Tracer Big Book

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ASSESS
COMMUNICATE
TRACER
QUESTIONS
EDUCATE
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CONTENTS
TARGET REVIEW ASSESS COMMUNICATE EDUCATE REPORT
Accreditation Programs/Settings
OME
AHC
BHC
CAH
NCC
OBS
HAP
LAB
INTRODUCTION...................................................................................................................................... 1
Tracer Questions Spreadsheet
MOCK TRACER FORM.......................................................................................................................... 4

TRACERS................................................................................................................................................... 7
MOCK TRACERS................................................................................................................................... 10
SECTION 1: PERFORMANCE IMPROVEMENT

1.1: Performance Improvement Data.................................................. .... .... .... ... .... .... .... ........ 17
1.2: Implementing Performance Initiatives......................................... .... .... .... ... .... .... .... ........ 19
1.3: Performance Improvement Management.................................... .... .... .... ... .... .... .... ........ 21
SECTION 2: LEADERSHIP
2.1: Leadership in Performance Improvement................................... .... .... .... ... .... .... .... ........ 25
2.2: Safety Culture............................................................................. .... .... .... ... .... .... .... ........ 26
2.3: Patient Flow...................................................................................................... ................................... 27
2.4: Contracted Services................................................................... .... .... .... ... .... .... .... ........ 28
SECTION 3: STAFFING AND MEDICAL STAFF

3.1: Staff Orientation, Training, and Education.................................... .... .... .... ... .... .... .... ........ 31
3.2: Credentialing and Privileging...................................................... .... .... .... ... .... .... .... ........ 32
3.3: Competency Assessment........................................................... .... .... .... ... .... .... .... ........ 34
SECTION 4: CARE OF THE PATIENT

4.1: Admission, Discharge, and Transitions of Care.......................... .... .... .... .......... .... .... ........ 39
4.2: Assessment and Plan of Care..................................................... .... .... .... .......... .... .... ........ 42
4.3: Emergency Department Processes........................................................... .... ................................... 45
4.4: Suicide Risk Assessment................................................................... ........... ................................... 47
4.5: Pain Management....................................................................... ........... ................. .... .... ........ 48
4.6: Abuse and Neglect..................................................................... .... .... .... .......... .... .... ........ 50
4.7: Nutrition...................................................................................... .... .... .... .......... .... .... ........ 51
4.8: Skin and Pressure Ulcers.......................................................................... .... .......... ........... ........ 52
4.9: Falls Risk..................................................................................... .... .... .... .......... .... .... ........ 53
4.10: Operative and High-Risk Procedures........................................ ........... .... ................. ............... 55
4.11: Radiology Processes................................................................ ........... .... ... ............................. 58
4.12: Transfusions and Blood Products.............................................. ........... .... ... .... .... ............... 60
4.13: Physical Therapy....................................................................... ........... .... .......... .... .... ........ 62
THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS III

OME
AHC
BHC
CAH
NCC
OBS
HAP
LAB
4.14: Chemotherapy........................................................................... ........... .... ........................ ........ 63
4.15: Restraint and Seclusion............................................................. .... .... .... .......... ........... ........ 65
4.16: Youth Addiction Program.................................................................. ................................................. 66
4.17: Advanced Directives................................................................. .... .... .... .......... .... .... ........ 67
4.18: Patient Education, Communication, and Rights......................... .... .... .... .......... .... .... ........ 68
SECTION 5: HEALTH INFORMATION AND TECHNOLOGY

5.1: Information Management............................................................ .... .... .... ... .... ........... ........ 73
5.2: Health Information Security......................................................... .... .... .... ... .... .... .... ........ 74
5.3: Informed Consent....................................................................... .... .... .... .......... .... .... ........ 75
5.4: The Medical Record.................................................................... .... .... .... .......... .... .... ........ 76
5.5: Verbal Orders.............................................................................. ........... .... .......... .... .... ........ 78
SECTION 6: INFECTION PREVENTION AND CONTROL

6.1: Infection Control Program........................................................... .... .... .... ... .... .... .... ........ 81
6.2: Infection Control NPSGs............................................................. .... .... .... ... .... .... .... ........ 84
6.3: Reprocessing Medical Equipment, Devices, and Supplies......... .... .... .... ... .... .... .... ........ 86
6.4: Vaccination Program................................................................... .... .... .... ... .... .... .... ........ 88
SECTION 7: MEDICATION MANAGEMENT

7.1: Medication Management System................................................ .... .... .... .......... .... .... ........ 91
7.2: Medication Procurement, Ordering, and Dispensing.................. .... .... .... .......... .... .... ........ 95
7.3: Medication Administration........................................................... .... .... .... .......... .... .... ........ 98
7.4: Medication Storage and Security................................................ .... .... .... .......... .... .... ...... 102
7.5: High-Alert and Hazardous Medications...................................... .... .... .... .......... .... .... ...... 104
7.6: Look-Alike/Sound-Alike Medications........................................... .... .... .... .......... .... .... ...... 106
7.7: Anticoagulant Therapy................................................................ .... .... .... .......... .... .... ...... 107
SECTION 8: TESTING, TRANSPLANTS, AND IMAGING

8.1: Test Orders and Results.............................................................. ........... .... ... ........................... 111
8.2: Laboratory Procedures and Equipment................................................................. ........................... 112
8.3: QSA Cytology Procedures..................................................................................... ........................... 114
8.4: Waived/Point-of-Care Testing...................................................... ........... .... ... ........................... 115
8.5: Tissue Handling and Tracking..................................................... ........... .... ... ........................... 116
8.6: MRI Suite Processes................................................................... ........... .... ... ........................... 118
SECTION 9: THE PHYSICAL ENVIRONMENT

9.1: EC Management Plans and Risk Management........................... .... .... .... ... .... .... .... ...... 121
9.2: Safety and Security..................................................................... .... .... .... ... .... .... .... ...... 123
9.3: Infant and Pediatric Security..................................................................... .... ................................. 126
9.4: Hazardous Materials and Waste.................................................. .... .... .... ... .... .... .... ...... 128
9.5: Fire Response............................................................................. .... .... .... ... .... .... .... ...... 132
IV THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

OME
AHC
BHC
CAH
NCC
OBS
HAP
LAB
9.6: Medical Equipment..................................................................... .... .... .... ... .... .... .... ...... 134
9.7: Utility Systems............................................................................. .... .... .... ... .... .... .... ...... 137
9.8: Construction................................................................................ .... .... .... ... .... .... .... ...... 141
9.9: EM Plans/Emergency Operations Plan........................................ .... .... .... ... .... .... .... ...... 144
9.10: Communications and Community in Emergencies.................... .... .... .... ... .... .... .... ...... 145
9.11: Emergency Response Exercises............................................... .... .... .... ... .... .... .... ...... 147
9.12: Disaster Volunteers................................................................... .... .... .... ... .... .... .... ...... 148
9.13: Fire and Smoke Protection Features.......................................... .... .... .... .......... ........... ...... 149
9.14: Means of Egress....................................................................... .... .... .... .......... ........... ...... 152
THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS V

VI THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS
INTRODUCTION
Tracers, tracers, tracers. Whether you’re new to the world of The Joint Commission
or a veteran of accreditation surveys, you’ve most likely heard about tracers and
you may even have a pretty good concept of what a tracer is—particularly if you’ve
been through a survey. But if not, this book includes an introduction to tracers and
mock (practice) tracers (see pages 9 and 10). This introduction tells you the purpose
of this book and how to use it as well.
This Big Book coordinate the PI program with staff, PI committees,

The Joint Commission Big Book of Tracer Questions, and leadership.
a companion to the best-selling Big Book of Checklists • Section 2—Leadership: Tracer questions in this
(2016), is specifically designed to help you conduct mock section are designed to assess compliance with
tracers more easily and effectively by providing you with leadership standards, although other sections ask
more than 2,000 categorized questions. The tracer questions about leadership as well. Questions in this
questions have been aggregated from Joint Commission section cover leadership responsibilities for patient
Resources (JCR) tracer workbooks that focus on flow and contracted services, safety culture, and
familiarizing health care staff with tracer methodology. leadership involvement in performance improvement.
Supplemented with new questions, including some used
in JCR’s tracer software, Tracers with AMP™, the tracer • Section 3—Staffing and Medical Staff: This section
questions cover some common issues that surveyors may includes tracer questions related to qualifications and
encounter during a survey. Note that the tracer question competency and required education, training, and
sets don’t cover every issue. The book doesn’t include orientation for all staff, as well as the focused
questions for every standard or for every issue addressed professional practice evaluations (FPPE) for medical
by a standard. The questions are a place to start to build staff. More specific questions related to competency,
your own organized library of tracer questions. education, and training are also addressed in other
sections that cover specific topics.
Sections and Question Topics in This Book • Section 4—Care of the Patient: Tracer questions in
So how are the questions categorized in this book? Well, this section focus on the basics of patient care and
surveyors conduct tracers by looking at how well the documentation and communication of vital
organization complies with standards. For that reason, information. They address plans of care and care
tracer questions in this book are grouped into sections that coordination; patient education, patient rights, and
loosely align with Joint Commission and JCI standards patient responsibilities; admission, discharge, and
chapters. Within each section are question sets on major transitions of care. Some question sets address
topics of the standards chapters (see the Table of specialized areas of treatment, such as
Contents for those topics). The question sets themselves chemotherapy and youth addiction programs.
are further divided by subtle shading to indicate shifts to
• Section 5—Health Information and Technology:
more specific topics. The sections are as follows:
The tracer questions in this section can help you
• Section 1—Performance Improvement: This section prepare for the persistent threats to protected health
includes tracer questions that will help you to assess information, including theft as well as loss from
how you manage and use performance improvement system issue or damage in disasters. Questions also
(PI) data, implement performance initiatives, and
THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 1

cover implementing new technologies, requirements Searchable spreadsheet: Each section of the
for medical record content, informed consent, and spreadsheet has a tab with all the questions from all the
general data management. questions sets that section. In addition, for each question,
general subtopics that cross sections are identified, such
• Section 6—Infection Prevention and Control:
as Documentation, Process, Risk Management, and
Infection prevention and control is a hot topic and vital
Worker Safety. You can search the tabs or the whole
to safe, quality care, so of course it’s part of many
spreadsheet for questions related to these general topics.
surveys. This section includes tracer questions that
address policies and procedures, strategies and
Logistics and legalities: As far as the logistics of
systems, and equipment and education necessary for
using the tracer questions, if you’re a health care
effective infection control. Topics covered include
organization, you can print them out, photocopy them,
vaccination, the infection control program, patient
modify them, post them, and store them on your internal
safety goals related to hand hygiene and control of
server. You do need to retain the copyright notice for The
health care–acquired infections, and reprocessing
Joint Commission, but if you make substantial changes
(cleaning, disinfection, and sterilization of medical
and/or update them over the years, you can simply cite
equipment, devices, and supplies).
this book as the source.
• Section 7—Medication Management: In this section,
you’ll find tracer questions related to various activities Accreditation/program settings: The tracer
in the medication management process, including questions are designed for use across many different
medication administration, medication storage and accreditation programs/settings. For that reason, the
security, high-alert and hazardous medications, questions are keyed to the various settings. The following
look-alike/sound-alike medications, all focused on is a key to those setting codes:
providing quality of care and preventing adverse
events. • AHC = Ambulatory Health Care
• BHC = Behavioral Health Care
• Section 8—Testing, Transplants, and Imaging: • CAH = Critical Access Hospital
Tracer questions related to testing, laboratory • HAP = Hospital
procedures and equipment, and MRI imaging are • LAB = Laboratory
included in this section. These functions are central to • NCC = Nursing Care Centers
diagnostic work in health care organizations. Tissue • OBS = Office-Based Surgery Practices
handling and tracking is also part of this section, and • OME = Home Care
includes questions that address talking with the
patient and family about tissue donations. When getting ready to incorporate the tracer questions in
• Section 9—The Physical Environment: Tracers are this book for your mock tracers, feel free to delete the
useful tools for ensuring continuous compliance with program setting references that don’t apply to your
standards that target the many activities involved in setting. Also, note that questions may apply to certain
the complexities of the environment of care, fire types of settings and not others, so check your manual for
protection, and emergency management. This section those exceptions; for example, if the questions are
includes a variety of questions that will help your designated as applying to OME, they may only apply to
organization assess general safety as well as OME hospice settings.
management plans, construction, security, suicide
prevention, and more. Tracer questions and Joint Commission
standards: The setting references reflect appropriate
Use of Tracer Questions in This Book application of the tracer questions in those settings.
The various questions sets contained in the sections Relevant Joint Commission standards for each set of
outlined above can be used in different ways. You can questions are provided, although not all the standards
use the questions as written, taking a whole set or mixing apply to all the questions. But you can still use questions
and matching among sets. You can also modify any of that don’t apply to your setting, as the questions reflect
the questions to suit the needs of your organization. good practices. And of course, the tracers should reflect
The questions are available in downloadable individual, your organization’s relevant policies and procedures.
writeable documents and in one large searchable
spreadsheet. Terms used in the tracer questions: This publication
uses the term patient to describe recipients of care,
2 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

treatment, and services; and it uses the terms care, (RFIs) using the Survey Analysis for Evaluating Risk™
treatment, and services to refer to all types of care, (SAFER™) approach. The tracer form provided in this
treatment, and services provided across the spectrum of book reflects that new approach.
accreditation programs/settings. In addition, unless
specifically noted, in this book the term family is inclusive Conclusion
of a patient’s family and/or their caregivers and/or You may already have a mock tracer program and an
significant others. If you like, you can globally change the established process for performing them and
term patient to resident or individual within any set of incorporating the information into your improvement
questions in the specific tracer topic documents, or in the efforts. Joint Commission surveyors know that tracers are
spreadsheet that contains all the questions. an efficient and effective way to evaluate the care,
treatment, and services provided to patients served by an
Tracer questions for specific types of tracers: organization. They know that tracers are also a productive
Most of the tracer questions in this book are useful for way to evaluate a specific care process as part of a larger
multiple types of tracers performed by Joint Commission system. This book can help you discover or confirm the
surveyors. You may find some more specific to systems value of tracers by providing you with an easy-to-use
and processes, making them ideal for systems and bank of tracer questions and other tools. Your success in
program tracers. using tracers will translate to success in accreditation
surveys and in providing the best care, treatment, and
Digital mock tracer worksheet: This book includes services possible to your patients. And what’s more
a digital mock tracer form (pages 4-6). You can copy and important than that?
paste the questions you want to use into the form,
modifying as needed, to streamline your process for Acknowledgments
creating mock tracers. You can select questions to use Joint Commission Resources gratefully acknowledges the
beforehand as well by using the check box next to each time and insights of the subject matter experts at The
question, either on a print version or electronic version. Joint Commission, identified as reviewers on the copyright
page. We would also like to thank James Foster for
Incorporation of the SAFER™ approach: organizing the tracer questions to use in this book.
Surveyors now plot all Requirements for Improvement

