensure that the data collection process has been implemented
as designed.
Has a measurable goal been established for hand hygiene compliance?
17
Do the IC program and plan encompass all of the organization’s care sites (such as ambulatory care sites and home care locations)?
Is the IC program integrated with the emergency management disaster program? Is a process for handling an influx of potentially
infectious patients clearly defined?
TIP: Consider incorporating the scenario of an influx of infectious patients or residents in your next Emergency
Operations Plan test.
Are isolation policies and procedures up to date and being followed?
Do staff members who perform low-level disinfection understand disinfectant contact times and follow them?
Is there a process to identify which equipment has been cleaned versus equipment that has not yet been cleaned?
Are procedures in place for preventative maintenance and cleaning of equipment such as sterilizers, washers, ultrasonic cleaners,
and automatic endoscopic reprocessors?
TIP: Consider tracing the storage, use, and cleaning of an individual piece of equipment, similar to tracing a patient
or resident, to determine potential cleaning and disinfecting gaps.
Are high-level disinfectant test strip indicators dated with an expiration date when a new container is opened? Is the manufactur-
er’s quality control process being followed when a new container is opened?
Is the temperature of high-level, disinfectant-based solutions actively monitored as required by manufacturer’s recommendations?
18
Are there correct air pressure relationships between areas where instruments are being processed? Are these measurements
documented?
Are temperature and humidity being recorded and appropriately acted upon in sterile storage and procedural areas?
Is the Centers for Disease Control and Prevention’s Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 being
followed?
Are the ANSI/AAMI ST58:2005/(R)2010 recommended practices from Chemical Sterilization and High-Level Disinfection in
Health Care Facilities being followed?
Do frontline staff members (as well as their managers) performing low-level disinfection, high-level disinfection, and sterilization
have the required competencies? Are these competencies documented?
Are laryngoscope blades packaged following high-level disinfection?
Have incremental influenza vaccination rates been established to reach the 90% goal by 2020?
Are vaccination rates being measured, and is the methodology documented?
Are staff throughout the hospital aware of the IC plan as it affects their particular areas? What is the description of the Infection
Preventionist’s involvement in high-level disinfection and sterilization?
19
Information Management (IM) Compliance Prompts
When was the plan for managing interruptions to electronic information systems most recently tested?
TIP: For efficiency, consider testing the plan for managing interruptions to electronic information systems when
testing the Emergency Operations Plan.
Do chart audits evaluate inappropriate editing, prohibited abbreviation use, and accuracy?
Does the information management process provide staff the specific information they need at the time they need it?
TIP: Engage staff in assessing the information management process. Ask what is working and what is not.
Has the security of protected information been maintained?
TIP: Make rounds throughout the facility with the mind-set of a visitor. Can you access any information that you
should not have access to?
20
Leadership (LD) Compliance Prompts

