ChecklistGuro logo ChecklistGuro Solutions Industries Company Pricing

Healthcare Joint Commission Compliance Checklist

Ensure Joint Commission readiness with our comprehensive checklist! Streamline processes, minimize gaps, and confidently demonstrate compliance for accreditation. Download now and elevate your healthcare standards.

This Template was installed 2 times.

Patient Safety Identification and Prevention of Harm

1 of 11

Covers patient identification, medication safety, fall prevention, surgical safety, and pressure ulcer prevention.

Patient Identification Verification Method

Fall Risk Score

Allergies Documented?

Last Fall Risk Assessment Date

Nurse Signature - Patient ID Verification

Detailed Description of Patient Education Provided (e.g., Fall Prevention)

Medication Reconciliation Complete?

Relevant Documentation (e.g., Fall Prevention Plan)

Emergency Management

2 of 11

Addresses emergency preparedness, disaster planning, and security protocols.

Last Disaster Drill Participants

Last Disaster Drill Date

Drill Start Time

Drill Debriefing Notes

Disaster Plan Document

Emergency Contact Person

Emergency Assembly Point

Emergency Communication Methods

Date of Next Disaster Drill

Environment of Care

3 of 11

Focuses on fire safety, hazardous materials management, and facility safety.

Fire Alarm System Test Frequency (Months)

Last Fire Safety Inspection Date

Hazardous Materials Present?

Location of Fire Extinguishers

Description of Emergency Power Generator Maintenance Log

Ventilation System Functionality

Fire Safety Plan Document

Time of Last Sprinkler System Inspection

Leadership

4 of 11

Covers governance, ethics, and compliance programs.

Number of Ethics Committee Meetings Held Annually

Last Ethics Committee Review Date

Ethics Hotline Availability (24/7, Business Hours, Limited Hours)

Summary of Key Leadership Decisions Regarding Compliance

Annual Compliance Training Documentation

Leadership Commitment to Patient-Centered Care (Scale 1-5)

CEO Commitment to Compliance Program

Human Resources

5 of 11

Focuses on credentialing, training, and performance evaluation.

Number of Active Employees

Last Credentialing Review Date

Background Check Policy Adherence

Required Employee Training Modules Completed

Next Employee Performance Review Due Date

Summary of Recent HR Policy Updates

Employee Training Records (Sample)

Medical Staff Services

6 of 11

Addresses physician credentialing, privileging, and performance improvement.

Physician Signature (Credentialing Verification)

Credentialing Verification Expiration Date

Number of Physician Privileges Granted

Physician Supervision Level

Clinical Areas of Competency

Last CME Completion Date

Summary of Peer Review Performance

Clinical Performance Improvement

7 of 11

Covers data analysis, process improvement, and outcome measurement.

Number of Process Improvement Projects Initiated

Number of Process Improvement Projects Completed

Summary of Key Performance Indicators (KPIs) Tracked

Date of Last Performance Review Meeting

Data Sources Used for Performance Measurement

Description of Corrective Actions Implemented based on Performance Data

Overall Assessment of Clinical Performance Improvement Efforts

Supporting Documentation (e.g., Performance Reports, Action Plans)

Information Management

8 of 11

Addresses data security, privacy, and electronic health record management.

Data Encryption Method

Detailed Description of Data Security Policies

Frequency of Data Backup (in days)

Last Security Risk Assessment Date

Access Control Method

Supporting Documentation (e.g., Security Audit Reports)

Data Types Protected by HIPAA

Medication Management

9 of 11

Focuses on medication ordering, dispensing, administration, and reconciliation.

Medication Reconciliation Completed?

Last Medication Reconciliation Date

Number of Medication Discrepancies Identified

Description of Medication Discrepancies (if any)

High-Alert Medications Verified?

Routes of Administration Verified?

Time of Medication Administration

Pharmacist Signature

Infection Prevention and Control

10 of 11

Covers surveillance, prevention, and control of healthcare-associated infections.

Last Environmental Cleaning Date

Hand Hygiene Compliance Observed (Last Audit)

Number of HAIs (Healthcare-Associated Infections) Reported This Month

Isolation Precautions Currently in Use

Description of any recent infection control breaches or incidents

Supporting Documentation (e.g., audit reports, cleaning logs)

Communication and Teamwork

11 of 11

Addresses internal and external communication protocols and team collaboration.

Team Handoff Communication Method

Number of Inter-Departmental Meetings Held Monthly

Last Team Conflict Resolution Training Date

Summary of Recent Team Communication Challenges

Communication Tools Utilized by the Team

Team's Perceived Level of Psychological Safety

Contact Person for Communication Issues

We can do it Together

Need help with Checklists?

Have a question? We're here to help. Please submit your inquiry, and we'll respond promptly.

Email Address
How can we help?