MOCK TRACER FORM
You may already have a mock tracer form that you use regularly, but this book
includes a digital mock tracer form you may want to try for your mock tracers.
The next few pages explain how to use the provided tracer questions and the form.
Step 1: Select the Tracer Questions Step 3: Insert Tracer Questions into the Form
Review the provided tracer questions you’re interested in Copy and paste your selected tracer questions into the
using. Next to each question are check boxes. For each mock tracer form—in whatever order seems appropriate to
question you want to use, check one of the boxes, you. Remember that you may not ask all of the questions
indicating Use Question As Is or Adapt Question For Use. and you may ask them in different order once you are
actually conducting the tracer. You may want to leave
• Option A – Paper First: Mark your selections and
some blank tracer question blocks so you can add any
changes on paper first by printing out the question
other questions you ask as you go. Save this form with the
set (or photocopying it from the print version of the
name and date of your intended tracer.
book if you have that). Then make any of your
changes electronically in the downloaded digital
Step 4: Using the Mock Tracer Form
version of the questions.
Now you’re ready to go. You may use the form in one of
• Option B – Digital Only: Download the digital version two ways:
of the questions. Electronically mark the selection
• Option A – Paper First: Print out the form and take it
boxes and make any of your changes as you select
with you on the mock tracer, marking compliance and
questions.
comments on paper. Later, input the information into
the electronic form, adding a plan of action or other
Step 2: Download the Mock Tracer Form
information. Save the form for data collection,
The mock tracer form is available to download in color and
analysis, and reporting.
black and white. Both the color version (see page 5) and
the black and white version (see page 6) include the • Option B – Digital Only: Take your ready mock tracer
SAFER™ Matrix in the format used by surveyors to record form with you on your electronic mobile device as you
compliance. Both versions include a header to add conduct the tracer, marking compliance and comments
information about your planned mock tracer and sections electronically. As with Option A, you can add a plan or
to add tracer questions, record compliance, and suggest a action or other information later, before saving the
plan of action in response to the compliance level. You can form for data collection, analysis, and reporting.
add or delete the blank tracer question blocks, as needed.

DOWNLOAD
Mock Tracer Form – color
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME
Mock Tracer Form

Organization Department
Unit
Date of Tracer Time of Tracer Tracer Topic
Type of Tracer ☐ Individual ☐ System ☐ Program ☐ High-Risk ☐ Tracer Team
Environment of Care ☐ Life Safety Code®
Patient Record # Documents
(if applicable) Reviewed
Tracer Question(s) Relevant Standard(s)

Person(s)
Asked
Compliant? If insufficient compliance: ☐ Immediate Threat to Life
Tracer question(s) go here. ☐ Yes Likelihood High ☐ ☐ ☐
☐ No to Harm Moderate ☐ ☐ ☐
☐ Not scored Low ☐ ☐ ☐
☐ Not applicable Limited Pattern Widespread
Scope of Noncompliance
Evidence of
Compliance
Plan of Due Date
Action


Person(s)
Asked
Evidence of
Compliance
Plan of Due Date
Action


Person(s)
Asked
Evidence of
Compliance
Plan of Due Date
Action
© 2017 The Joint Commission. May be adapted for internal use. Page 1 of 1

DOWNLOAD
Mock Tracer Form with SAFER Matrix
Mock Tracer Form with SAFER™ Matrix

Organization Department
Unit
Date of Tracer Time of Tracer Tracer Topic
Type of Tracer ☐ Individual ☐ System ☐ Program ☐ High-Risk ☐ Tracer Team
Environment of Care ☐ Life Safety Code®
Patient Record # Documents
(if applicable) Reviewed

Person(s)
Asked
Evidence of
Compliance
Plan of Due Date
Action


Person(s)
Asked
Evidence of
Compliance
Plan of Due Date
Action


Person(s)
Asked
Evidence of
Compliance
Plan of Due Date
Action


TRACERS
If you’re new to The Joint Commission or Joint Commission International (JCI),

one of the first things you need to learn about is tracers. Tracer methodology is a
central part of Joint Commission and JCI accreditation and certification surveys.
This introduction will prepare you with some tracer basics.
Tracer Basics During a tracer, the surveyor interacts with leaders,

The Joint Commission and JCI standards are designed to physicians, nurses, and other providers and staff, making
help an organization maintain safe, high-quality health observations and asking questions. The surveyor may also
care. By identifying where your organization is and isn’t in speak directly to a patient and to that patient’s family.
compliance with these standards, tracers can help you
target areas for improvement. When Do Tracers Take Place?
Tracers occur during each of an organization’s surveys for
Let’s take a closer look. accreditation or certification. These surveys are conducted
on a regular cycle (triannual for most accreditation
What Is a Tracer? programs/settings). Usually, the survey is unannounced.
A tracer is the key survey assessment method used by
Joint Commission and JCI surveyors. Its purpose is to Duration of tracers: Tracers make up about 60% of a
assess a health care organization’s compliance with survey. Each tracer is scheduled to take 60 to 90 minutes.
Joint Commission and JCI accreditation and certification Some take longer. During a typical three-day survey, a
standards. It involves “tracing” an actual patient’s surveyor or survey team may complete several tracers.
experience through a health care organization, using the During a single-day survey, it may be possible to complete
patient record as a guide. Some tracers address other only one or two tracers.
aspects of health care organizations, such as systems.
Why Conduct Tracers?
What Happens During a Tracer? Health care organizations are made up of a series of
Along the tracer path, the surveyor (or team of surveyors) systems and subsystems. Tracers are an effective way to
assesses compliance with standards. This includes study these complex systems. Finding the system
evaluating how well the organization adheres to its own imperfections or flaws is critical. That makes it possible to
policies and procedures. Additionally, the surveyor correct them and prevent potential harm to patients, staff,
assesses the level of risk for any cited noncompliance. or visitors.
Tracers rarely take a straight route. The surveyor diverges Goals for all tracers: Reasons for conducting tracers
onto new paths while following opportunities for are a reflection of both survey and organization goals.
investigation. It may require several tracers to cover The following outcomes are the goals of all tracers:
everything. Surveyors can visit—and revisit—any area of
• An integrated and cross-sectional review of areas that
the organization related to the care of the patient or the
are most critical to safe, high-quality care
functioning of a system.
• A focused analysis of compliance with standards
• Specific information about the organization that can
be used to design and target improvements

Types of Tracers In international organizations, these tracers are called
Most tracers fall within three basic types: individual department/service quality measurement tracers.
(patient) tracers, system tracers, and program-specific
tracers. Variations on those tracers focus on the physical Program-Specific Tracers
environment and high-risk issues. During a program-specific tracer, the focus is on a topic
specific to an accreditation program/setting. As in an
Individual (Patient) Tracers individual (patient) tracer, the surveyor uses the patient
During an individual tracer, the focus is on an individual record as a guide. The surveyor assesses compliance
patient’s experience in the health care organization. The with standards related to the topic, which focus on
patient’s record serves as a guide along the path of care. particular clinical services and high-risk or high-volume
The surveyor assesses compliance with standards as they patient populations.
relate to the care, treatment, and services the organization
provides to the patient. Examples of topics for Joint Commission program-specific
tracers include equipment and supply management, fall
The surveyor chooses the patient based on the reduction, and hospital readmission for home care
organization’s care, treatment, and services as well as its organizations, and suicide prevention, laboratory
top risk areas and the complexity of the patient’s care. integration, and patient flow for hospitals. JCI surveys
Starting where the patient is located, the surveyor first don’t include program-specific tracers.
reviews the medical record with the staff person responsible
for the patient’s care. The surveyor then follows the path Physical Environment Tracers
of patient care from preadmission through and possibly Other types of tracers assess organization systems and
beyond discharge (or the end of an episode of care). processes related to the environment of care, emergency
management, and fire protection. These are covered by
System Tracers Joint Commission Environment of Care (EC), Emergency
During a system tracer, the focus is on a complex health Management (EM), and Life Safety (LS) standards, and
care system within an organization. System tracers are JCI Facility Management and Safety (FMS) standards.
used to assess medication management, infection control,
and data management systems. The data management A tracer that assesses the physical environment is often
system tracer is the only system tracer to occur on most triggered by an environment-based risk a surveyor
surveys. Other system tracers take place based on the observes during an individual (patient) tracer. Some
care, treatment, and services the organization provides, physical environment tracers (such as life safety tracers)
the duration of the survey, and the organization’s are conducted as part of a special session of the survey.
accreditation history.
High-Risk Tracers
System tracers for medication management During any tracer, a surveyor may see a specific high-risk
and infection control: A medication management or issue and decide to conduct an additional tracer to
infection control system tracer may be scheduled for a examine it more closely. Or the surveyor may be aware of
survey. Or it may be triggered when a surveyor sees a potential high-risk issues in the organization and decide to
system-related issues during an individual (patient) tracer. perform a special tracer. These special tracers allow a
Through group discussion and review of documents, the deeper and more detailed exploration of a particular
surveyor first explores processes and identifies concerns high-risk area, process, or subject.
within the system. The surveyor can then follow a patient’s
care experience to evaluate how well the particular system High-risk tracer topics are identified from the field or
functioned related to that patient’s care. In addition to within organizations. They may differ by accreditation
assessing compliance with standards, the surveyor program/setting. For example, in an ambulatory setting,
identifies system-based risks and provides education high-risk tracers might address diagnostic imaging or
about system issues. radiation safety.
System tracers for data management: To perform Core Tracer Activities

a data management system tracer, the surveyor conducts Each type of tracer may have a different focus, but
a group meeting session. The goal is to assess the surveyors perform some of the same activities in all
organization’s use of data in performance improvement. tracers. These core tracer activities can be remembered

through the mnemonic device of TRACER—Target, • Communicate: The surveyor communicates with
Review, Assess, Communicate, Educate, and Report. tracer participants, asking questions and sharing
concerns in a way that encourages them to answer
• Target: The surveyor targets (or selects) a tracer thoroughly and provide perspective and context.
subject—an individual patient, a system, or a Surveyors need to employ various communication
program-specific topic—based mainly on the skills to create a supportive, interactive exchange of
organization’s care, treatment, and services. Choosing information. These include setting an appropriate tone
the right subject for a tracer is important because you and active listening.
want the tracer to give you an accurate representation • Educate: The surveyor educates tracer participants
of your organization’s functions. The tracer subject whenever possible to help organizations solve
may change during the tracer, depending on what’s compliance problems. Surveyors offer suggestions
discovered. New subjects for additional tracers may in an objective, blame-free manner to help foster
be identified as well. cooperation and demonstrate commitment to a
• Review: The surveyor reviews documents, such as common goal: Improve compliance to improve the
policies, medical records, management plans, data organization’s performance.
reports, service contracts, and so on. Surveyors • Report: The surveyor reports the results of the tracer,
review these materials to verify compliance with which are shared in a clear and timely way so the
documentation standards and to clarify issues that organization can make any required improvements.
come up during the tracer. Document review can also Surveyors indicate if there’s a time limit on how soon
reveal new subject to trace. any noncompliance must be corrected (for example,
• Assess: The surveyor assesses compliance with immediately or within 60 days).
standards by making observations and asking
questions, and also defines the level of risk for any Dynamic Nature of a Tracer
cited noncompliance. Surveyors may have a set of The core tracer activities are ongoing during a tracer,
starter questions on particular topics that help them except Report. Even the Target activity can occur at any
cover key points in the standards. Because tracers time because of the way a surveyor responds to triggers
can go in any direction, many other questions that may require shifting the tracer subject. The active,
surveyors ask are unplanned. To define the risk level responsive nature of tracers makes them truly dynamic.
for noncompliance, surveyors use a standardized
scoring method. The Joint Commission uses the Conclusion
SAFER™ Matrix as scoring method, which indicates Tracers are also accessible. One of the interesting things
the scope of noncompliance and likelihood to harm about tracers is that, although their dynamic nature means
(see Introduction, page 1). JCI scores noncompliance they can be complex in action, the concept is fairly simple.
along a continuum of from “fully met,” “partially met,” And you can perform mock (practice) tracers in your own
and “not met,” or “not applicable.” organization without a lot of equipment or expense.
(see page 10).

MOCK TRACERS
All the information gathered from a tracer during your Joint Commission or Joint
Commission (JCI) on-site survey can be used to design and target improvements
in your organization. Of course, you don’t want to wait until a survey to get this
information. You need to do regular risk assessments. Simulated—or mock—tracers
are one way to do that. This introduction to mock tracers will give the information
you need to get started. It will explain mock tracers and their purpose, when to
perform mock tracers, and mock tracer skills such as selecting a mock tracer
subject, asking tracer questions, and communicating during a tracer.
Mock Tracer Basics Why Conduct Mock Tracers?

Mock tracers can be thought of as a risk assessment tool. Mock tracers are helpful for achieving continuous
They can help your organization to maintain and sustain compliance. Specifically, they’re helpful in the following
compliance with standards and your own organization’s ways:
performance improvement goals. In other words, you can • To engage staff and leadership in accreditation
use tracers the same way surveyors do and for similar activities, such as regular assessment of compliance
purposes by conducting mock tracers. with standards
• To help you identify deficiencies so you can address
Here are the basics. them with interventions and sustain improvements
• To better prepare you for your next on-site survey
What Is a Mock Tracer? • To reduce anxiety about the survey process, which
Essentially, a mock tracer is a practice tracer meant to will allow for a more relaxed and beneficial experience
simulate an actual tracer experienced during an on-site
survey. During a mock tracer, one or more people may Mock Tracer Skills
play the role of a surveyor. The mock surveyor performs Learning to conduct mock tracers, like learning any new
the core tracer activities just like an actual surveyor does activity, may involve developing some new skills. These
(see page 8): Targets a tracer subject, Reviews skills are necessary to effectively perform the tracer core
documents, Assesses compliance, Communicates with activities: Target, Review, Assess, Communicate,
tracer participants, Educates staff about quality and safety Educate, and Report. Perhaps the most important skills
issues, and Reports the results of the tracer. for conducting a tracer are the ability to select appropriate
tracer subjects (Target), ask good tracer questions
When Do Mock Tracers Take Place? (Assess), and maintain a productive exchange of
Mock tracers occur as part of your risk assessment information (Communicate).
activities, so you decide when to schedule them. Ideally,
they should occur regularly. You can make them announced Selecting a General Tracer Topic
or, like actual surveys, unannounced. And, like actual On an actual survey, the surveyor selects a tracer topic
tracers, each mock tracer may take an hour or longer. based mainly on the organization’s care, treatment, and
Some organizations develop mock tracer teams and services. The general tracer topic is usually a risk area in
conduct regular mock tracers as part of an ongoing mock your organization or organizations like yours, such as
tracer program. Mock tracer programs may have one to medication reconciliation or diagnostic imaging.
several mock tracers scheduled each month.