TIP: Identify the time frames, as defined by the organization, under which leaders evaluate the following issues, as
well as the last time each was evaluated:
n Leadership qualifications and oversight of operations to assigned areas
n Nurse leadership participation in decision making at the executive level
n Performance improvement activities
n Staffing effectiveness:
o Number and skill mix required for services provided to the population served
o Staffing impact on adverse or sentinel events
n Evaluating and maintaining a culture of safety and quality
n Regular reporting of safety and quality issues to the governing body
n Input from the populations served
Are all policies up to date, and do they reflect current practice?
What is the role of the governing body in ensuring continuous compliance with the Centers for Medicare & Medicaid Services
(CMS) Conditions of Participation (CoPs)?
What are the organization’s requirements for how frequently policies and procedures are reviewed? What evidence will you provide
to the surveyor to demonstrate that your policies and procedures are reviewed in accordance with the expectations?
How is the efficacy of leadership evaluated in terms of oversight of programs, sites, and services operations?
Are staff consistent in following policies? How is this evaluated?
TIP: Ensure that there is a process in place for a regular review of policies and procedures. The frequency of policy
review and approval is based on an organization-defined time frame.
Have the annual environment of care and infection control risk assessments been completed? Have all services and all locations
been incorporated into these risk assessments? Have risks been prioritized?
21
Is the list of clinical contracts current and complete?
Have performance expectations been clearly defined and communicated, in writing, to all contractors?
What metrics are being monitored to ensure that contract services are performing as required?
What process is in place to periodically review the contracted services to ensure that they continue to meet the needs of the
organization?
How are clinical leaders and medical staff members given the opportunity to offer advice about the sources of clinical services to
be provided via contract? If interviewed, would a member of the medical staff be able to discuss his or her role in the contract
selection process?
Is the contract approval process clearly defined?
Does a qualified doctor of medicine or osteopathy direct anesthesia, nuclear medicine, and respiratory services?
TIP: Incorporate data that are already being collected in the performance improvement program that are relevant to
contract evaluations. This will streamline the data collection efforts to simultaneously support both processes.
Who is responsible for compliance with the human resources requirements as they apply to contracted staff? Have you defined this
responsibility within the contract?
22
Does the organization have timely access to documents should they be requested by a surveyor—documents such as a current
license, competence assessments, performance evaluations, and evidence of primary source verification?
When do state and local licenses and registrations (including the Clinical Laboratory Improvements Act of 1988 [CLIA ’88]
waiver certificate) need to be renewed?
Does a qualified member of the medical staff direct and supervise emergency services? Who assumes this responsibility in the
absence of the director?
License/Registration Renewal Date
TIP: Ensure compliance with law and regulation by planning ahead for license and registration renewals.
How are decisions made for assessing high-risk/high-volume, high-risk/low-volume, and/or problem-prone processes for perfor-
mance improvement activities? What strategies have you proactively implemented in order to reduce risk associated with these
processes?
On what high-risk process did leaders perform a proactive risk assessment within the past 18 months?
What metrics specific to patient flow are being monitored? In order to identify trends and patterns over time, how is this data
displayed?
TIP: Managing patient flow and caring for patients in temporary locations can be a challenge. Have processes
in place to ensure that patients in temporary locations are receiving the same level of care they would receive if
assigned to a permanent bed.
23
What strengths do your data reveal?
What opportunities for improvement are you pursuing, based on the data obtained? How are the opportunities prioritized, and
how are the prioritized opportunities communicated to members of the leadership team?
What role do members of the medical staff play in expediting timely flow of patients throughout the organization?
What is the role of anesthesia staff in overseeing all anesthesia services provided throughout the organization?
Is the availability and responsiveness of ancillary services to patients held in temporary locations included in the evaluation? Do
you have any metrics in place to quantify timely availability of these services?
When patients are held in temporary locations, are admission orders, assessments, and so forth being implemented in a timely
manner? Are patients’ rights being observed in these locations? How is this evaluated?
If your organization has licensed swing beds, has compliance with all swing bed requirements been evaluated?
24
Life Safety (LS) Compliance Prompts
Who manages building assessment, repairs of identified deficiencies, and the electronic Statement of Conditions™ (SOC)?
TIP: One or more individuals may be responsible for the assignments described above. Identify the roles in some
manner, such as through a job description.
Is the SOC monitored consistently? Are the BBI (Basic Building Information) and PFI (Plan for Improvement) current?
What is the policy/procedure for identifying and managing Life Safety Code®* deficiencies, either caused by construction or identi-
fied during building tours or rounds?
Does the organization have a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code
deficiencies cannot be immediately corrected or during periods of construction?
Is there a current and accurate set of life safety drawings for all buildings/areas required to be managed in the SOC? Do the life
safety drawings include all of the following?
n Areas of the building that are fully sprinklered (if the building is partially sprinklered)
n Locations of all hazardous areas
n Locations of all fire-rated barriers
n Locations of all smoke barriers
n Suite boundaries, including the sizes of the identified suites—both sleeping (maximum 5,000 square feet) and nonsleeping
(maximum 10,000 square feet) suites
n Locations of designated smoke compartments
