Hospital Compliance Assessment Checklist

Hospital Compliance Assessment Checklist
2023 Ed.
2023 © Joint Commission Resources
Kathy DeMase
ISBN-13: 978-1-63585-291-2
eISBN-13: 978-1-63585-292-9
Patient Safety and Quality Improvement , Healthcare Administration


A straightforward, hands-on resource, the 2023 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.

A color-coded compliance matrix allows you to capture your compliance level with each EP and the evidence you used to assess standards compliance. 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'll use the Plan of Action Follow-Up worksheets to develop and prioritize the next steps to bring noncompliant EPs back into compliance. The Required Documentation worksheets help you to track how your hospital meets those EPs with Required Written Documentation.

Hospitals need resources when preparing for a Joint Commission survey to ensure they are compliant and ready for the survey. The 2023 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 2023 version includes all standards updates that occurred over the past year, including changes to the Accreditation Participation Requirements (APRs), new environment of care requirements for water management programs, new information management requirements related to the electronic exchange of patient health information, new life safety requirements for mitigating fire and smoke hazards and events.

Key Topics

  • • Standards assessment and compliance
  • • Application of the SAFER® Matrix
  • • Tracer methodology
  • • Compliance improvement

Key Features

  • • Questions to assess each element of performance as of January 1, 2023
  • • Downloadable, adaptable tools and templates for standards assessment and compliance
  • • Writable PDFs

Table of Contents

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