Hospital Compliance Assessment Checklist

Hospital Compliance Assessment Checklist
2021st Ed.
2021 © Joint Commission Resources
Kathy DeMase
ISBN-10: 1-63585-187-4 / ISBN-13: 978-1-63585-187-8
eISBN-10: 1-63585-188-2 / eISBN-13: 978-1-63585-188-5
ISSN: 2332-5232
Patient Safety and Quality Improvement , Healthcare Administration


A straightforward, hands-on resource, the 2021 Hospital Compliance Assessment Workbook engages staff and leadership in accreditation activities with questions, templates, and tools to identify areas of non-compliance and plan to address them. The workbook includes ALL hospital standards and elements of performance (EPs), including those used for deemed status purposes and primary care medical home certification in the hospital setting.

Clear questions correlated directly to each EP help your hospital assess whether you are meeting standards—a "No" or "ITL" ("Immediate Threat to Life") answer should prompt action from your accreditation team. Downloadable, adaptable tools and templates help you identify and prioritize needed improvements and maintain continuous survey readiness. For example, you will use the Plan of Action Follow-Up worksheets to develop and prioritize the next steps to bring non-compliant EPs back into compliance. The Required Documentation worksheets help you to track how your hospital meets those EPs with Required Written Documentation icons in the E-dition®/Comprehensive Accreditation Manual for Hospitals (CAMH).

Hospitals need resources when preparing for a Joint Commission survey to ensure they are compliant and ready for survey. The 2021 Hospital Compliance Assessment Workbook allows you to self-assess compliance with all hospital requirements and plan and implement corrective actions before surveyors arrive onsite, focusing compliance efforts and simplifying where possible. A PDF site license allows you to download a copy to a central, secure location so your accreditation prep team can capture and share these learnings and data across the organization.

The 2021 version includes all standards updates that occurred over the past year, including the changes to National Patient Safety Goals covering blood and blood components and healthcare-associated infections, new maternal health requirements, revised medication titration order elements, the elements of an assessment (in lieu of a comprehensive medical history and physical examination) for patients receiving specific outpatient surgical or procedural services, and enhanced discharge planning requirements for hospitals that use Joint Commission accreditation for deemed status purposes.

Key Topics:

  • • Assessment of standards compliance
  • • Application of the new SAFERTM Matrix
  • • Tracer methodology
  • • Compliance improvement

Key Features

  • • Questions to assess each element of performance in the E-dition®/Comprehensive Accreditation Manual for Hospitals as of January 1, 2021
  • • Downloadable, adaptable tools and templates for standards compliance and survey readiness
  • • Writable PDFs (Site License only)

Standards: All hospital standards effective January 1, 2021

Setting: Organizations accredited under the Hospital Accreditation Program, including general, acute psychiatric, pediatric, medical/surgical specialty, long term acute care, and rehabilitation hospitals

Key Audience:

  • • Accreditation managers
  • • Quality improvement managers
  • • Physician and nurse leaders
  • • Chapter leaders and department heads
  • • Department heads

Table of Contents

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