n Locations of chutes and shafts
n Any approved equivalencies or waivers
TIP: Once identified, deficiencies should be assessed for resolution; implementation time frames and criteria should
be based on organization policy. (See LS.01.02.01, EPs 4–15, for guidance.)
Does all door hardware operate as designed, including exit doors, stairway doors, doors to hazardous areas, doors off corridors,
smoke barrier doors, and fire barrier doors?
* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.
25
TIP: Placing doors on a scheduled maintenance inspection will assist in identifying problems. Ranking doors based
on low or high use may be of value in establishing inspection frequencies.
How does the organization inspect and maintain fire and smoke barriers?
Are all rooms that are utilized as storage of combustible materials maintained as a hazardous area?
Are all stairwells free of any device or storage that does not service the stairwell?
TIP: The Joint Commission, as an Authority Having Jurisdiction, does not permit any device in a stairwell enclosure
that does not service the stairwell. Examples of devices not permitted in a stairwell that are commonly found include
security cameras, proxy access devices, evacuation sleds/chairs, etc. However, organizations may seek approval of
the installation of these devices by submitting a Traditional Equivalency with The Joint Commission.
Are all egress corridors clear of obstructions, including projections?
TIP: Monitor corridors and stairwells for staff storing items. Storage is defined as items not in use for more than 30
minutes.
Are all exits and intersections in the egress path adequately illuminated?
TIP: Place exits on the fire drill inspection form to evaluate if the lighting is operational and to ensure illumination. At
no time may the exit light be a single bulb (two or more bulbs should provide backup lighting).
Are there “No Exit” signs posted on any door, passage, or stairway that is neither an exit nor access to an exit but may be mistaken
for an exit?
Are all exit signs visible when the path to the exit is not readily apparent? Are the signs fully lit?
26
Is the master fire alarm control panel located in a 1-hour fire-rated room that is continuously occupied or in an area that has a
smoke detector?
Are all stored items at least 18 inches below each sprinkler head diffuser?
Are all sprinkler heads not damaged and free from corrosion, foreign materials, and paint?
Are piping for sprinkler systems not used to support any other items?
TIP: Sprinkler coverage may be considered a plane of protection at 18 inches below the sprinkler head diffuser. Use
regular inspections to confirm that nothing invades this plane of protection.
Are soiled linen and trash receptacles larger than 32 gallons located in a room protected as a hazardous area?
27
Medication Management (MM) Compliance Prompts
Is relevant information about the patient accessible to licensed independent practitioners and staff who participate in the manage-
ment of the patient’s medications? How is this information accessed?
TIP: Ensure that all practitioners involved in the medication management process have access to comprehensive
patient information.
How confidently can staff speak to the strategies in place to manage high-risk, hazardous, and look-alike/sound-alike medications?
Is there evidence that the list of high-risk/hazardous medication has been reviewed annually?
TIP: Make sure both your high-risk and look-alike/sound-alike medication lists reflect medications actually used in
your organization. Include questions about these lists in your mock tracer activities. Be sure staff know where to find
this information.
What additional training and competencies have been provided to nurses authorized to remove medication from designated
storage areas?
Is the pharmacy performing retrospective review on all medication orders received after hours?
What quality controls are in place to ensure that the correct medication is being retrieved? Is a pharmacist on call during off-hours
should questions arise—and available to come in if necessary? If so, do staff know how to contact this individual?
Has the organization defined who is authorized to have access to medication storage areas?
What is the frequency for checking medication storage areas? When was the last time medication storage areas were checked for
expired medications? How are the results of these inspections documented?
Who is responsible for checking medication storage areas? Who is the information reported to?
Are staff noting the revised expiration dates (as opposed to “date opened”) on multidose vials of sterile injectable medication?
TIP: Ensure that all medications are safely stored. Make rounds in clinical areas where medications are stored and
prepared. Evaluate if medications are being stored properly and have expiration dates noted. These data can be
incorporated into performance improvement activities.
28
Does the policy on addressing the control of medication between its receipt by an individual health care provider and its adminis-
tration reflect current practice in regard to safe storage, handling, security, disposition, and return to storage?
What evidence-based guidelines are followed for using multidose vials? Are vials of sterile, injectable medications being used in a
manner consistent with the manufacturer’s intended use? (For example, vials intended for single-patient use must not be used on
multiple patients; vials intended for single-dose use must not be used for multiple doses.)
Does the organization permit nonnursing and/or nonpharmacy personnel to transport medication? If so, what training have these
personnel had regarding their responsibilities when in possession of medication? How are these individuals identified as authorized
to perform this function?
How are pediatric medications identified and managed? In emergency situations, what resources are available to assist in dose
calculation for these specific medications?
Has the hospital defined, in writing, the circumstances for which weight-based dosing is required for pediatric populations?
TIP: Ensure that emergency medications and their associated supplies have been defined, based on populations
served, and are readily accessible to staff.
How quickly are emergency medication sources replenished after use? Who is responsible for this process? Is the same process
followed on weekends and holidays?
How does the hospital define a complete medication order?
What are staff expected to do when faced with incomplete written orders? Is there a process for monitoring orders for complete-
ness? How is a practitioner’s pattern of writing incomplete orders addressed?