Here are a few approaches to selecting a general mock • Hit the highs and lows: Focus on high-volume/
tracer topic: high-risk and low-volume/high-risk areas and
activities. Find out more about demographics for
• Reflect your organization: Start with your
those areas or activities to help determine whether
organization’s mission, scope of care, range of
care, treatment, and services are targeted to a
treatment or services, and population(s) served.
particular age group or diagnostic/condition category.
Choose representative tracer topics that support and
Then pick corresponding tracer topics.
define your organization.
• Investigate time-sensitive tasks: Look at time-
• Tap the top compliance issues: Review the Joint
sensitive tasks, such as frequency of staff performance
Commission’s top 10 standards compliance issues
evaluations, critical result reporting, and the signing,
your organization’s accreditation program, published
dating, and timing and entry of physician orders,
regularly in The Joint Commission Perspectives®
including whether they’re present and complete.
(available for subscription and provided free to all
These are often challenging compliance areas.
accredited organizations). Also check any issues
highlighted in Sentinel Event Alerts and Quick Safety • Consider vulnerable population(s): Review the risks
alerts, which are available on the Joint Commission in serving particularly vulnerable, fragile, or unstable
website. Check to see if any of those compliance populations in your organization. Select tracer topics
issues have been problem-prone in your organization. that might reveal possible failing outcomes. Address
International sentinel event information submitted to related processes of care, treatment, and services
JCI is de-identified and reported to The Joint that are investigational or new, or otherwise may
Commission. International organizations can refer to present safety risks.
the same resources referenced above for information
on compliance issues. Selecting a Specific Tracer Subject
Once you identify the general topic for a tracer, start
• Review what’s new: Address any new Joint Commission
listing problems in your organization related to it. Are the
or JCI standards that relate to your organization.
problems mostly related to patient care? System processes?
New standards and requirements for US organizations
Program-specific services? The physical environment?
are announced throughout the year, but changes are
High-risk issues? Answers to those questions will help you
made to your Comprehensive Accreditation Manual
find the type of tracer to perform.
generally twice a year. A summary of the changes
made since the manual was last published is
Once you know that, you have to choose a particular
available with each update, and is also available in
patient, system, program service, area of the physical
the E-dition® version of the manual. Always refer to
environment, or high-risk issue. That’s your specific mock
the most recent update of the manual. In addition,
tracer subject. Here are strategies for doing that for each
The Joint Commission Perspectives®, publishes
of the tracer types.
revised or updated requirements and other useful
information as the year progresses. International
Individual (patient) tracers: For individual (patient)
organizations should refer to the JCI webpage for the
mock tracers, adopt the way actual surveyors choose
latest edition of the Joint Commission International
patients to trace. Base your selection on criteria such as
Accreditation Standards. JCI-accredited organizations
the following:
are also notified about revised standards manuals via
• The patient is currently getting care in your
“Direct Connect.” Also focus on any new equipment
organization or was recently discharged (ended an
or new programs or services in your organization.
episode of care).
Consider mock tracers that will allow opportunities to
• The patient has received clinical services in your
evaluate newly implemented, controversial, or
organization that are commonly used or high-risk.
problematic organization policies and procedures,
• The patient’s experience of care, treatment, or services
and how consistently they’re being followed.
allows the surveyor to access as many areas of the
• Start with the type: Look at typical tracers from any organization as possible
past surveys and choose several common or relevant • The patient qualifies for admission to an accreditation
topics for the types of tracers completed—individual program–specific service related to the tracer topic
(patient), system, program-specific, physical • The patient moves between and receives care,
environment, and high-risk. treatment, and services in multiple programs, sites,
or levels of care within your organization.

In international organizations, use information provided in But many tracer questions are unplanned and free-flowing,
your organization’s accreditation survey application to arising during the tracer according to need. This reflects
select tracer care recipients from an active list that shows the dynamic nature of a tracer: The answer to one
who has received multiple or complex services. question can trigger the need for additional questions.
That’s when you need to “drill down.”
System tracers: Individuals (patients) selected for
tracing a system typically present opportunities to explore Drilling down: Important details about a patient’s care
both routine processes and potential challenges to the or a system’s function can be explored by asking a series
system. For example, to evaluate medication management of related questions. You progressively narrow the topics
systems, select patients who have complex medication of your questions to focus on areas of concern revealed in
regimens, who are receiving high-alert medications, or answers to prior questions. When you notice a policy
who have had an adverse drug reaction. Or, to evaluate violation or an inconsistency in clinical practice, you
infection control, select someone who is under contact should always drill down.
precautions due to an existing infection or compromised
immunity. These same individuals could be the subjects EXAMPLE The Joint Commission and JCI require
for data management system tracers. Why? Because each consistent use of two patient identifiers across the
might be included in performance measurement activities organization. In this example, the surveyor drills down to
for infection control surveillance or adverse drug-reaction focus on possible causes of a problem with patient
monitoring data. identifiers—policy content and/or use as well as staff
training. Key trigger words and phrases are in italics.
Program-specific tracers: The focus for these tracers
depends on the services provided by the organization. • Surveyor: What was your role in caring for this patient?
In home care, for example, those include programs such • Nurse: I am the nurse responsible for this patient,
as equipment and supply management, fall reduction, or so I was the one who administered the medications.
hospital readmission. To evaluate a falls reduction program • Surveyor: Would you describe the process you used?
in a home care program, you would select a patient at risk • Nurse: I started by checking the two patient
for falls and trace components of the program, such as identifiers. For this unit, we usually check the patient’s
risk assessment, patient and family education, and full name and birthdate, and I think I did that here.
implementation and evaluation of interventions. • Surveyor: How do you determine which identifiers
you’re going to use?
Physical environment tracers: Subjects for this • Nurse: Well, sometimes it’s easier for us to ask for
type of mock tracer—conducted only in facility-based name and birthdate, some people prefer to get the
programs—may include systems and processes for safety, national ID number, it’s just personal preference.
security, hazardous materials and waste, fire safety, utilities, • Surveyor: May I see your policy on patient
and medical equipment. For example, a mock tracer might identification?
examine the maintenance of new medical equipment. AND/OR
• Surveyor: How did you develop your patient
High-risk tracers: Subjects for high-risk area tracers identification policy?
grow naturally out of tracers involving high-risk points AND/OR
because this type of tracer is a deeper and more detailed • Surveyor: How were you trained to identify patients?
exploration of the tracer subject.
Validating: After drilling down, you should validate—
Asking Tracer Questions or confirm—that the issue is a problem across the
Selecting a tracer subject is mostly done before a tracer. organization. Look for examples of the problem in other
Asking tracer questions happens throughout a tracer and settings or with other practitioners. Is this an isolated
is a critical skill for conducting effective tracers. Along with incident, or a trend? That may impact the risk level you
reviewing documents and making observations, asking assign for noncompliance.
questions is how you gather information during a tracer.
Asking open, neutral questions: Interviewing tracer
You can prepare a set of tracer questions before the participants requires asking lots of questions, so make them
tracer. Some actual surveyors do this; mock tracer count. Use your time productively by following these two rules:
surveyors, who have less experience, do it regularly.
Having a set of starter questions helps to ensure that you
cover the key points in a standard.

• Ask open-ended questions that don’t result in a yes/ Avoid a confrontational tone; the goal is to gather
no answer, unless you follow-up with a question that information, not “catch” someone doing
probes deeper: “How do you know the correct way to something wrong.
operate this equipment?” and not “Have you been Use “I” statements (“I think,” “I see”) to avoid
trained to operate this equipment?” unless you then appearing to challenge or blame the interview
ask, “If so, what was your training like?” subject: for example, “I see that the patient was
given aspirin,” not, “You gave the patient aspirin.”
• Ask neutral questions that don’t lead your subjects to
the correct answer: “What kind of hand-washing • Take time:
protocols have you adopted? How effective have Seize the moment, but don’t interrupt patient care.
these protocols been?” and not “Do you always wash Remain flexible.
your hands before interacting with a patient?” Stay time-aware and topic-focused.
Speak slowly and carefully.
Assessing compliance: While asking any tracer Allow yourself time to make notes as you go.
questions, keep the purpose in mind. All questions should
• Listen actively:
be based on a standard or organization policies and
Gesture to show you understand, with head nods,
procedures. Not on best practices. Not on your opinion.
for example.
Not on organization habit or culture. Here are a few
Restate the subject’s words as necessary for
additional tips to keep the emphasis on compliance:
clarification.
• Ask “How” questions to get information about
Pause before responding to an answer to
processes.
encourage more information.
• Ask questions that address several standards related
to a process, not just one standard. • Be open and positive:
• Ask questions about the patient or system being Inform tracer subjects when you need to just
traced, not hypothetical questions. observe.
• Ask questions to staff rather than management, unless Give positive feedback for well-thought out answers.
the question is for management. Always thank your interview subject for his or her
• Ask several staff members the same question to time and information.
check consistency and staff training.
• Manage conflict:
In difficult situations, take a deep breath and wait
Communicating During the Tracer at least three seconds before responding.
Communication in a tracer is a special kind of
As necessary, gently restate that the tracer
communication: You’re interviewing subjects while
purpose isn’t “peer” review.
evaluating their answers. Asking questions and listening
to answers is only part of it. Some of it’s nonverbal. • Be security-sensitive:
Some of it’s just being polite. It takes practice for tracer Maintain patient confidentiality.
communication to be effective. Here are some tips Be respectful about reviewing documents. Return
to help you: them as you found them.
Ask politely for visiting and viewing privileges to
• Set the tone: secure areas and documents.
Dress professionally.
Use a serious but approachable style. Conclusion
Pretend you don’t know the people you’re Clearly, to conduct mock tracers you need various skills.
interviewing. You also need comprehensive, appropriate tracer
Explain the purpose of tracer with each new questions—good questions, and lots of them. Having that
interview subject. bank of sample questions to draw from for starter
To help set the interview subject at ease, try questions on a tracer topic is a big help. By reviewing
mirroring: Adjust your volume, tone, and pace to sample questions and practicing with them in mock
match those of the person to whom you are tracers, you become familiar with appropriate and
speaking. (If the subject is nervous or defensive, effective phrasing of tracer questions. When the sample
however, use a quiet and calm approach to questions are grouped by topic and subtopics, you can
encourage that person to match your example.) also learn how tracer questions relate to and lead to other
tracer questions. That’s where this book can help.

1 PERFORMANCE
IMPROVEMENT
DOWNLOAD
Performance Improvement: Performance Improvement Data

Performance Improvement You may wish to

select questions you
You can use these sample questions for your mock tracers, adapting them as appropriate. want to use before
Relevant standards cited are not necessarily applicable to every question. copying them into the
NOTE: The term patient is used here to describe a recipient of care, treatment, and services. provided mock tracer
It can be replaced with the appropriate term for your accreditation program/setting. form or other form.
1.1: Performance Improvement Data

Relevant Standards: HR.01.05.03, HRM.01.05.01, LD.03.02.01, LD.04.03.11, LD.04.04.01, Use Adapt
PI.01.01.01, PI.02.01.01 Question Question
As Is for Use
NOTE: HRM standards are for BHC only.
What performance improvement reports do you regularly produce for administrative and clinical
☐ ☐
leadership? Can you please provide access to the most recent data reports that were presented?
Who has responsibility and oversight for performance improvement data in your organization? ☐ ☐
How have the data assisted you with performance improvement initiatives? ☐ ☐
What is your planning process for performance improvement data use? ☐ ☐
What kinds of data do you collect for performance improvement initiatives? ☐ ☐
What methods do you typically use to collect performance improvement data? ☐ ☐
How do you ensure that all data is collected as planned? ☐ ☐
Who identifies the frequency for performance improvement data collection? ☐ ☐
How is performance improvement data input? ☐ ☐
How often do you update and review performance improvement data? ☐ ☐
Has the organization ever used data in the medical equipment database to track and monitor
☐ ☐
performance? If so, how?
What methods of data collection are associated with specific monitors? ☐ ☐
What is the focus of your data collection and use for this performance improvement initiative? ☐ ☐
What methods, tools, and techniques do you use to aggregate and analyze data for performance
☐ ☐
improvement initiatives?
How do you compare analyzed data to external sources for benchmarking (when possible) as well
☐ ☐
as comparing the data internally over time?
How did data analysis help you identify the problem in this performance improvement initiative? ☐ ☐

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Performance Improvement: Performance Improvement Data

When has your data analysis helped in recently prioritizing performance improvement initiatives? ☐ ☐
How are your formats for data analysis designed to be easy to use, understand, and share? ☐ ☐
How do you report your performance improvement data analysis results? Who sees the reports? ☐ ☐
How are these data shared with organization leadership? ☐ ☐
How do leaders use reported data to set priorities for performance improvement initiatives? ☐ ☐
How do you usually track performance improvement data? ☐ ☐
How long have you been tracking these performance improvement data? ☐ ☐
How are you tracking sustained improvement? ☐ ☐
If the data show excellent performance for several years, why track the data in the same way? ☐ ☐
How do you track data on areas of patient safety risk that you have deprioritized as a committee? ☐ ☐
What electronic support do you have for your performance improvement data use processes? ☐ ☐
If you are using data software, what is your contingency plan for problems with the software? ☐ ☐
How do you plan for implementation of new data software? ☐ ☐
How do you decide on performance improvement data software and training? ☐ ☐
How do you manage quality control records for the performance improvement data software? ☐ ☐
What kind of training and education are provided for performance improvement data users and
☐ ☐
data management staff?
Are your data management processes responsive to organizational changes? ☐ ☐
How do you collect and report data on adverse events? ☐ ☐
How do you measure patient satisfaction using data? [N/A for LAB] ☐ ☐
What data have you been collecting on patient readmissions? How often do you share that
☐ ☐
information with leadership? [CAH, HAP, NCC, and OME only]


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Performance Improvement: Implementing Performance Initiatives


1.2: Implementing Performance Initiatives

Use Adapt
Relevant Standards: HR.01.05.03, HRM.01.05.01, PI.03.01.01
Question Question
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME As Is for Use
What are some current performance improvement efforts your organization is undertaking?
☐ ☐
Please select one to outline and describe.
Can you identify any projects or implementation efforts that did not achieve or sustain the
planned improvements? What was the response to these results? What lessons were learned ☐ ☐
from studying this attempt that will help inform other improvement initiatives?
What process did you follow to design and implement this project? ☐ ☐
What is the current state of this improvement project? ☐ ☐
How did this process work before the implemented initiatives? Please describe what changed as a
☐ ☐
result of the implementation.
What procedures or processes did you change to help facilitate this improvement? ☐ ☐
How do you typically implement performance improvement interventions changes? What kinds of
☐ ☐
accompanying education do you provide?
How do you provide staff training on performance improvement interventions? ☐ ☐
What specific monitors are you using to measure performance? How long have these monitors
☐ ☐
been in use? What do they measure?
How have you been monitoring progress on performance? What are your goals and measures of
☐ ☐
success?
What are you learning so far in performance improvement interventions underway? How do you
plan to track results? What reporting process will you follow?
☐ ☐
What types of reporting have you done for performance improvement interventions? ☐ ☐
What progress have you documented so far for performance improvement interventions? What
☐ ☐
additional measures will you consider putting in place if this initiative is successful?
Do you have documentation on specific monitors for performance improvement interventions?

