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2018 Hospital Compliance Assessment Checklist
All levels

2018 Hospital Compliance Assessment Checklist

Give your hospital staff the tools to assess compliance with the revised 2018 standards quickly and efficiently!

Release Date: January 30, 2018. 812 pages.

  • site license allows this ebook to be shared among unlimited users but only within one facility or site, either by posting to a secure intranet site or by providing other means of secure access. 
  • system license allows this ebook to be shared among unlimited users within all facilities or sites within a health care system, either by posting to a secure intranet site or by providing other means of secure access. Please contact JCR Customer Service (877.223.6866 option 1) for pricing of a system license.

$179.00 - $259.00
Product Description

Product Description

A straightforward, hands-on resource, the 2018 Hospital Compliance Assessment Checklist engages staff and leadership in accreditation activities with questions, checklists, and tracer tools. This self-assessment workbook is designed to help organizations maintain continuous standards compliance and survey readiness. You have the option of reviewing high-risk or highly challenging areas in a given compliance area, or taking a more detailed look at individual elements of performance (EPs). The convenient compliance checklist includes ALL hospital standards and EPs, including those used for deemed status purposes and primary care medical home certification.
Buy one for each member of your accreditation team, or a site license for all to share!
Key Topics
  • Assessment of standards compliance
  • Application of the SAFER MatrixTM
  • Evaluation of policies and procedures
  • Tracer methodology
  • Survey logistics
Key Features
  • High-level compliance prompts to help stimulate staff discussion and cultivate compliance strategies
  • Checklist with questions to assess each element of performance in the Comprehensive Accreditation Manual for Hospitals as of January 1, 2017
  • Tracer questions and worksheets to help with mock tracers and promote survey readiness
  • Writable PDFs (e-book only)
  • Available site license to allow accreditation prep team to share learnings and data
Standards: All hospital standards effective January 1, 2018
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

Joint Commission Resources, Inc. (JCR), a wholly controlled, not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission.

JCR is an expert resource for health care organizations, providing advisory services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides advisory services independently from The Joint Commission and in a fully confidential manner.

Table of Contents

Table of Contents


Part 1: Prompts to Assess Your Standards Compliance
Accreditation Participation Requirements (APR) Compliance Prompts
Environment of Care (EC) Compliance Prompts
Emergency Management (EM) Compliance Prompts
Human Resources (HR) Compliance Prompts
Infection Prevention and Control (IC) Compliance Prompts 
Information Management (IM) Compliance Prompts
Leadership (LD) Compliance Prompts
Life Safety (LS) Compliance Prompts
Medication Management (MM) Compliance Prompts
Medical Staff (MS) Compliance Prompts 
National Patient Safety Goals® (NPSG®) Compliance Prompts 
Nursing (NR) Compliance Prompts 
Provision of Care, Treatment, and Services (PC) Compliance Prompts
Performance Improvement (PI) Compliance Prompts
Record of Care, Treatment, and Services (RC) Compliance Prompts
Rights and Responsibilities of the Individual (RI) Compliance Prompts 
Transplant Safety (TS) Compliance Prompts 
Waived Testing (WT) Compliance Prompts 

Part 2: Compliance Assessment Checklist

Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC) 
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM)
Medical Staff (MS)
National Patient Safety Goals® (NPSG®)
Nursing (NR) 
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS) 
Waived Testing (WT)

Part 3: Survey Logistics: Tracer Methodology and Planning Worksheets

Overview of Tracer Methodology
Conducting Mock Tracers 
Worksheets for Planning a Mock Tracer
Worksheet 3-1: Mock Tracer Worksheet 
Worksheet 3-2: Planning a System Tracer—Medication Management 
Worksheet 3-3: Planning a System Tracer—Infection Control
Worksheet 3-4: Planning a System Tracer—Data Management 
Worksheets for Conducting Program-Specific Tracers
Worksheet 3-5: Program-Specific Tracer—Suicide Prevention 
Worksheet 3-6: Program-Specific Tracer—Laboratory Integration
Worksheet 3-7: Program-Specific Tracer—Patient Flow
Worksheets for Tracing the Environment of Care
Worksheet 3-8: Environment of Care—Safety
Worksheet 3-9: Environment of Care—Security
Worksheet 3-10: Environment of Care—Hazardous Materials
Worksheet 3-11: Environment of Care—Fire
Worksheet 3-12: Environment of Care—Medical/Laboratory Equipment
Worksheet 3-13: Environment of Care—Utilities
Worksheet 3-14: Environment of Care—Construction and Other EC Considerations
Worksheets to Facilitate Hospital Logistics Planning
Worksheet 3-15: Competence Assessment Process
Worksheet 3-16: Medical Staff Credentialing and Privileging
Worksheet 3-17: Emergency Management 
Worksheet 3-18: Facility Orientation—Life Safety Code Surveyor
Worksheet 3-19: Life Safety Code Building Assessment
Worksheet 3-20: Leadership 
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