Standard Measureable Element

APR Annual update to the E-

APP
The process is evaluated to
Standard see if it meets the needs of
ACC.4.4. the clinicians and improves
M.E.4 the quality and safety of
outpatient clinical visits.
Standard AOP Lab safety program to
5.3 hospital safety structure
atleast annually

AOP 5.10.1 Annual report of the data

from reference/contracts
labs is provided to hospital
leadership to facilitate
renewal
AOP 6 Radiation safety program
reports to the hospital safety
structure atleast annually

AOP 6.8 Annual report of the QC

data from
reference/contracts labs is
provided to hospital
leadership to facilitate
renewal of contracts
Standard There is at least one
MMU.1. documented review of the
M.E.4 medication management
system, addressing items a)
through h) of the intent as
appropriate, within the
previous 12 months.
MMU 2.1 When medications are newly
added to the list, there is a
process or mechanism to
collect, aggregate and
monitor data on how the
drug is used and any
unanticipated adverse
events.

QPS 5 one determination of impact

of hospitalwide priority
improvement on Cost and
Efficiency

QPS 11 Risk reduction exercise

HVA/FMEA atleast annually

PCI 6.1 Infection control risk

assessment annually

PCI 8.2 Annual testing if Emergecny

preparedness program to
respond to the presentation
of global communicable
diseases
Annual review of infection
control program annually
GLD 1 ME 1.4 Annual evaluation of the
governinig entity and
documented

GLD 1.1 Annual evaluation of CEO

GLD 1.2 Annual review and approval

of Quality program

Standard Measures selected by the

GLD.11.1 department/service leaders
that are applicable to
evaluating the performance
of physicians, nurses, and
other professional staff
participating in the clinical
care processes, are used in
the staff’s performance
evaluation.
Standard On an annual basis,
GLD.11.2 department/service leaders
M.E.1 collectively determine at
least five hospital wide
priority areas on which to
focus the use of clinical
practice guidelines.

Standard The quality of services by

GLD.6.2 independent practitioners
M.E.5 outside the hospital is
monitored as a component
of the hospital’s quality
improvement program. (Also
see AOP.5.10.1, ME 1)

Standard Hospital leadership uses

GLD.13.1 measures to evaluate and
M.E.4 monitor the safety culture
within the hospital and
implement improvements
identified from
measurement and
evaluation.

FMS 2 Facility management

propgram is reviewed
annually

FMS 3 Annual facility management

report to the governing
entity
 FMS 6 Annual testing of disaster
preparedness program

FMS 9.3 DIALYSIS WATER TESTING

FOR CHEMICAL
CONTAMINATION ATLEAST
ANNUALLY OTHER
TESTINGS ARE LESS
FREQUENT

FMS 11 Staff education on Facility

Management and safety
annually

Standard The data and information

SQE.11 from the monitoring are
M.E.4 reviewed at least every 12
months by the individual’s
department or service head,
senior medical manager, or
medical staff body, and the
results, conclusions, and any
actions taken are
documented in the medical
staff member’s credentials
file and other relevant files.
(Also see GLD.11.1, ME 1)
MOI 14 ATLEAST ONE DOWNTIME
TESTING ANNUALLY

HRP Review of research program

annually