☐ ☐
Where do you keep that documentation? With whom do you share that documentation?

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Performance Improvement: Implementing Performance Initiatives

Do you document what performance improvement projects are selected for implementation
☐ ☐
during any given year?
How have you involved staff in contributing feedback as you planned performance improvement
☐ ☐
projects?
How have you informed staff about results of your initial pilot test(s) and any additional pilot
☐ ☐
testing and monitoring of performance improvement interventions?
What kind of response have you seen to the performance improvement initiative? How is that
☐ ☐
communicated to you?
How have patients and their families responded to the improvement project? ☐ ☐
Have you engaged patients and their families in the improvement project? How is this
☐ ☐
engagement accomplished?
What were the results of your performance improvement activities for this project? Has a new
compliance goal been set based on those results?
☐ ☐
What are your next steps in this performance improvement initiative? Are you making any
modifications to your processes?
☐ ☐
How are you maintaining the improvements from the initiative and monitoring its results? ☐ ☐
What steps are you taking to continue monitoring the performance improvement project? ☐ ☐
Has the organization taken steps to resolve any error-rate problem cited in its data? What
specifically has taken place?
☐ ☐
Please give an example of a high-risk process. What monitoring and improvement activities do
☐ ☐
you have related to that process?
What performance improvement initiatives have been taken or are in development to prevent
☐ ☐
adverse events from happening again?


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Performance Improvement: Performance Improvement Management


1.3: Performance Improvement Management

Use Adapt
Relevant Standards: HR.01.05.03, HRM.01.05.01, PI.01.01.01, PI.02.01.01, PI.03.01.01
Question Question
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME As Is for Use
Please tell me who is responsible for performance improvement activities in your organization. ☐ ☐
If you have a performance improvement committee, how does it function? What kind of
representation do you have from across the organization?
☐ ☐
How often does your performance improvement committee meet? Who else attends the
meetings? What is the typical structure of the meeting?
☐ ☐
Do you network or collaborate with any other organization or performance improvement group in
your region?
☐ ☐
How do you stay apprised of current literature or best practices on performance improvement
initiatives?
☐ ☐
Do you have any staff meetings or training on performance improvement for general staff? How is
this subject introduced during orientation or ongoing training activity?
☐ ☐
What kind of training and ongoing education have you received to support your work on the team
or in your job capacity (as performance improvement staff)?
☐ ☐
What kind of training and support do you provide to staff involved in your improvement
processes?
☐ ☐
Who has been involved in the process of designing and implementing your improvement
projects?
☐ ☐
How do you involve staff members in improvement projects? How are they informed about
them? How are physicians and other practitioners involved in the project?
☐ ☐
How do you familiarize staff members with changes that are part of performance improvement
interventions? How do you secure their engagement in the effort?
☐ ☐
How are nurses involved in your performance improvement activities? ☐ ☐
What is the role of medical staff in performance improvement activities, especially in relation to
setting priorities? [CAH and HAP only]
☐ ☐

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Performance Improvement: Performance Improvement Management

How does leadership stay apprised of performance improvement initiatives? Who is responsible
for recommending performance improvement priorities to leaders?
☐ ☐
How do you become aware of the need for a performance improvement initiative? ☐ ☐
What happens after your organization identifies a near miss? Is a root cause analysis performed? ☐ ☐
Have you ever used failure mode and effects analysis (FMEA) in your performance improvement
work? If so, please explain how this was done and share the documentation of this process.
☐ ☐
In what areas of operation, clinically or administratively, do you think you might need to improve
performance? Why? What measures might you use to evaluate performance in those areas?
☐ ☐
How do you decide the design of the interventions? ☐ ☐
How often are performance monitors created? ☐ ☐
What are the organization’s processes for creating performance monitors? ☐ ☐
Once data is analyzed, how do you make sure that those who need to know the results are
informed?
☐ ☐
What is your reporting process? What reports do you produce? Who receives them? ☐ ☐
How often does your organization update and review performance improvement reports? ☐ ☐
How are you tracking progress on your performance improvement projects and communicating
results?
☐ ☐


2 LEADERSHIP
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Leadership: Leadership in Performance Improvement

Leadership You may wish to

2.1: Leadership in Performance Improvement Use Adapt

Relevant Standards: LD.01.03.01, LD.02.01.01, LD.03.04.01, LD.03.05.01, LD.04.04.01, LD.04.04.05 Question Question
As Is for Use
How does your governing body make sure that performance improvement activities reflect your
organization’s structure, involve all departments and services, and include services provided ☐ ☐
under contract?
How have the leaders aligned performance activities to support the organization’s mission, vision,
☐ ☐
and goals?
How have the leaders set priorities for performance improvement activities and patient health
☐ ☐
outcomes?
Have the leaders given priority to high-‐volume, high-‐risk, or problem-‐prone processes for
☐ ☐
performance improvement activities?
What is one example where leaders reprioritized performance improvement activities in response
☐ ☐
to changes in the internal or external environment?
How have leaders assured that performance improvement occurs across the organization? ☐ ☐
Do leaders provide governance with annual written reports on the following?
• All system or process failures
• The number and type of sentinel events ☐ ☐
• Whether the individual served and the families were informed of the event
• All actions taken to improve safety both proactively and in response to actual occurrences
How have leaders designed communication structures/methods to meet the performance
☐ ☐
improvement needs of internal and external users?
How have leaders provided the resources required for communication, based on the performance
☐ ☐
improvement needs of patients, the community, physicians, staff, and management?
How have leaders evaluated the effectiveness of communication methods for performance
☐ ☐
improvement purposes?


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Leadership: Safety Culture

2.2: Safety Culture Use Use

Relevant Standards: LD.01.02.01, LD.02.01.01, LD.03.01.01, LD.04.01.07, LD.04.04.05 Question Question
As Is As Is
How do leaders evaluate the culture of safety and quality? What types of tools are used for this
☐ ☐
evaluation? How often do you repeat the evaluation?
Do leaders prioritize and implement changes identified by a culture of safety evaluation? If so, can
☐ ☐
you provide an example?
Does your organization embed safety culture training into performance improvement projects
☐ ☐
and organizational processes to strengthen safety systems? If so, can you provide an example?
How do leaders support and facilitate application of a transparent, nonpunitive approach to

☐ ☐
reporting and learning from adverse events, close calls, and unsafe conditions?
Does your organization use clear, just, and transparent risk-based processes for recognizing and
☐ ☐
distinguishing human errors and system errors from unsafe, blameworthy actions?
Does your organization have policies that support safety culture and the reporting of adverse
events, close calls, and unsafe conditions? If so, how are these policies enforced and ☐ ☐
communicated to all staff?
What do you do to recognize staff who have suggestions for safety improvement? ☐ ☐
Does your organization have a code of conduct or other type of policy addressing appropriate
☐ ☐
behavior? What types of conduct are defined in it?
What is the organization’s process for addressing and managing behaviors that undermine a
☐ ☐
culture of safety, such as disruptive or intimidating behavior?
How are incidents involving violations of the code of conduct handled when they occur? ☐ ☐
Do leaders adopt and model appropriate behaviors and champion efforts to eradicate
☐ ☐
intimidating behaviors? Please provide an example.
How does your organization define a patient safety event? How does that definition guide your
☐ ☐
patient safety program and safety culture?


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Leadership: Patient Flow
Accreditation Programs/Settings: HAP


2.3: Patient Flow Use Use

Relevant Standards: HR.01.05.03, LD.04.03.11 Question Question
As Is As Is
Accreditation Programs/Settings: HAP
Please describe your own processes to manage patient flow. What are your goals in relation to
☐ ☐
patient flow?
Which staff is involved in conferring on patient flow? How are staff on different units or
☐ ☐
departments involved in patient flow processes or improvement efforts?
How do you train and educate staff on patient flow? ☐ ☐
How is oversight of patient flow monitored by management and reported to leadership? ☐ ☐
What oversight structure (such as a team or committee) do you have in place to manage patient
☐ ☐
flow? How is oversight data monitored and reported back to leadership?
What data collection processes do you have in place to track and monitor patient flow? ☐ ☐
What reports or dashboard data do you review that help you monitor and mitigate patient flow
☐ ☐
issues that might occur on the various units and over time?
What processes do you have in place to manage and respond to boarding? Do your processes
☐ ☐
include a time limit on boarding?


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Leadership: Contracted Services

2.4: Contracted Services

Use Use
Relevant Standards: HR.01.04.01, HR.01.05.03, HRM.01.03.01, HRM.01.05.03, LD.04.03.09
Question Question
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, LAB, NCC, OBS, OME As Is As Is
What services do you use from contracted providers? Pharmacy? Laundry? Environmental
Services? Who is responsible for management and oversight of these contracted services for your ☐ ☐
organization?
What is the role of leadership in relation to contracted services? ☐ ☐
How do you plan for use of contracted staff? ☐ ☐
Please show me a copy of a contract for outside services. How is the contract managed? ☐ ☐
What is the process leaders use to set organization expectations for performance of contracted
☐ ☐
services? Please give an example.
What is the process leaders use to evaluate contracted services per organization expectations?
☐ ☐
Please give an example.
Please give an example that describes how leaders took steps to improve contracted services that
☐ ☐
did not meet expectations.
How do you determine qualifications for contracted staff? ☐ ☐
What performance criteria for contracted staff are set in advance? How do you monitor
☐ ☐
performance? How is performance evaluated and by whom?
What kinds of orientation and training do you provide to contracted staff? Where do you
☐ ☐
document this education?
How are you addressing the oversight of contracted staff supplied by organizations that are also
☐ ☐
accredited by The Joint Commission?


3
MEDICAL STAFF
STAFFING AND
DOWNLOAD
Staffing and Medical Staff: Staff Orientation, Training, and Education
Staffing and Medical Staff You may wish to

3.1: Staff Orientation, Training, and Education

Relevant Standards: HR.01.02.01, HR.01.04.01, HR.01.05.03, HR.02.02.01, HRM.01.03.01, Use Adapt
HRM.01.05.01 Question Question
As Is for Use
NOTE: HRM Standards are for BHC only.
What is the content of the orientation you provide for staff? How do you provide the orientation?
☐ ☐
How is this documented?
What kind of training have you received to support your work? ☐ ☐
What topics were covered in recent training? How was the training provided? ☐ ☐
What education resources and opportunities are available to you for professional development? ☐ ☐
Do you feel that the organization’s training and education adequately prepare you for preventing
☐ ☐
adverse events? Do you know how to respond to an adverse event and other incidents?
What kind of orientation and training do you provide to contracted staff? Where do you
☐ ☐
document this?
What training is provided for leaders regarding organization policy and compliance with
regulatory requirements?
☐ ☐
What kind of training and orientation is provided to staff providing care, treatment, and services
☐ ☐
to children, youth, and geriatric individuals?


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Staffing and Medical Staff: Credentialing and Privileging

3.2: Credentialing and Privileging

Relevant Standards: HR.01.02.01, HR.01.02.05, HR.01.02.07, HR.01.07.01, HR.01.05.03,
HR.02.01.03, HR.02.01.04, HR.02.01.05, HR.02.01.07, HR.02.03.01, HR.02.04.01, HR.02.04.03,
HRM.01.01.01, HRM.01.01.03, HRM.01.02.01, HRM.01.05.01, HRM.01.07.01, LD.04.03.09, Use Use
MS.01.01.01, MS.03.01.03, MS.06.01.01, MS.06.01.03, MS.06.01.05, MS.06.01.07 MS.06.01.09, Question Question
MS.06.01.11, MS.06.01.13, MS.07.01.03, MS.08.01.01, MS.08.01.03, MS.09.01.01, MS.10.01.01, As Is As Is
MS.12.01.01
Who is responsible for performing your credentialing? Do you use a credentials verification
☐ ☐
organization (CVO) for verification? If so, how do you evaluate the services of the CVO?
When are practitioner licenses and other credentials verified? How is this process documented? ☐ ☐
What sources do you use to verify a practitioner’s education, training, and licensure? How do you
☐ ☐
perform your primary and secondary source verification?
Do you require a criminal background check for credentialing? ☐ ☐
Do you require specific health screenings for credentialing? What about proof of immunizations?
☐ ☐
Is any other health information required?
What is the process for recredentialing? How does the recredentialing process differ from the
☐ ☐
initial credentialing process?
Do you have a different process to verify the credentials of nonprivileged practitioners (if you
☐ ☐
choose to credential)? Can you please describe that process?
Please provide the credentialing files for your licensed independent practitioners. ☐ ☐
What is your process for granting initial clinical privileges to practitioners? Is the process approved
☐ ☐
by leadership?
Does the process for granting renewed or revised privileges differ from the process for granting
☐ ☐
initial privileges? If so, how?
Do you have an expedited process for initial appointment and reappointment to the medical staff
☐ ☐
and for granting privileges? Can you please describe that process? [HAP only]
How is the medical staff involved in the privileging process? [CAH and HAP only] ☐ ☐