Are titration and range orders written with complete information, including minimum/maximum dose(s), starting dose, incre-
mental increase(s)/decrease(s), intervals for changing dose(s), and/or patient assessment scale (such as the RASS scale), to ensure
clear, consistent implementation and administration of such orders?
TIP: Ensure that policies on complete medication orders are clear, are complete, and reflect current practice. Pay
close attention to range and titration orders, ensuring that clear parameters are defined to provide for safe adminis-
tration.
29
Have all appropriate disciplines been involved in the approval and regular review processes for protocols, standing orders, and
order sets? At what frequency are these types of orders reviewed for relevancy?
What nationally recognized and/or evidence-based guidelines (if any) are protocols and standing orders based on?
Are orders to implement protocols, standing orders, and order sets being entered into the medical record? Have copies of these
been made part of the permanent medical record?
Does the state’s nursing scope of practice permit nurse-initiated protocols? What is the role of the chief nurse executive in deter-
mining if nurse-initiated protocols are permitted by state law?
How is safe and proper disposal of hazardous medications monitored and evaluated?
TIP: Ensure that your policies and practices on disposal of hazardous medications are consistent with accepted
standards of practice, law, and regulation.
Is the policy regarding the reporting and management of adverse drug events consistent with Medicare Conditions of
Participation?
How are staff educated regarding adverse drug events? Can staff explain what the organization defines as an adverse drug event?
How is information related to adverse drug events incorporated into performance improvement activities?
TIP: Timely reporting and management of adverse drug events is imperative for maintaining patient safety.
Does the organization permit the use of sample medications? If so, are all locations where these medications are permitted known
to those responsible for the medication management program? Is prospective pharmacy review required or is the ordering, label-
ing, and dispensing of sample medications under the control of the licensed independent practitioner?
How are sample medications reflected in the medical record? Who is authorized to dispense sample medications based on law/
regulation?
Where are sample medications stored? Are they safe from tampering, theft, and diversion? Who has authorized access to these
medications? Where is the key or lock code located when that secured area is not open?
30
How are sample medications tracked? Does the state have specific recordkeeping requirements for tracking sample medications
when dispensed?
If a dispensed sample medication is recalled by its manufacturer, how would the patient who received the medication be identified
and notified of the recall?
If sample medications are permitted, how is the management of sample medications evaluated by the pharmacy?
TIP: Don’t minimize the importance of proper oversight of sample medications. They are included in the definition of
medication and are addressed in the overview of the “Medication Management” (MM) chapter in the CAMH.
What data are being collected regarding medication management processes, and how are these data incorporated into the organiza-
tion’s performance improvement activities?
TIP: A comprehensive evaluation of the organization’s medication management systems is an effective way to
identify strengths of and improvement opportunities for safe medication management practices.
How does the pharmacy oversee and evaluate the use of contrast agents in imaging areas? What role does pharmacy leadership play
in the organization’s infection prevention and control initiatives specific to the use and administration of contrast agents?
When bulk contrast is used, what quality monitoring of contrast administration is in place to ensure safe administration practices?
Does the hospital dispense oral contrast for self-administration by the patient? If so, how is this ordered and who is dispensing the
oral contrast to the patient?
Does the organization have an antibiotic stewardship program? If so, describe how its effectiveness is evaluated.
What role does the pharmacy have in managing anesthesia medications?
What quality control processes are in place to monitor the use of controlled substances by anesthesia providers?
Have there been any identified episodes of medication tampering, theft, or diversion? If so, what did the organization learn, and
what processes were changed as a result of the investigation to improve the security of medications?
31
Medical Staff (MS) Compliance Prompts
Have medical staff bylaws been updated to include all the requirements identified in Standard MS.01.01.01, EPs 12–37?
Is there a process to verify the identity of each new medical staff applicant by viewing a government-issued ID and comparing the
picture to the applicant? (Note that a copy of the photo does not meet the intent. It is neither required nor recommended that a
copy of the photo be made.)
What process is used to determine whether there is sufficient clinical information to make a decision to grant, limit, or deny a
privilege?
Has all required credentialing information been verified before reviewing and taking action on the application?
TIP: Create a manual or electronic checklist of all information requiring verification.
Have all licensed independent practitioners been reprivileged by their privilege expiration dates?
TIP: Create a manual or electronic tracking system that identifies the dates of license expiration and dates of
reprivileging to ensure that the status of the license is verified.
Has a period of focused professional practice evaluation (FPPE) been implemented for all new privileges? Is there a clearly defined
process for ongoing professional practice evaluation (OPPE)?
32
Have all application requirements for credentialing and privileging been met?
Was entity-specific data used for the FPPE for these practitioners?
How is OPPE managed for these practitioners?
TIP: Discuss how the organization monitors its environment to ensure that ethical practices are sustained.
Have the medical staff departments defined the types of data to be collected to make a privileging decision? Have these data been
approved by the organized medical staff?
Is there evidence that the data have been used to make the decision whether to maintain, limit, or revoke privileges for each privi-
leged practitioner at each review point?
