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.
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Patient Safety Identification and Prevention of Harm
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
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
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
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
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
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
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
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
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
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
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
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