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Staffing and Medical Staff: Credentialing and Privileging
What criteria do you use to determine the scope of the practitioner’s privileges? ☐ ☐
How do you know if practitioners are credentialed and trained for privileges requested? ☐ ☐
What evidence do you use to determine a practitioner’s current ability to perform the privileges
☐ ☐
requested? How is this documented?
How is peer review involved in the privileging process? ☐ ☐
What else is evaluated before granting initial, renewed, or revised privileges to a practitioner for
☐ ☐
requested privileges? How is leadership involved in this evaluation?
Is there a time constraint on resources needed to support granting of requested privileges? If so,
☐ ☐
please explain what that is. [CAH and HAP only]
How do you know if a practitioner’s license has expired or been terminated? ☐ ☐
For how long are privileges granted? ☐ ☐
How do you notify practitioners about decisions to grant, renew, or deny privileges? ☐ ☐
Is there a time limit for notifying practitioners about decisions regarding requested privileges?
☐ ☐
How is that determined? [CAH and HAP only]
Does your organization grant temporary privileges? If so, for what reasons? For how long? What is
☐ ☐
the process?
Please provide the documentation showing the practitioner’s credentials and training for the
☐ ☐
privileged procedures.
How are performance evaluations factored into maintaining, renewing, revising, or revoking
☐ ☐
privileges?
How does your organization evaluate each practitioner’s performance on an ongoing basis? What
does your organization do if issues affecting the provision of safe, high-quality patient care are ☐ ☐
identified? [CAH and HAP only]
What is the role of the medical staff in responding to reported concerns about the clinical
☐ ☐
competence of a privileged practitioner? [CAH and HAP only]
What is your fair hearing and appeal process for addressing denial, suspension, revocation,
☐ ☐
reduction, and reappointment of privileges?
What continuing education have privileged practitioners participated in recently? Can you please
☐ ☐
provide documentation of this? [CAH and HAP only]


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Staffing and Medical Staff: Competency Assessment

3.3: Competency Assessment

Relevant Standards: HR.01.06.01, HR.01.07.01, HRM.01.06.01, HRM.01.06.03, HRM.01.06.05,
Use Use
HRM.01.06.07, HRM.01.06.09, HRM.01.06.11, HRM.01.07.01, LD.04.03.09, MS.08.01.01,
Question Question
MS.08.01.03, MS.09.01.01
As Is As Is
What processes do you have in place for competency assessment? How are these processes
☐ ☐
documented?
What structure do you have in place to oversee your competency assessment processes? ☐ ☐
How do you evaluate your competency assessment program? ☐ ☐
What qualifications and competencies are required for staff who are responsible for performing
competency assessments? How do you assess the competency of those staff to perform ☐ ☐
competency assessments?
How do you assess competency for contracted staff? ☐ ☐
How often is competency assessed? When do you first assess competency? ☐ ☐
How does the organization verify competency? How is verification of competency documented? ☐ ☐
How do you conduct internal audits of your policies and procedures relating to staffing
☐ ☐
competency?
How do you ensure that your competency assessment processes meet all regulations and
☐ ☐
requirements?
What types of skills are you evaluated on for your job? ☐ ☐
How does your organization assess the competency of those who work with equipment? ☐ ☐
Would you please show me a personnel record for a staff member who has undergone
☐ ☐
competency training for operating a specific piece of equipment?
What competencies does the organization require of those who provide care, treatment, and
services for children and youth? Can you show me where this is documented in the personnel ☐ ☐
record?

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Staffing and Medical Staff: Competency Assessment
Is there documentation of competency testing conducted at training sessions? ☐ ☐
What types of data do you collect to inform your ongoing professional practice evaluation
☐ ☐
(OPPE)? How is this analyzed and tracked? [CAH and HAP only]
What do your policies specify regarding focused professional practice evaluations (FPPEs)? [CAH
☐ ☐
and HAP only]
When do focused professional practice evaluations (FPPEs) occur and why? How is the FPPE time
☐ ☐
period determined? [CAH and HAP only]
Who is responsible for creating the focused professional practice evaluations (FPPEs) plan? [CAH
☐ ☐
and HAP only]
Who fills out the focused professional practice evaluations (FPPEs)? [CAH and HAP only] ☐ ☐
What supportive mechanisms do you have in place to respond when an FPPE or OPPE warrants it?
☐ ☐
[CAH and HAP only]
May I please see examples of OPPEs and FPPEs? [CAH and HAP only] ☐ ☐


4
THE PATIENT
CARE OF
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Care of the Patient: Admission, Discharge, and Transitions of Care
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, NCC, OBS, OME

Care of the Patient You may wish to

4.1: Admission*, Discharge†, and Transitions of Care

Relevant Standards: HR.01.05.03, HRM.01.05.01, LD.04.03.01, PC.01.01.01, PC.02.02.01, Use Adapt
PC.02.01.21, PC.02.03.01, PI.01.01.01, PI.02.01.01, PI.03.01.01, RC.01.03.01, RC.02.04.01 Question Question
As Is for Use
What is your process to admit new patients? ☐ ☐
When a patient is admitted, what members of the staff are involved? How are patients and
☐ ☐
families involved in the process? [N/A for AHC and OBS]
What methods are used to identify the patient during the registration process? ☐ ☐
What education and/or information do you provide to patients at admission and/or in the initial
screening/assessment? How do you ensure and confirm that the patient and family understand ☐ ☐
what you share with them at that time?
How do you document the registration/admission? How do you document the education and/or
information provided to patients at that time? What do you do for a patient that is non-English ☐ ☐
speaking?
Please show me the intake/referral form for this patient. ☐ ☐
What is your registration or check-in process for surgery? Is a learning assessment performed? Do
you perform any presurgical assessments of the patients? If so, what are they? [CAH, HAP, OBS ☐ ☐
only]
If the patient presents at admission with any high-risk factors, such as diabetes or self-harm, what
☐ ☐
additional assessments are performed or ordered for referral, if any?
Does your physical space for admission permit privacy? How to you mitigate if admission is
☐ ☐
conducted in a noisy, busy area?
What is your discharge planning process? When does discharge planning begin? Who is involved? ☐ ☐
What kind of role do you play in the patient’s discharge planning? Are you included in the
interdisciplinary patient care team meetings?
☐ ☐
What kind of discharge planning do you have in place for patients receiving behavioral health
☐ ☐
care, particularly in relation to any medications after discharge?
What is the discharge plan for this patient? Is it documented? Please provide this patient’s
☐ ☐
discharge plan.

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Where is the discharge summary for this patient? May I see it, please? ☐ ☐
How have you informed and involved the patient and family in the discharge plan? How do you
accommodate any questions or concerns? How do you ensure and confirm that patients and ☐ ☐
family members understand what you share with them during discharge planning?
What information, education, and material do you provide to the patient at discharge? How do
☐ ☐
you know the patient understands what you provided?
Patient: Please tell me about your experience with discharge. Can you tell me when you need to
follow up on, how to take your medications, and what type of activity you can or cannot do? Did ☐ ☐
you have enough information when you left? Were you able to have your questions answered?
How do you follow up with patients after they are discharged? How do you ensure and confirm
☐ ☐
that patients understand what you share with them during follow-up?
What data do you receive about discharged patients? What is the rate of returns to your hospital
within 30 days of discharge? How do you track patients who go to a different hospital within 30 ☐ ☐
days of discharge? [CAH and HAP only]
What do you do with data on readmissions to your hospital? How do you report it and to whom?
☐ ☐
[CAH and HAP only]
Who is involved in ensuring safe transition of a patient to a new location, home, or another
☐ ☐
organization? Please describe the handoff communications process.
How do staff members educate the patient and family about transition home or to a different
facility? How do you ensure and confirm that patients and family members understand what you ☐ ☐
share with them at that time?
What is your process for transferring a patient to a higher level of care? What is communicated to
the next provider of care? What is your process and policy on calling 911–EMS (emergency ☐ ☐
medical services) system and/or a private ambulance?
How do you refer a patient to a hospital? What information do you communicate to the hospital?
How is this information communicated? [N/A for CAH and HAP]
☐ ☐
What kind of interaction do you have with local hospitals and/or long-term care facilities to better
☐ ☐
communicate issues that may result in hospital readmissions? How effective is this interaction?
Please explain the process for making the decision to send a patient to the emergency
☐ ☐
department. [N/A for CAH and HAP]
How do you receive patients from the emergency department? What kind of information do you
receive? How is this information communicated to you? How do you know what must be set up in ☐ ☐
the patient’s room prior to transfer? [CAH and HAP only]
What kind of referral or discharge information do you receive for a new individual transferred to
☐ ☐
your organization? What materials or guidance was the previous organization able to provide?

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Who orders tests in your organization? How do you document when an order is made? How are
patients informed of any necessary tests before discharge? How are patients educated about the ☐ ☐
test? How do you ensure and confirm that patients understand that information? [N/A for BHC]
How are referrals made for additional care and services, such as for ongoing opioid addiction
treatment or home health care? How are referrals documented? How are patients informed and
☐ ☐
educated about the referrals? How do you ensure and confirm that patients understand that
information?
Please explain how you mitigate any potential issues during transitions of care and if an issue
requires immediate response. How do you factor such issues into your transitions of care ☐ ☐
processes?
How do you educate and train staff on admission, discharge, and transitions of care processes?
☐ ☐
How often do you provide staff with updates on these processes?

* The term admission and its forms (admit) is also used to indicate any initial point of contact such as registration,
acceptance into a program, beginning of services, and so on. You may change the terms to any that are more appropriate
for your organization.
† The term discharge and its forms (discharging) is used to indicate any point of contact at the end of an episode of care,
including transfer. You may wish to use the phrase continuity of care or other terms that are more appropriate for your
organization.


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Care of the Patient: Assessment and Plan of Care

4.2: Assessment and Plan of Care

Relevant Standards: CTS.02.01.07, CTS.02.02.01, CTS.02.02.03, CTS.02.03.01, CTS.02.03.07,
CTS.05.04.05, PC.01.02.01, PC.01.02.03, PC.01.02.05, PC.01.02.11, PC.01.02.13, PC.01.03.01, , Use Adapt
PC.01.03.05, PC.02.01.01, PC.02.01.03, PC.02.01.05, PC.02.01.19, PC.02.01.21, PC.02.02.01, Question Question
PC.02.03.01 As Is for Use
NOTE: CTS standards are for BHC only.
What kinds of screenings/assessments do you perform? Who conducts them? ☐ ☐
Please show me a copy of your organization’s policies for screening and assessing patients for
☐ ☐
each service you provide.
How do you determine which screenings/assessments you will perform? How is this written into
your policies and what processes do you have in place to review and, if necessary, update those ☐ ☐
policies?
What is your process for conducting screenings/assessments? How often are they performed? ☐ ☐
How do you communicate results of screenings/assessments with the rest of the interdisciplinary
☐ ☐
treatment team?
Where do you document screenings/assessments? May I see the documentation? ☐ ☐
Can the results of a screening trigger a referral or a full assessment? How would a member of the
treatment team communicate the need for this comprehensive assessment to the appropriate ☐ ☐
team member?
Do you ever conduct any specialized or specific additional screenings/assessments for patients? If
☐ ☐
so, what are they? Where do you document these screenings/assessments?
What types of screenings/assessments do you complete for patients on admission? ☐ ☐
What are your time frames for completion of initial screenings/assessments and how do you
☐ ☐
communicate results with staff?
What is your process for screening/assessing a new patient? How do you document the
☐ ☐
screening/assessment?
What kinds of assessments do you conduct when a patient arrives on the medical/surgical unit?
☐ ☐
Who conducts these assessments? [CAH and HAP only]

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Please describe the initial screenings/assessments that you conducted for this patient. What kind
of ongoing assessment do you conduct for patients?
☐ ☐
How are behavioral health patients assessed when admitted through the emergency department
(ED)? When patients transition to another area of the hospital from the ED, how is this handled ☐ ☐
and documented? [CAH and HAP only]
Does your organization perform any specialized types of screenings/assessments for specific
☐ ☐
populations, such as pediatric or geriatric patients?
What screenings/assessments do you conduct for children/youth? What special assessments do

☐ ☐
you conduct and when are those warranted?
Who is responsible for determining a parent’s ability to safely assess/monitor a child/youth by

☐ ☐
using equipment provided for when the nurse or practitioner is not present?
How do you assess patients who may have dementia? What reassessments do you conduct? ☐ ☐
How do you coordinate and document the assessment of a new hospice patient? What processes
☐ ☐
do you have in place to ensure timely assessment and documentation? [OME only]
How do you assess the needs of the patient and family? ☐ ☐
Please describe your interdisciplinary care team planning process. ☐ ☐
Who is on your interdisciplinary team? How is it structured to support the care, treatment, and
☐ ☐
services your organization provides?
What role does the referring physician have on the interdisciplinary team? How do you
☐ ☐
communicate with the referring physician?
What kind of involvement have you had in the plan of care for this patient? How is this
☐ ☐
involvement documented?
How often does each interdisciplinary team meet? How and where are its activities documented? ☐ ☐
How do you update and modify the plan of care, treatment, and services? Who monitors it? How
☐ ☐
is this documented?
What kind of plan of care is involved with new patients? ☐ ☐
Can you tell me about the plan of care for this patient? What kinds of patient activities are you
required to do in order to implement this plan of care? How often do you review and update a ☐ ☐
care plan for a patient receiving this type of care?
What is the process you follow when your patient’s status changes? As an example, can you tell
me what happened the last time your patient’s status changed? How did you communicate this to ☐ ☐
others on the care plan team?
How are care, treatment, or service plans developed? What information is included in the plan
☐ ☐
reviews? [BHC only]

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What model does your organization use for developing care, treatment, or service plans and
tracking progress? What information is recorded in the progress notes? How has the
☐ ☐
documentation system been revised to reflect the care, treatment, or service plan model? [BHC
only]
How do care, treatment, or service team members communicate with one another regarding the
☐ ☐
care, treatment, or service plan as well as updates to the plan? [BHC only]
Does the care, treatment, or service plan reflect the individual’s needs, strengths, references, and
☐ ☐
goals? Who contributes to the plan? [BHC only]
How does the care, treatment, or service plan team monitor the individual’s progress toward
goals? What measure of a successful clinical outcome has been identified for individuals? [BHC ☐ ☐
only]
What strengths and outcomes does the care, treatment, or service plan team expect to see for
☐ ☐
each individual? What happens if an individual is not meeting expected outcomes? [BHC only]
What do you define as care, treatment, or service plan outcomes at your organization? How do
you evaluate whether you are achieving outcomes for individuals served, as well as for all ☐ ☐
individuals served in the aggregate? [BHC only]
What kind of interdisciplinary work do you undertake when planning care, treatment, or service
☐ ☐
for a youth? Who is involved? How is this documented? [BHC only]
How do you involve the youth and parents in the care, treatment, or service plan process? How
☐ ☐
are teachers involved? What do you communicate and when? [BHC only]
How has the youth adapted to the care, treatment, or service plan? Have you had to make any
☐ ☐
adjustments? If so, may I see documentation of that? [BHC only]
What is the response to violent behavior by the youth? How does this impact the care, treatment,
☐ ☐
or service plan, if at all? [BHC only]
What is the process for the physical therapy department to receive orders for a patient? How is
physical therapy staff informed about a patient’s plan of care? How do you coordinate the plan of
care with the floor? How do you also communicate with practitioners regarding
☐ ☐
recommendations and treatment plans? [N/A for BHC]
Physical Therapist: Are you included in the interdisciplinary patient care team meetings? What
☐ ☐
kind of role do you play in the patient’s discharge planning? [N/A for BHC]


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Care of the Patient: Emergency Department Processes
Accreditation Programs/Settings: CAH, HAP

4.3: Emergency Department Processes

Use Adapt
Relevant Standards:* LD.04.03.11, MM.04.01.01, NPSG.02.03.01, PC.01.02.01, PC.01.02.15, Question Question
PC.02.01.05, PC.02.01.21, PC.02.02.01, PI.01.01.01, PI.02.01.01, PI.03.01.01 As Is for Use
What happens when a patient arrives in the emergency department? ☐ ☐
What kinds of screenings and assessments do you perform in the emergency department?
What is your triage process in the emergency department? ☐ ☐
Do you use protocols and/or standing orders? How are these developed and maintained? Are
they reviewed annually and signed off by the medical executive committee?
☐ ☐
What information does the emergency department provide when transferring a patient to
☐ ☐
another department in the organization or to other organizations? How is this documented?
Have admission backups in the emergency department been a problem? If so, how are you
☐ ☐
addressing that?
What kinds of communication processes do you have in place to help the hospital address an
☐ ☐
upsurge in patients coming into the emergency department?
How do you educate and inform the patient and family about what will happen in the emergency
☐ ☐
department regarding a patient’s care?
How do you make certain the patient and family understand what is happening in the emergency
department during the patient’s visit?
☐ ☐
How does the emergency department interface with the radiology department when an x-ray is
☐ ☐
needed?
How do you communicate a stat test order from the emergency department to the laboratory?
☐ ☐
What follow-up do you need to do?
What is the process to deliver a sample to the laboratory from the emergency department? ☐ ☐
How do you receive stat test results from the laboratory? ☐ ☐
How are critical results managed? ☐ ☐

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Care of the Patient: Emergency Department Processes
Are verbal orders used in situations other than an acute emergency? What is the process for
☐ ☐
obtaining, documenting, and implementing a verbal order?
Have you identified any issues in communication among staff and between departments? What
type of data have you collected to help determine the extent and cause of these issues? What ☐ ☐
changes have you made to mitigate these issues?
How does the hospital provide patient flow data to the Centers for Medicare & Medicaid Services
☐ ☐
(CMS) on its inpatient emergency department measures?

