Hospital Compliance Assessment Checklist

Hospital Compliance Assessment Checklist
2018 © Joint Commission Resources
Jennifer K. Ahearn
ISBN-10: 1-63585-027-4 / ISBN-13: 978-1-63585-027-7
ISSN: 2332-5232
Patient Safety and Quality Improvement , Healthcare Administration


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.

Key Topics:

  • • Assessment of standards compliance
  • • Application of the new 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 scenarios 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

Table of Contents

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