Are temporary privileges used only for either important patient care needs or for new privileges?
TIP: If telemedicine or tele-interpretive services are used, evaluate compliance of the teleproviders with the medical
staff requirements.
33
National Patient Safety Goals (NPSG) Compliance Prompts
What are the organization’s two patient identifiers?
What options do staff have when a patient is unable to verbalize either of the two established identifiers?
What do staff do before initiating a blood transfusion?
To whom are staff supposed to report critical tests and results?
What do staff do if a person is unavailable to accept critical tests and results?
What is the acceptable time frame between the availability of critical tests and results, and reporting them?
Can staff articulate the key components of labeling a medication or solution label?
What is the anticoagulant management process? Is it current? Is it based on national evidence-based guidelines?
How are anticoagulation safety practices evaluated and improved upon? How is the effectiveness of those improvements measured?
How consistently is the medication reconciliation process implemented? Describe the effectiveness of the process.
Is the medication reconciliation process consistent throughout the organization? Is there a different process for non–24-hour
patient care areas?
TIP: Chart audits provide a great opportunity to assess implementation of medication reconciliation activities.
What measurable goals have been set for hand hygiene?
34
If hand hygiene goals were achieved, were new goals established? If hand hygiene goals were not achieved, was the plan updated or
revised?
When, how, and in what manner are staff informed about successfully meeting hand hygiene goals?
TIP: Train and use “secret shoppers” on all shifts to collect de-identified hand hygiene data. This may provide more
accurate information on actual compliance. Consider using the Targeted Solutions Tool™ for hand hygiene from the
Center for Transforming Healthcare, available on your Joint Commission Connect™ extranet site.
What is the process to prevent and manage multidrug-resistant organisms? Is it current? Is it based on national evidence-based
guidelines?
How is the organization’s process for preventing and managing multidrug-resistant organisms evaluated? What action is typically
taken to improve the process, and how is the effectiveness of those actions measured?
How, when, and in what manner are staff informed about the organization’s rates of multidrug-resistant organisms?
What is the central line protocol? Is it current? Is it reflective of national evidence-based guidelines?
What is the process to prevent and manage central line–associated blood stream infection (CLABSI)? Is the process up to date?
How are these practices evaluated, and what actions are taken to improve practices and measure the effectiveness of those actions?
How, when, and in what manner are staff informed about the organization’s rates of CLABSI?
What is the surgical site protocol? Is it current? Is it reflective of national evidence-based guidelines?
What is the process to prevent and manage surgical site infections? Is it current? How do you evaluate these practices, take action
to improve practices, and measure the effectiveness of those actions?
How, when, and in what manner are staff informed about the rates of surgical site infections?
What is the urinary catheter protocol? Is it current? Is it reflective of national evidence-based guidelines?
35
What is the process to prevent and manage catheter-associated urinary tract infection (CAUTI)? Is it current? How are these
practices evaluated, and how is action taken to improve and measure the effectiveness of those practices?
When, how, and in what manner are staff informed about the rates of CAUTI?
What is the protocol to identify patients at risk for suicide?
What screening tool for assessing risk of suicide is used? Is the screening tool based on current evidence and leading practice?
TIP: Consider the unique screening and assessment of suicide risks in multicultural and special populations.
What will staff do when a patient is identified as at risk for suicide?
What is the policy on contraband for patients identified as at risk for suicide?
When and how are staff educated about suicide risk?
Can staff describe the Universal Protocol?
What is the preprocedure verification process?
How would staff describe the preprocedure site marking?
What is an alternative process for site marking if a patient refuses or it is impossible to mark the site?
What are the elements of a time-out?
What do staff do if a preprocedural time-out is not performed correctly?
36
Nursing (NR) Compliance Prompts
Does the nurse executive direct the delivery of nursing care, treatment, and services?
Does the nurse executive function at the senior leadership level? Does the nurse executive have an active role along with the
hospital’s governing body, senior leadership, medical staff, management, and other clinical leaders in the hospital’s decision-
making structure and process?
TIP: Review the nurse executive’s role and identify examples of how the role is being performed according to the job
description and standards requirements.
Does the nurse executive have a written contract, agreement, job description, position description, or other document?
What is the educational background of the nurse executive? Is the nurse executive qualified to direct the nursing services for the
hospital?
Does the nurse executive direct the hospital’s services and coordinate hospitalwide plans, policies, and programs to provide nursing
care, treatment, and services?
TIP: Identify the organizational structure that is used for policy oversight by the nurse executive. Review the process
of policy/procedure development, approval, education, and implementation.
Is there a program to measure, analyze, and improve nursing services?
Are the needs of all patients considered when developing policies and procedures?
37
What are the standards for nursing practice and patient care, treatment, and services in the hospital?
Do nursing policies and procedures support nursing care? Has the nurse executive approved them? Are staff educated regarding
these policies and procedures?
Are there nurse staffing plans?
Are there standards to measure, assess, and improve patient outcomes?
Is the nurse executive responsible for nursing services 24 hours a day, 7 days a week?
38
Provision of Care, Treatment, and Services (PC) Compliance Prompts
Has the scope of screenings, assessments, and reassessments been identified? Are they completed within the time frames required?
TIP: Use chart audits to evaluate the following:

n Complete and timely initial assessments and reassessments
n Timeliness of history and physicals (H&Ps)
n Complete pain assessments and reassessments
n Timeliness of plan-of-care updates from the interdisciplinary care team
n Learning needs assessment completed and addressed in the plan of care
n Consistent implementation of the discharge planning process
n Compliance with the restraint and seclusion policy
Are H&Ps and H&P updates completed within the time frames required?
What information is included in the H&P and H&P updates?
TIP: Conduct chart audits to determine compliance with screenings, assessments, reassessments, history and phys-
ical (H&P), and H&P updates. Do all staff know the required time frames for the screenings and assessments?
Are pain and fall assessments completed? What processes are implemented based on the results of those assessments?
Are there criteria to identify patients (elderly, pediatric, or other) who may be victims of abuse or neglect, physical assault, sexual
assault, or sexual molestation?
Is the plan of care individualized and based on a patient’s needs?
Have staff been educated in and can they address the processes used to plan patient care?
TIP: Review plans of care to ensure that they are collaborative, are interdisciplinary, and have goals based on
patient needs. How is education provided to the patient and the patient’s family?
Is it possible to evaluate a patient’s progress based on the goals established? Are there time frames for when the goals need to be
completed?
39
Have clinical and nonclinical staff been trained to provide care for patients awaiting care for emotional illness or the effects of
alcoholism or substance abuse? Is there a location for the safe boarding of these patients?
Are assessments/reassessments conducted for boarded patients? Do these patients receive services and care based on identified
needs?
How is care coordinated between disciplines?
How is a learning needs assessment performed?
How do staff provide patient education? Where is this documented?
Do all disciplines know about the education provided?
How is the patient’s understanding of the education evaluated?
If a verbal telephone order is implemented, is there a read-back and record? Are the orders authenticated within defined time
frames?
Is there a licensed independent practitioner’s order for care, treatment, and services?
TIP: Review all care that requires a licensed independent practitioner’s order. Review all diagnostic tests, labs, and
so forth for an order.
Has the read-back process been evaluated and updated?
How is handoff communication conducted between departments, between staff, and with other facilities?
Have emergency procedures been evaluated and updated?
40
Are crash carts checked per policy? Are there expired medications or supplies on the cart?
Have all staff been educated about the resuscitation equipment?
Do staff know how to respond to a change in the patient’s condition?
TIP: Run mock emergencies. Does everyone understand his or her role? Is all the necessary equipment available?
How do staff communicate with patients?
What language services are available in your organization?
Do staff know how to access the services and document their use?
TIP: Review the provision of language services and translation services in your organization.
Are refrigerators on the units monitored and operating within the correct temperature range? If not, do staff know the process to
have the situation corrected?
How is the food stored? Is there expired food or related supplies?
TIP: Be sure to examine the refrigerators that contain food on the units and in the kitchen.
What documentation is required when a patient has an operative or high-risk procedure?
What do staff review in the chart before a high-risk procedure? What process do they follow if documentation, such as H&P, is
missing?
TIP: Review the charts of patients who have had a high-risk or operative procedure for the necessary documents.
41
Who is administrating moderate or deep sedation and anesthesia? Are staff qualified to manage the patient at any level of
anesthesia?
Are there sufficient, qualified staff to evaluate, monitor, and recover the patient during the sedation or anesthesia procedure, as well
as assist with the procedure?
Are the necessary equipment and supplies for administering sedation or anesthesia readily available?
Who is conducting the presedation and preanesthesia assessment?
Who is performing the procedure? Is a time-out conducted and the results documented?
Who conducted the postanesthesia evaluation?
How are tissue specimens handled?
What is the process to follow if a patient needs a blood product?
What is the process to follow to address potentially infectious blood?
TIP: Establish if the organization is using Joint Commission accreditation for deemed status purposes. If not using
for deemed status purposes, follow Standards PC.03.02.01 through PC.03.03.31. If using accreditation for deemed
status purposes, follow Standards PC.03.05.01 through PC.03.05.19.
Do your policies regarding restraint and seclusion include alternatives to restraint and seclusion?
Has the restraint process been consistently implemented?
Have all staff who participated in a restraint and seclusion episode been trained in the process?
42
Are there orders for restraint?
Are plans of care modified when a patient is placed in restraints?
How often is monitoring conducted during restraint or seclusion? Is this monitoring documented?
Is the assessment of patient restraint or seclusion documented?
How is the use of restraint and seclusion measured and assessed?
What type of data is being collected for restraint and seclusion use?
Are there any opportunities for improvement in the restraint and seclusion process?
Has the discharge planning and transfer process been consistently implemented?
Is the discharge planning process meeting the needs of patients? How is this documented or measured?
TIP: Assess the discharge planning and transfer process. There may be a need to involve a team to determine the
effectiveness of this process.
Has the patient and/or family received written discharge instructions?
How is patient information conveyed to the next provider of services?
43
Performance Improvement (PI) Compliance Prompts
Have data been collected for the prescribed elements as well as for the performance improvement (PI) priorities identified by
leadership?
TIP: Ensure that an action plan is developed and implemented when goals are not obtained and sustained.
Have PI data been collected at the intervals defined by leadership?
Have PI data been aggregated and analyzed at the defined intervals and compared over time?
How are PI data used to identify opportunities and determine Plans of Action?
TIP: Design a consistent agenda to be used by the performance improvement or safety committee that regularly
evaluates all of the issues noted.
When undesirable patterns or trends were identified in the past, was inadequate staffing considered as a possible contributing
cause?
Is the PI program achieving the organization’s goals based on the organization’s mission?
Is the PI program agile enough to address relevant issues?
How are radiation reporting requirements being presented to leadership, and at what intervals? Is the organization collecting data
on patient thermal injuries that occur during magnetic resonance imaging (MRI) exams as well as injuries resulting from the
presence of ferromagnetic objects in the MRI scanner room?
Does the hospital review and analyze incidents during which a computed tomography (CT) exam’s radiation dose index exceeds
expected ranges?
44
Record of Care, Treatment, and Services (RC) Compliance Prompts
What is the policy for conducting ongoing review of clinical records?
TIP: Use chart audits to evaluate the following:

n At least quarterly documentation of nutritional services
n Complete documentation for medical, nursing, rehabilitation, and social services
n If verbal orders are being managed per policy, law, and regulation
n For paper documentation: Entries in the medical record have the date, time, and signature of the author.
n Accurate and complete pre- and postprocedure documentation
n Review the postprocedure note to ensure all of the required elements are documented.
Is the documentation process designed in a manner that supports staff success?
Is the documentation process streamlined to support compliance and accuracy? Is there unnecessary documentation redundancy?
TIP: Ask staff for ideas to improve documentation. Offer incentives for successful solutions.
Does the medical record contain a summary list for patients continuing ambulatory services?
TIP: Review documentation in ambulatory settings to ensure that the summary list has been completed by the third
visit.
45
Rights and Responsibilities of the Individual (RI) Compliance Prompts
Does the hospital have policies regarding patient rights?
How does the organization ensure that the rights of the patient are respected?
TIP: Review your organization’s patient rights policies and how this information is made available to patients and
their families.
How are privacy, dignity, respect, and effective communication ensured?
How is respect for cultural and personal values and beliefs guaranteed?
Does the patient know how to access and amend his or her medical record?
What are the policies regarding visitors?
Is information provided in a manner that the patient understands? What types of language or interpreting services are provided?
Do patients have the right to participate in decisions about their care? If so, how is this demonstrated? Do patients realize that they
can refuse care?
How does the hospital involve a surrogate decision-maker or guardian for the patient who needs/desires one?
How are patients informed about unanticipated outcomes of care?
How is informed consent obtained? What does the informed consent process discuss?
46
Is there a designated place for documentation in the medical record for identifying what language the patient wants to use to
communicate with his or her provider (to determine whether an interpreter is required at the patient level or whether language
access services need to be modified at the organization level)? Whose responsibility is it to obtain this information, and when does
it need to be placed in the patient’s medical record?
Do staff and licensed independent practitioners receive education and training on the organization’s policy on how to obtain
informed consent?
Do staff and licensed independent practitioners receive education and training on the complaint and grievance policy? Do staff or
licensed independent practitioners know how to or when to engage leadership?
Which services, treatments, and/or specific care need an informed consent?
TIP: Review the organization’s informed consent policy. Ensure that all consent processes have been standardized
throughout the organization. Develop a periodic audit process to demonstrate periodic compliance.
Is there any filming or recording occurring during patient care? If so, are patients routinely given the opportunity to provide or
deny consent?
Does the hospital conduct research, investigation, or clinical trials? Are patients informed when they are included in the process
and provided the opportunity to give their consent to participate?
What does the policy state in regard to advance directives? Are there resources available to aid a patient who wants to develop an
advance directive? How are staff informed about a patient’s advance directive?
Do patients understand that they have a right to be safe in the hospital, to have any complaint addressed, and to receive advocacy
services? If so, how is this explained to them?
Is the patient free from neglect; exploitation; and verbal, mental, physical, and sexual abuse?
What is the complaint process in the hospital?
47
Do the patient and the patient’s family know about the complaint process?
How are complaints resolved? What is the time frame for resolution?
TIP: Monitor receipt of all grievances received by the organization and the organization’s response times.
Does the hospital maintain a list of current advocacy services?
Does the patient know about his or her own responsibilities related to care, treatment, and services?
48
Transplant Safety (TS) Compliance Prompts
Is there a written agreement with at least one tissue bank and one eye bank?
Is there a relationship between the hospital’s organ procurement organization and the tissue and eye banks?
Do the policies and procedures address family and patient involvement in organ donation?
Is there documentation that supports the services and any processes that have been followed regarding organ donation?
Does the hospital comply with organ donation responsibilities and records that need to be maintained?
TIP: Organ or tissue transplant services need to have policies and procedures supporting the processes for donation
and documentation. Staff need to be educated and aware of the processes to follow.
Is there is a standardized written process and procedure for acquisition, receipt, storage, and issuance of tissue? Does the process
and procedure stipulate confirmation that tissue suppliers are registered with the US Food and Drug Administration as a tissue
establishment?
TIP: Review the organ/tissue log for all required data items.
Are there one or more individuals assigned the responsibility of overseeing the acquisition, receipt, storage, and issuance of tissue
throughout the hospital?
Are tissue suppliers’ or tissue manufacturers’ written directions for transporting, handling, storing, and using tissues followed?
Does the organization verify at the time of receipt the integrity of any packaged tissue and that transport temperature range was
controlled and acceptable for tissues requiring a controlled environment? Is this verification documented?
49
Are daily records maintained demonstrating that tissues requiring a controlled environment were stored at the required
temperatures?
Are the temperatures of refrigerators, freezers, nitrogen tanks, and other storage equipment used to store tissue continuously moni-
tored? Do these units have functional alarms? Is there an emergency backup plan in place?
Does the hospital comply with state and/or federal regulations when it acts as a tissue supplier?
Do records exist allowing any tissue to be traced from the donor or tissue supplier to the recipient or other final disposition,
including discard, and from the recipient or other final disposition back to the donor or tissue supplier?
Are materials and related instructions used to prepare or process tissue documented? Are the dates, times, and staff involved when
tissue is accepted, prepared, and issued documented as well?
Do patients’ medical records contain the tissue type and its unique identifier?
Are tissue records on storage and temperature, as well as outdated procedures manuals and publications, retained for a minimum
of 10 years or longer if required by state and/or federal regulations?
Are tissue records retained for a minimum of 10 years beyond the date of distribution, transplantation, disposition, or expiration
of tissue, whichever is longer?
Are adverse events related to tissue use or donor infection investigated, and are written procedures followed? Is the tissue supplier
immediately notified of any adverse events?
Are tissue recipients identified and notified that they are at risk of infection when donors are found to have human immunodefi-
ciency virus, human T-lymphotropic virus, viral hepatitis, or other infectious agents known to be transmitted through tissue?
50
Waived Testing (WT) Compliance Prompts
Is a current valid CLIA ’88 certificate available for each area performing waived testing?
Have written procedures been established for each of the areas identified in Standard WT.01.01.01, EP 2?
Are policies and procedures related to waived testing being approved by either the individual named on the CLIA certificate or a
designee?
Is documentation available that validates the orientation of the individuals performing waived testing?
Is competency testing for waived testing being done using at least two methods, and are these being done annually?
How often is waived testing quality control being performed for the non–instrument-based waived testing?
If available, are two levels of control being used for instrument-based waived testing?
Are qualitative testing results accompanied with a reference value?
51
52