* HAP standards related to pain assessment and management (namely, PC.01.02.07) are undergoing revision at the time of
this printing, so pain management questions have been eliminated here. Check the forthcoming HAP manuals for correct
relevant standards and adapt tracer questions to the new standards as necessary.


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Care of the Patient: Suicide Risk Assessment
Accreditation Programs/Settings: BHC, HAP

4.4: Suicide Risk Assessment

Relevant Standards: CTS.06.02.01, HR.01.05.03, HR.01.07.01, HRM.01.02.01, HRM.01.05.01, Use Adapt
NPSG.15.01.01, PI.01.01.01, PI.03.01.01 Question Question
As Is for Use
Accreditation Programs/Settings: BHC, HAP
NOTE: CTS and HRM standards are for BHC only.
What methods or criteria do you use to screen patients at risk for suicide? ☐ ☐
What questions do you ask to screen patients at risk for suicide? What criteria are used to decide
☐ ☐
whether to conduct a full assessment? How does that assessment differ from the screening?
When do you conduct suicide risk screenings and assessments? How are they documented? What
☐ ☐
do you do when potential risk factors are identified?
If a patient reports previous suicide attempts, how are those attempts and their triggering events
☐ ☐
evaluated? How are the reports documented?
How are patients reassessed for suicide risk during their treatment? ☐ ☐
What training do emergency department and medical/surgical staff receive in relation to suicide
☐ ☐
risk assessment and prevention? [HAP only]
What is the competency of staff to complete the suicide risk screening? What is the competency
☐ ☐
of staff to conduct a full assessment? May I see competency documentation?
How are staff educated on suicide risk assessment? ☐ ☐
Can you describe your process to prevent suicide among the individuals you serve? For example,
☐ ☐
what kinds of interventions do you employ for individuals at risk for suicide?
Tell me about your environmental risk assessment addressing suicide prevention. ☐ ☐
During discharge, how do you communicate community resources for those at risk for suicide? ☐ ☐
Have you planned any improvements relating to suicide risk assessment and prevention? Who is
involved in this planned improvement project? What will you do to help implement and monitor ☐ ☐
improvements?


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Care of the Patient: Pain Management
Accreditation Programs/Settings: AHC, CAH, NCC, OBS, OME

4.5: Pain Management

Use Adapt
Relevant Standards: HR.01.04.01, PC.01.02.01, PC.01.02.07, PC.01.03.01, PC.02.01.01, Question Question
PC.02.03.01, PC.03.01.07, RI.01.01.01 As Is for Use
Accreditation Programs/Settings:* AHC, CAH, NCC, OBS, OME
Can you please explain your process for performing pain assessment? How is this documented? ☐ ☐
How do you assess pain in the pediatric patient, the patient with cognitive disabilities, the patient
who is physically challenged, the patient with sensory or verbal deficiencies, and non-English- ☐ ☐
speaking patients?
How do you perform initial assessment for pain? When does this occur? ☐ ☐
What kind of monitoring and reassessment for pain do you perform? ☐ ☐
Please tell me your process to document assessment and care planning in relation to ongoing pain
☐ ☐
management. How is this communicated to staff?
How is pain management handled in the ongoing provision of care? ☐ ☐
In addition to medication management, what other pain management techniques are used? ☐ ☐
What kind of pain management have you been providing for this patient? How do you assess for
☐ ☐
pain management in an ongoing manner?
Patient: Have you been assessed for pain? How often does the staff do this assessment? Is your
☐ ☐
pain being managed well? Please explain why or why not.
Patient: How well do you understand the care that you have been provided, such as medications
☐ ☐
and pain management? What do you do if you have a question about your care?
Have you educated patients and family about the pain management process and treatment
☐ ☐
options? How is this education done?
Patient and Family: What information have you been given about pain assessment and pain
☐ ☐
management?
How do you inform staff of alternatives to medication-related pain management interventions?

☐ ☐
How is this information documented? How do you implement best practices?
Please describe what you know about the cultural aspects of pain expression and management. ☐ ☐

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Care of the Patient: Pain Management
Accreditation Programs/Settings: AHC, CAH, NCC, OBS, OME
How are pain management patients scheduled for procedures? ☐ ☐
How is radiation exposure minimized during pain management procedures? ☐ ☐
What improvement efforts are you undertaking regarding the organization’s approach to pain
☐ ☐
management? Have you made improvements? How do you know?

* HAP standards related to pain assessment and management (namely, PC.01.02.07) are undergoing revision at the time of
this printing, so application of pain management standards questions for HAP have been eliminated here. Check the
forthcoming HAP manuals for correct relevant standards and adapt tracer questions to the new standards as necessary.


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Care of the Patient: Abuse and Neglect


4.6: Abuse and Neglect

Relevant Standards: CTS.02.02.05, CTS.02.04.19, HR.01.05.03, HR.01.06.01, HRM.01.05.01, Use Adapt
HRM.01.06.01, PC.01.02.09, RI.01.06.03, RI.03.01.05 Question Question
As Is for Use
Please provide a copy of your organization’s policy and procedures for addressing possible
trauma, abuse, neglect, or exploitation of a patient.
☐ ☐
What criteria do you use to identify who may be a victim of trauma, abuse, neglect, or
exploitation? When is an assessment performed? How is this documented?
☐ ☐
How does your assessment process address past trauma, abuse, neglect, or exploitation? ☐ ☐
If the patient reports a history of trauma, abuse, neglect, or exploitation, what sort of follow-‐up is
conducted?
☐ ☐
To whom would you communicate suspicions of trauma, abuse, neglect, or exploitation? How
would you report this? When would you file a report of abuse, neglect, or exploitation with your ☐ ☐
local agency?
Please describe your understanding of the signs and symptoms of abuse or neglect. Do you use
any specific tools or guidelines to assist in the assessment process?
☐ ☐
What specific training have you received in recognizing signs and symptoms of abuse or neglect?
May I review the training materials?
☐ ☐
How is competency in the assessment of abuse, neglect, or exploitation evaluated? How often is
this done?
☐ ☐
How has trauma-‐informed care training been incorporated into the assessment or treatment
process? May I see documentation of that training?
☐ ☐


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Care of the Patient: Nutrition
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, NCC, OME

4.7: Nutrition
Relevant Standards: CTS.04.01.03, CTS.04.02.16, CTS.04.03.33, HR.01.05.03, HRM.01.05.01, Use Adapt
PC.01.02.01, PC.02.02.03, PC.02.03.01, RC.02.01.11, RC.02.04.01 Question Question
As Is for Use
Do you have a process for nutrition screenings/assessments? What is that process? ☐ ☐
Who developed the nutrition screening? ☐ ☐
What types of findings would necessitate a consultation with a dietitian? ☐ ☐
How are dietary consultations arranged? ☐ ☐
Please tell me about the ongoing treatment and services provided to the patient, such as nutrition
education and counseling.
☐ ☐
How do you plan menus for patients with certain dietary concerns? [N/A for AHC] ☐ ☐
What are the potential barriers to this patient’s following the recommended diet? How did you
address these barriers?
☐ ☐
How do you address the different religious and cultural dietary customs of patients? ☐ ☐
What do practitioners do to address a patient’s weight loss? What changes are made to a
patient’s diet to encourage weight gain? Where are the effects of those changes documented?
☐ ☐
How does the staff prepare to care for a total parenteral nutrition (TPN) patient? [N/A for AHC
and BHC]
☐ ☐
How is the total parenteral nutrition (TPN) currently being provided to the patient? [N/A for AHC
and BHC]
☐ ☐
Please describe the total parenteral nutrition (TPN) process. [N/A for AHC and BHC] ☐ ☐
Please describe your staff training and experience with total parenteral nutrition (TPN). May I see
documentation of your certification in total parenteral nutrition (TPN)? [N/A for AHC and BHC]
☐ ☐


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Care of the Patient: Skin and Pressure Ulcers
Accreditation Programs/Settings: CAH, HAP, NCC, OME

4.8: Skin and Pressure Ulcers Use Adapt

Relevant Standards: HR.01.05.03, PC.02.01.01, PI.01.01.01, PI.03.01.01, NPSG.14.01.01 Question Question
As Is for Use
Accreditation Programs/Settings: CAH, HAP, NCC, OME
Do you always assess the patient for skin and pressure ulcer risk? If so, when? How is the
assessment documented?
☐ ☐
What is your process to assess skin and wounds for potential pressure ulcers or other
complications? Do you use any evidence-‐based guidelines or tools? If so, may I see them?
☐ ☐
How is the staff educated and trained to perform skin and pressure ulcer assessments? ☐ ☐
If you use a wound care specialist, what role does that person play in your assessment and plan of
care process?
☐ ☐
How do you communicate any concerns about skin and pressure ulcers issues during assessment?
What type of escalation do you normally plan for?
☐ ☐
How do you collect data on skin and pressure ulcer rates? What do you do with that data? Has the
data led to any improvements? If so, what?
☐ ☐


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Care of the Patient: Falls Risk


4.9: Falls Risk

Relevant Standards: CTS.02.03.11, HR.01.05.03, HRM.01.05.01, NPSG.09.02.01, PI.01.02.08, Use Adapt
PI.01.01.01, P1.02.01.01, PI.03.01.01 Question Question
As Is for Use
What is the process for assessing a patient for falls risk? What ongoing fall assessments and
☐ ☐
reassessments do you conduct?
What criteria are used for a falls risk designation? What else can trigger a falls risk designation? ☐ ☐
What interventions do you put in place when a patient is designated a falls risk? ☐ ☐
How are any changes in the patient’s condition considered in a falls re-evaluation? ☐ ☐
What kind of education do you provide to patients and families about falls risk and prevention? ☐ ☐
Patient: You have been designated as a falls risk by the nursing facility. Do you understand what
☐ ☐
that means? Do you understand why the staff has put certain interventions in place?
Patient: Do you understand why you have been determined to be a falls risk? Do you understand
what that means? Have staff members been responsive to your needs?
☐ ☐
How are staff members trained in falls risk and prevention? How often is that training provided? ☐ ☐
What interventions do the staff carry out to reduce falls? How are these actions documented? ☐ ☐
Staff Member: What orientation and training have you received regarding fall prevention? ☐ ☐
Staff Member: How do you respond if a patient falls? How is the fall reported and documented? ☐ ☐
Staff Member: How do you prevent yourself from falling while assisting a patient during a fall? ☐ ☐
Nurse Leader: What do you as a manager do to prevent patient and employee falls? ☐ ☐
Staff Member: How are you informed that a patient is at risk for falls? ☐ ☐
What is the process for preventing a fall during transport? What is the process for informing other
☐ ☐
units or organizations of a falls risk?
How do you assess the home environment for falls risk? How do you reassess the environment for
☐ ☐
falls risk on returning home visits?

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Care of the Patient: Falls Risk

How are patients and families educated about home environment hazards? ☐ ☐
What falls risk interventions have you put in place in the home environment? ☐ ☐
Family Caregiver: How have you been educated about falls risk? Do you understand why you have
☐ ☐
been asked to make changes in the home? Do you understand what constitutes a falls risk?
When physical therapy staff members visit the home, what types of falls risk reduction activities
☐ ☐
do they carry out?
What environmental controls does the organization have in place to prevent falls? What do you
☐ ☐
do if that technology fails?
Does the organization examine environmental risks regarding falls during environmental tours? ☐ ☐
Staff Member: What do you do when you see an environmental risk for falls, such as a spill? ☐ ☐
Has the organization done a root cause analysis on environmental risks for falls? ☐ ☐
Does the organization monitor data regarding falls and the causes thereof—for example,
☐ ☐
inclement weather? If so, what has the organization discovered?
What process does the organization have to identify environmental falls risk such as slippery
☐ ☐
areas? How do you address these risks?
What types of data do you collect in relation to falls risk? How do you analyze and use these data? ☐ ☐
Please provide event reports for falls. ☐ ☐
What external reporting requirements relating to falls risk do you meet? ☐ ☐
What do your data indicate about falls risk? Are there opportunities for improvement around fall
☐ ☐
reduction? How have the falls risk data assisted you with your agency’s improvement efforts?
If you have a falls risk reduction program, please describe it, including any recent interventions. ☐ ☐
How does your organization address the potential of certain medications to trigger falls? ☐ ☐
As part of your falls risk assessment process, do you review medication profiles? If so, why? ☐ ☐
Do you have a formal list of medications associated with falls, like blood pressure medications,
☐ ☐
sedating medications, diuretics, and analgesics—opiates and muscle relaxants in particular?
How is the pharmacy involved in falls risk? ☐ ☐


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Care of the Patient: Operative and High-‐Risk Procedures
Accreditation Programs/Settings: AHC, CAH, HAP, OBS

4.10: Operative and High-‐Risk Procedures

Use Adapt
Relevant Standards: MS.05.01.01, PC.01.01.01, PC.01.02.03, PC.03.01.01, PC.03.01.03, Question Question
PC.03.01.05, PC.03.01.07, PI.01.01.01, RC.02.01.01, RC.02.01.03, RC.02.01.07 As Is for Use
How are patients undergoing operative or high-‐risk procedures checked in? ☐ ☐
What kind of education do you provide to patients in relation to the procedure, risk factors, and
any postprocedural care? Do you have any documentation to accompany this process?
☐ ☐
What is involved in the patient preoperative process? How do you obtain informed consent? ☐ ☐
What is your sedation and operative consent process? Can you show me the form you use? ☐ ☐
How do you address medication reconciliation prior to the procedure? What happens if there are
contraindications for the patient to receive the medications ordered?
☐ ☐
How do you obtain information prior to the procedure about any allergies that the patient might
have?
☐ ☐
What clinical information (such as labs or diagnostic test results) needs to be available prior to the
procedure?
☐ ☐
Will you please describe the kind of testing conducted prior to the procedure? Who monitors
these tests? How are they documented?
☐ ☐
What interaction and communication do you have with the laboratory in relation to your
preoperative testing practices?
☐ ☐
How do you address preoperative abnormal diagnostic test results? ☐ ☐
Do you perform any presurgical assessments of patients? If so, what are they? ☐ ☐
Please describe the preanesthesia assessment and the preanesthesia assessment policy. ☐ ☐
Please describe your presedation or preanesthesia assessment. Who performs this assessment? ☐ ☐
Was a preoperative assessment done by the nurse? ☐ ☐
Did the patient have an opportunity to ask questions about the procedure? Were his or her
learning needs met?
☐ ☐

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How was the patient education about the procedure documented in the patient record? ☐ ☐
Was the information about the procedure only provided verbally to the patient, or were printed
materials provided as well?
☐ ☐
Patient: What instructions were you given regarding preparation for this procedure? Did you
understand and follow the instructions?
☐ ☐
Patient: What did your physician tell you about how this procedure would be performed? ☐ ☐
Patient: What did the physician tell you about the consent form for the procedure that you
signed?
☐ ☐
Patient: What did your physician tell you about alternatives to this procedure? ☐ ☐
What kind of presedation assessment do you perform? ☐ ☐
Where is your presedation assessment documented in the patient’s record? How do you update
it?
☐ ☐
How do you prepare patients for surgery? What kind of process do you follow? ☐ ☐
How do patients get from the exam room to the surgical suite? How are nonambulatory patients
managed?
☐ ☐
How and when do you identify the patient before surgery? ☐ ☐
What kind of preoperative check do you perform for the procedure? What do you verify? ☐ ☐
Do you use a preoperative standardized list, and does it include documentation regarding the
patient’s informed consent?
☐ ☐
What is your time-‐out process? Please describe it to me. Who is responsible for it? Where do you
document its completion?
☐ ☐
When was the surgical site marked? How was it marked? ☐ ☐
What is your process to verify the surgical site? How do you involve the patient in the process? ☐ ☐
What are the roles of the surgical staff at the start of the procedure? What are the roles of the
surgical staff while the procedure is under way?
☐ ☐
How are medications managed in the operating area? Who has access to the medication cart and
how is that monitored and controlled?
☐ ☐
What is the protocol if a patient becomes oversedated? ☐ ☐
What is your process in the event of resuscitation? How is this process documented? ☐ ☐
Who is responsible for preparing any postsurgical specimens for pathology? ☐ ☐

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Who is responsible for cleaning the surgical room? ☐ ☐
Who is responsible for reprocessing the surgical instruments? ☐ ☐
Please tell me about the postsurgical recovery process. ☐ ☐
What types of postsurgical assessment do you perform? When are they performed? ☐ ☐
How is the patient monitored postoperatively? How is the patient assessed for recovery from
anesthesia?
☐ ☐
Do postoperative instructions include signs and symptoms that require a call to the surgeon? ☐ ☐
What criteria are used to assess a surgical patient’s adequate recovery for discharge? Who is
responsible for making that decision?
☐ ☐
What kind of postoperative care was ordered for this patient? How are you kept apprised of the
patient’s condition?
☐ ☐
How do you follow up with surgical patients? ☐ ☐
What postoperative information and material do you provide to the patient and family? ☐ ☐
What kind of education do you provide to the patient regarding home care and infection
prevention?
☐ ☐
Do postoperative instructions include signs and symptoms that require a call to the surgeon? ☐ ☐
When do surgery patients typically return to your organization for any reevaluation? ☐ ☐
What postoperative documentation was performed? ☐ ☐
Surgical Staff: What kinds of competency assessments and ongoing training have you received in
relation to perioperative care?
☐ ☐
Please provide the documentation showing your physicians’ credentials and training in this
procedure. May I see the physicians’ most recent evaluations from their department heads?
☐ ☐
What type of training has your staff received on the fundamentals and techniques of endoscopy
and moderate sedation?
☐ ☐
What are some frequent high-‐risk procedures performed by your organization? What data do you
collect in relation to them? What type of analysis have you performed?
☐ ☐
What type of outcome has an analysis of data on your most common high-‐risk procedures
provided?
☐ ☐
What action have you taken in response to data relating to high-‐risk procedures? ☐ ☐


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Care of the Patient: Radiology Processes
Accreditation Programs/Settings: AHC, CAH, HAP, LAB

4.11: Radiology Processes

Relevant Standards: EC.02.01.01, EC.02.02.01, EC.02.04.03, HR.01.05.03, HR.01.02.05, Use Adapt
LD.04.03.11, MM.05.0l1.01, MM.06.01.01, PC.01.03.01, PC.01.02.15, QSA.19.01.01 Question Question
As Is for Use
NOTE: QSA standards are for LAB only.
How do you receive x-ray orders for radiological testing and procedures? How are radiology test
☐ ☐
results communicated back to the ordering provider?
How do you prepare equipment for the imaging? How is a patient transported to radiology? How
☐ ☐
is patient care managed in radiology?
How do you identify the patient to ensure that you are performing the ordered radiology test on
☐ ☐
the correct patient?
What radiation safety equipment is used to protect patients during radiological procedures and
☐ ☐
tests to minimize overexposures?
What kind of patient education do you provide about x-rays and other radiology processes? ☐ ☐
Patient: What education have you received regarding safety precautions for your radiological
☐ ☐
tests and procedures?
Patient: Describe, as best you can, the type of radiological tests and procedures you had and why. ☐ ☐
Please provide a recent assessment of delays in the radiology department. Describe the system
☐ ☐
your department has in place for prioritizing procedures in such a situation.
How do you screen patients prior to MRI testing? Do you screen staff as well? ☐ ☐
What is your process for managing patients with anxiety or claustrophobia who are set to
☐ ☐
undergo MRI testing?
What qualifications do you require for the MRI technologists? How do you verify staff
☐ ☐
qualifications?
What quality control activities do you perform on the radiology equipment to ensure that it is
☐ ☐
functioning properly?
What guidelines are the imaging protocols based upon? Who reviews and approves them? How
☐ ☐
are they kept current?

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Care of the Patient: Radiology Processes
Please describe the patient safety training that you have received at this organization regarding
☐ ☐
radiology processes.
Does your training for radiology processes include caring for non-English-speaking patients? ☐ ☐
Who interprets the radiological testing results, and how are the findings communicated to the
☐ ☐
ordering provider?
What is the process for handling radioactive source material, from delivery through
☐ ☐
administration and then disposal?
What training have you received about radioactive source material handling and preparation? ☐ ☐
How do you prepare radioactive source material? What risks are involved in preparing such
material? How do you minimize the risk of exposure? What personal protective equipment (PPE) ☐ ☐
do you wear when preparing radioactive source material?
What training have you had regarding the safe preparation of radioactive source material? ☐ ☐
How do you decide which staff members need to wear dosimetry badges? How often and by
☐ ☐
whom are the badges monitored?
Describe how you would respond to an unintended overexposure to radiation. To whom would
☐ ☐
you report such an event?
How does the organization receive radioisotopes? ☐ ☐
How does the organization receive after-hours delivery of radioisotopes? ☐ ☐
How are radioisotopes transported through the organization? ☐ ☐
How does the hot lab receive radioisotopes? ☐ ☐
Where are the radioisotopes stored in the hot lab? Who has access to that storage area? How
☐ ☐
does the hot lab maintain the security of that storage area?
How does the hot lab keep radioisotopes secure during transportation in the organization? ☐ ☐
How are radioisotopes transported to the radiology department? ☐ ☐
What are the safety and security risks associated with radioisotopes? ☐ ☐
What personal protective equipment should you wear when using or handling radioisotopes? ☐ ☐
What protection do patients require when interacting with radioisotopes? ☐ ☐
What has your training taught you about how to use radioisotopes properly? ☐ ☐
Has the organization conducted an emergency drill related to hazards of radioisotopes? What
☐ ☐
were the results of that drill?


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Care of the Patient: Transfusions and Blood Products
Accreditation Programs/Settings: AHC, CAH, HAP, LAB, NCC, OBS

4.12: Transfusions and Blood Products

Relevant Standards: APR.01.03.01, HR.01.02.03, HR.01.06.01, LD.04.05.03, NPSG.01.03.01, Use Adapt
PC.02.01.07, RC.02.01.03, QSA.05.01.01, QSA.05.02.01, QSA.05.03.01, QSA.05.03.03, Question Question
QSA.05.12.01, QSA.05.17.01, QSA.05.18.01, QSA.05.19.01, QSA.05.19.03, QSA.05.19.05 As Is for Use
Please provide the laboratory policies and procedures, including those for blood transfusions.
☐ ☐
[LAB only]
What organizations or agencies must be notified of changes in directorship, services, or location

☐ ☐
of the laboratory? Who is responsible for notification? [LAB only]
How do you receive an order for blood products in the laboratory? [LAB only] ☐ ☐
May I see the transfusion order and consent form? May I observe as you confirm this transfusion
☐ ☐
order? How long can you wait before starting the transfusion?
What process do you follow to prepare and test the blood product before providing it to the
patient? How are tests documented? [LAB only]
☐ ☐
What process do you follow to administer blood to a patient? ☐ ☐
What is the process for patient identification during blood collection? How is the patient
identification retained throughout the transfusion?
☐ ☐
How can you ensure that patient information stays attached to the blood unit throughout the
☐ ☐
transfusion process?
What process do you follow to check for a transfusion reaction? How is this process documented? ☐ ☐
What would you do in the event that a patient had a transfusion reaction? ☐ ☐
May I review the transfusion reaction policy documents? ☐ ☐
How do you instruct the patient regarding transfusion reactions? ☐ ☐
What training and competency have you had in relation to handling and administering blood
☐ ☐
products?
How does your laboratory obtain blood products? [LAB only] ☐ ☐
What is the process to obtain blood in an emergency? Please give an example. [LAB only] ☐ ☐

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Care of the Patient: Transfusions and Blood Products
May I review a specimen tube label? [LAB only] ☐ ☐
How do you monitor the blood utilization and criteria for transfusion? ☐ ☐
How do you monitor blood transfusion documentation and safety? ☐ ☐
How does your laboratory perform the quality control in the blood bank daily and document the
☐ ☐
lot numbers? Please provide your quality control documentation for review. [LAB only]
How are the blood products stored? May I see the refrigerator used for this? May I review the
☐ ☐
temperature logs? [LAB only]
What sort of backups are used on the main refrigerator and freezer, in case of power outages or
☐ ☐
other emergencies? [LAB only]
May I review the credentialing file on the new laboratory director? [LAB only] ☐ ☐
May I review the training and competency documentation for the transfusion staff and laboratory
☐ ☐
technician? [LAB only]


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Care of the Patient: Physical Therapy
Accreditation Programs/Settings: AHC, CAH, HAP, NCC, OBS, OME

4.13: Physical Therapy Use Adapt

Relevant Standards: HR.01.02.01, LD.04.03.01, PC.01.02.05 Question Question
As Is for Use
What is the process for the physical therapy department to receive orders for a patient? How is
the physical therapy staff informed about a patient’s plan of care? How do you coordinate the ☐ ☐
plan of care with the staff regarding recommendations and treatment plans?
What physical therapy are you doing for this patient? How is this care documented? ☐ ☐
Are you included in the interdisciplinary care plan team meetings? ☐ ☐
When did you receive this referral? How long have you been seeing this patient? When do you
☐ ☐
report to the case manager?
What kind of role do you play in the patient’s discharge planning? ☐ ☐
What training and orientation have you received regarding hand hygiene? Can you tell me what is
☐ ☐
required?
What do you do if the patient appears to be in distress? To whom do you report it? ☐ ☐
What training and orientation have you received related to falls risk and patient safety? ☐ ☐
When physical therapy staff members visit the home, what types of falls risk reduction activities
do they carry out?
☐ ☐

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Care of the Patient: Chemotherapy
Accreditation Programs/Settings: AHC, CAH, HAP, OME

4.14: Chemotherapy
Use Adapt
Relevant Standards: HR.01.05.03, HR.01.06.01, HR.01.07.01, EC.02.02.01, MM.01.01.03, Question Question
MM.07.01.03 As Is for Use
How do you safely handle high-alert and hazardous medications such as oral chemotherapy
☐ ☐
agents?
What part do you play in making sure chemotherapy is used safely in this organization? ☐ ☐
Who oversees the processes to ensure that there is consistency in meeting safe practice
☐ ☐
requirements with chemotherapy medications?
What is organization policy regarding the use of personal protective equipment (PPE) during
chemotherapy administration?
☐ ☐
What process do you follow to add a chemotherapy drug to the hospital formulary? ☐ ☐
Where are chemotherapy medications stored? How do you address safety issues associated with
storage of chemotherapy medications?
☐ ☐
How do you prepare chemotherapy medications? What steps do you take to ensure that
☐ ☐
preparation of chemotherapy drugs is done as safely as possible?
Pharmacist: What information do you need before preparing the chemotherapy infusion? ☐ ☐
Pharmacist: Do you use “clean” or “sterile” technique in preparing chemotherapy infusions?

Why? Provide a step-by-step description of the way you ensure that mixing occurs under ☐ ☐
conditions of proper cleanliness.
Pharmacist: Does a second person check the concentration of chemotherapy preparations? If so,
☐ ☐
why?
How do you label the preparations when chemotherapy orders are filled? ☐ ☐
How do you determine and ensure required competencies for staff involved in chemotherapy
☐ ☐
preparation and dispensing?
How does chemotherapy medication get delivered to the unit and then to the patient? ☐ ☐
How are nurses who work in this area trained and deemed competent for the administration of
☐ ☐
chemotherapy medications? Please show documentation of this assessment.