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2016

Joint Commission Resources Mission

The Joint Commission Mission

© 2016 The Joint Commission

Printed in the USA 5 4 3 2 1

Part 1: Prompts to Assess Your Standards Compliance. . . . . . . . . . . . . . . . . . . . 1

Part 2: Compliance Assessment Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Medication Management (MM). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Part 3: Survey Logistics: Tracer Methodology

Prompts to Assess Your

Accreditation Participation Requirements (APR) Compliance Prompts

TIP: Ensure accurate and timely submission of information by planning ahead.

Environment of Care (EC) Compliance Prompts

Is the smoking policy up to date and enforced as written?

Ambulatory Occupancy (once per shift, per quarter)

Does the inventory identify all high-risk medical equipment?

Does the inventory identify all high-risk utility operating components?

Are the following systems connected to emergency power?

Emergency Management (EM) Compliance Prompts

Human Resources (HR) Compliance Prompts

Have all new hires completed orientation?

Have competencies been defined for all staff?

Are initial and subsequent competencies up to date for all staff?

Infection Prevention and Control (IC) Compliance Prompts

Are surveillance activities documented?

Has a measurable goal been established for hand hygiene compliance?

Are isolation policies and procedures up to date and being followed?

Are laryngoscope blades packaged following high-level disinfection?

Are vaccination rates being measured, and is the methodology documented?

Information Management (IM) Compliance Prompts

Has the security of protected information been maintained?

Leadership (LD) Compliance Prompts

n Nurse leadership participation in decision making at the executive level

n Performance improvement activities

o Staffing impact on adverse or sentinel events

n Evaluating and maintaining a culture of safety and quality

n Regular reporting of safety and quality issues to the governing body

n Input from the populations served

Are all policies up to date, and do they reflect current practice?

Are staff consistent in following policies? How is this evaluated?

Is the list of clinical contracts current and complete?

Is the contract approval process clearly defined?

License/Registration Renewal Date

What strengths do your data reveal?

Life Safety (LS) Compliance Prompts

Are all egress corridors clear of obstructions, including projections?

Medication Management (MM) Compliance Prompts

How does the hospital define a complete medication order?

What role does the pharmacy have in managing anesthesia medications?

Medical Staff (MS) Compliance Prompts

TIP: Create a manual or electronic checklist of all information requiring verification.

How is OPPE managed for these practitioners?

National Patient Safety Goals (NPSG) Compliance Prompts

What are the organization’s two patient identifiers?

What do staff do before initiating a blood transfusion?

To whom are staff supposed to report critical tests and results?

What do staff do if a person is unavailable to accept critical tests and results?

What measurable goals have been set for hand hygiene?

What is the protocol to identify patients at risk for suicide?

What will staff do when a patient is identified as at risk for suicide?

When and how are staff educated about suicide risk?

Can staff describe the Universal Protocol?

What is the preprocedure verification process?

How would staff describe the preprocedure site marking?