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Care of the Patient: Chemotherapy
How much experience do you have in administering chemotherapy? How has this hospital helped
you enhance your competencies in administering chemotherapy?
☐ ☐
Patient: What does the nurse do to make sure that you are the correct patient before
☐ ☐
administering your chemotherapy?
What patient safety precautions are taken before administering chemotherapy? ☐ ☐
What are your criteria for reporting adverse drug reactions involving chemotherapy agents? What
☐ ☐
is the follow-up process?
How do you track chemotherapy administration and monitor effects on the patient’s blood
☐ ☐
count?
How do you determine which physicians can prescribe chemotherapy drugs? ☐ ☐
What are the typical side effects one can expect with this type of chemotherapy? What are the
interventions that can help reduce these side effects? How were these interventions discussed ☐ ☐
with the patient and documented in the patient’s chart?
Patient: At the beginning of your treatments, what were you told about the risks and side effects,
☐ ☐
as well as the effectiveness, of receiving chemotherapy?
Patient: Have you had any side effects from the chemotherapy? If so, how have the nurses
☐ ☐
responded?
Patient: What did your caregivers say about chemotherapy safety issues? What information did
they provide regarding the handling of urine and waste?
☐ ☐
Patient: Please define what you think “neutropenic precautions” means. Why do your caregivers
take special precautions with your immune system?
☐ ☐
Patient: What behavioral changes have you made due to what you have learned about
☐ ☐
chemotherapy and your immune system? How have the precautions affected your visitors?
What training have you received relative to chemotherapy? What action would you take if a
☐ ☐
chemotherapy infusion spilled?
How is the chemotherapy IV bag safely removed once it is empty? ☐ ☐
How do you dispose of chemotherapy waste? ☐ ☐


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Care of the Patient: Restraint and Seclusion


4.15: Restraint and Seclusion

Relevant Standards: CTS.05.06.01, CTS.05.06.15, CTS.05.06.17, CTS.05.06.19, CTS.05.06.21,
CTS.05.06.23, CTS.05.06.25, CTS.05.06.27, CTS.05.06.29, CTS.05.06.33, HR.01.05.03, HR.01.07.01,
HRM.01.02.01, HRM.01.05.01, PC.02.03.01, PC.01.03.03, PC.03.02.03, PC.03.02.07, PC.03.02.09, Use Adapt
PC.03.02.01, PC.03.02.13, PC.03.03.01, PC.03.05.01, PC.03.05.03, PC.03.05.05, PC.03.05.07, Question Question
PC.03.05.09, PC.03.05.11, PC.03.05.15, PC.03.05.17, PC.03.05.19, RC.02.01.05, RC.02.03.07, As Is for Use
RI.01.06.01
Do you have a policy on restraint and seclusion? May I see the policy? ☐ ☐
What alternatives to restraint are used in your organization? ☐ ☐
Please describe your assessment of a patient’s need for restraint and/or seclusion. ☐ ☐
What screening is used to decide on an immediate (emergency) use of restraint and/or seclusion? ☐ ☐
How does staff respond to a call for immediate (emergency) use of restraint and/or seclusion? ☐ ☐
Who orders restraint and/or seclusion? How are orders made? ☐ ☐
How is restraint and/or seclusion monitored? How is monitoring documented? ☐ ☐
When is restraint and/or seclusion discontinued? How is that decided and documented? ☐ ☐
Are the patient and family provided information on the use of restraint? ☐ ☐
How is the staff educated and trained in the appropriate and safe use of restraint and seclusion?
☐ ☐
Is de-escalation and management of challenging behaviors part of that training?
How are staff and providers evaluated on competencies related to the use of restraint and
☐ ☐
seclusion? May I see an example of documentation of that competency assessment?
How are adverse events as a result of restraint and/or seclusion reported and investigated? ☐ ☐
How does your organization prevent, reduce, and strive to eliminate restraint and seclusion?
☐ ☐
What resources are provided for performance improvement in this area?


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Care of the Patient: Youth Addiction Program
Accreditation Programs/Settings: BHC

4.16: Youth Addiction Program

Use Adapt
Relevant Standards: CTS.02.01.07, CTS.02.03.03, CTS.02.03.07, CTS.03.01.01, CTS.04.02.13, Question Question
CTS.04.02.15, HRM.01.01.01 As Is for Use
Accreditation Programs/Settings: BHC
How do you receive new youths into the addiction program? What types of
screenings/assessments do you perform? Where is this documented? Who has access to this ☐ ☐
documentation?
What planning of care, treatment, or services do you perform for individuals served in a youth
addiction program? Describe your program’s process for creating a care, treatment, or services ☐ ☐
plan. How do you review and update the process, if needed? Who is involved?
How are youths and their parents involved in the assessment and planning of care, treatment, or
☐ ☐
services?
How do you document the plan for care, treatment, or services for individuals served in a youth
addiction program? How do you document the diagnosis by a qualified practitioner and any ☐ ☐
sessions with a youth or his or her parents?
How do you determine and proceed with a medically supervised detox for individuals served in a
☐ ☐
youth addiction program?
How do you ascertain specific needs, such as de-escalation methods for individuals served in a
youth addiction program?
☐ ☐
What happens in the event of an escalation? How is this documented? What safety measures do
☐ ☐
you have in place for staff and youths?


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Care of the Patient: Advance Directives

4.17: Advance Directives

Use Adapt
Relevant Standards: CTS.01.04.01, RI.01.05.01
Question Question
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, NCC, OBS, OME As Is for Use
Does your organization honor advance directives? May I see the policy that explains this? ☐ ☐
What process does your organization use to resolve ethical issues that might arise related to
advance directives? Who is involved in that process? What happens if staff involved in that ☐ ☐
process are not able to come to agreement?
What is the process for making decisions about a patient’s condition if no family is available and
☐ ☐
the patient has not left advance directives?
How do you determine a patient’s or family’s preferences related to resuscitation and life-
☐ ☐
sustaining treatment?
How do you document preferences regarding resuscitation and life-sustaining treatment that
come from someone other than the patient or physician (for example, a family member or ☐ ☐
significant other)?
How is the interdisciplinary team for the patient’s plan of care informed about the patient’s and
☐ ☐
family’s wishes?
What mechanisms are in place to facilitate interdisciplinary team communication about advance
☐ ☐
directives?
Where are the advance directives documented? ☐ ☐
Have there been any recent incidents related to advance directives? If so, please describe what
☐ ☐
happened. What changes are being implemented as a result of the incident?
What training have you provided staff on the processes used to address ethical issues related to
their job duties and responsibilities? Where is this training documented? How have you oriented ☐ ☐
staff on patients’ rights and preferences regarding life-sustaining treatment and resuscitation?
Does the organization have anyone to help staff in cases of ethical dilemmas? ☐ ☐
What screening/assessment is performed to determine if an individual served has a psychiatric

advance directive (PAD) and what his or her preferences are for care, treatment, or services, as ☐ ☐
spelled out in the document? [BHC only]


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Care of the Patient: Patient Education, Communication, and Rights


4.18: Patient Education, Communication, and Rights*

Relevant Standards: CTS.04.01.03, HR.01.05.03, HRM.01.05.01, PC.02.01.21, PC.02.03.01,
Use Adapt
PI.03.01.01, RI.01.01.01, RI.01.01.03, RI.01.02.01, RI.01.03.01, RI.01.03.03, RI.01.03.05,
Question Question
RI.01.04.01, RI.01.05.01, RI.01.06.03, RI.01.06.05, RI.01.07.01, RI.01.07.05, RI.02.01.01
As Is for Use
What kind of patient education do you provide? ☐ ☐
Will you please show me some examples of patient education documented in the medical record? ☐ ☐
Patient: What instructions were you given regarding preparation for this treatment/procedure?
☐ ☐
Did you understand and follow the instructions?
Patient: What were you told about the forms that you signed? ☐ ☐
Patient: What were you told about alternatives to your treatments/procedures? ☐ ☐
Patient: What tests did you undergo? Were you informed of the reasons and the results of each
☐ ☐
test?
Patient: Please tell me about your condition. What information have you received about your
☐ ☐
condition and the treatment you have been receiving?
Patient: What treatment are you currently undergoing? Have you been informed of any risks
☐ ☐
associated with that treatment?
Patient: Have you been educated about symptoms that indicate a worsening of your condition?
What should you do if that occurs?
☐ ☐
Patient: How will you manage your health when you return home? Do you feel prepared to do
☐ ☐
that?
Patient: What additional information, if any, do you need to make informed decisions about your
☐ ☐
care?
What kind of family education do you provide? ☐ ☐
May I see the documentation related to family education? ☐ ☐
Family: Have you been educated about symptoms of your family member that you should report
☐ ☐
to the nurse?

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Family: What have you been taught about taking care of your family member’s condition? ☐ ☐
How do you verify that patients and family have understood the information you have provided?
☐ ☐
What type of follow-up do you provide to ensure understanding?
Patient: How well do you understand the care that you have been provided? What do you do if
you have a question about your care?
☐ ☐
How do you accommodate the cultural and linguistic needs of patients and families? ☐ ☐
How do you ensure that patients receive information in their preferred language? ☐ ☐
What processes have you put in place to address any linguistic or cultural differences between
☐ ☐
patients and staff?
Have you offered any additional skills training for staff with regard to cultural competency? If so,
☐ ☐
what improvements have you tracked or documented as a result of additional training?
How do you ascertain the role or presence of family or significant others for this patient? ☐ ☐
What is the process for communicating unexpected outcomes with patients and families? ☐ ☐
Patient: Do you understand why your stay in the facility has been prolonged? How was this
☐ ☐
information communicated to you?
Family: What instructions have you been given about bringing food and other items into the
patient’s room? Do you understand why there might be limitations in relation to such items?
☐ ☐
Is information provided to the patient and family given only verbally, or are printed materials
☐ ☐
provided as well?
Patient: Do you think this organization respects your rights as a patient? If not, why not? If so,
☐ ☐
how is that demonstrated?
Patient: Can you please tell me how you were informed of your rights as a patient? ☐ ☐
Patient: What do you know about your rights as a patient? For example, do you know about your
right to participate in decisions about your care, treatment, and services? To give or withhold ☐ ☐
consent? To be free from abuse, neglect, and exploitation?
How do you ensure an environment that preserves a patient’s dignity? ☐ ☐
What rights do patients have regarding visitors? ☐ ☐
How do you confirm that patients have received information about their rights and
☐ ☐
responsibilities? Where is that documented?
Patient: Can you please tell me how you were informed of your responsibilities as a patient? ☐ ☐

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Patient: What do you know about your responsibilities as a patient? For example, do you know
about your responsibilities to provide accurate information about your health? To share
☐ ☐
expectations and ask questions about your care and treatment? To follow instructions for your
plan of care? To follow the organization’s policies and procedures?
Patient: How have you been informed of the organization’s expectations for your financial
☐ ☐
obligations for your care, treatment, and services?
How do you handle patients who do not show respect or consideration for staff and other
☐ ☐
patients?
How do you reiterate to patients the potential for undesirable outcomes if they do not follow
their plan of care, treatment, and services? How do you encourage patients to accept ☐ ☐
responsibility for outcomes if they do not follow their plan of care, treatment, and services?
Patient and Family: How has your experience of care been here? Have you had your care needs
met? Have there been any concerns? If so, how have you communicated them?
☐ ☐
Patient: Have you felt well informed throughout your care experience? If not, how could that be
☐ ☐
improved, in your opinion?
Patient and Family: What have you done if you have had questions? How do you get responses to
☐ ☐
your questions?
Patient: How did staff members encourage you to ask questions about your treatment? What do
you think of the answers they gave you?
☐ ☐
Patient and Family: Do you know how to file a complaint about safety or care concerns in the
☐ ☐
organization?
* Tracer questions about education and communication related to specific areas of patient care, treatment, or services are
included in tracer question sets on those topic areas.


AND TECHNOLOGY
5
INFORMATION
HEALTH
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Health Information and Technology: Information Management
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, LAB, NCC, OME
Health Information and Technology You may wish to

5.1: Information Management

Use Adapt
Relevant Standards: HR.01.05.03, HRM.01.05.01, IM.01.01.01, IM.01.01.03
Question Question
Accreditation Programs/Settings: AHC, BHC, CAH, HAP, LAB, NCC, OME As Is for Use
Who has responsibility and oversight for data management and use in your organization? ☐ ☐
What kind of training and education are provided for data users and data management staff? ☐ ☐
What types of data are collected in your organization? ☐ ☐
How do you ensure that all data is collected as planned? How is data received from external
☐ ☐
sources?
How is the collected data input? ☐ ☐
How often is collected data updated and reviewed? ☐ ☐
How are data aggregated and analyzed? ☐ ☐
How are data reported or shared, both internally and externally? ☐ ☐
Are your data management processes responsive to organizational changes, including expansion? ☐ ☐
If you are using data software, what is your contingency plan if there is a problem with the
☐ ☐
software?
How do you determine the most appropriate data software and training for your organization? ☐ ☐
How do you plan for implementation of new data software? ☐ ☐
How do you manage quality control records for the software (document, report, store, back up)? ☐ ☐


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Health Information and Technology: Health Information Security

5.2: Health Information Security Use Adapt
Relevant Standards: IM.02.01.01, IM.02.01.03, PC.02.01.21 Question Question
As Is for Use
May I see your written policies that address health information privacy and security? ☐ ☐
Who is responsible for health information privacy and security? ☐ ☐
How do you manage risk of breaches in health information privacy and security? ☐ ☐
How are health information breaches reported and investigated? ☐ ☐
Is there a defined process for responding to theft of health information? ☐ ☐
Do you have a plan for recovery from accidental loss of health information? ☐ ☐
Do you have an emergency response plan for damages to health information (from fire,
vandalism, system failure, natural disasters, and so on)?
☐ ☐
How do you limit the use and disclosure of health information? How do you monitor unauthorized
access of health information?
☐ ☐
What is your process for setting up and removing rights to access, use, and disclose health
information?
☐ ☐
How are medical records safeguarded against tampering? ☐ ☐
May I see the secure medical records room? [N/A for LAB or OME] ☐ ☐
Who gets training on sharing information in a medical record? Do you require annual HIPAA
training for all employees?
☐ ☐
How do you maintain the patient’s health information privacy during registration? [N/A for OME] ☐ ☐
How do you deal with requests from the patient or family for information in the patient’s medical
record? [N/A for LAB]
☐ ☐


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Health Information and Technology: Informed Consent

5.3: Informed Consent Use Adapt

Relevant Standards: PC.02.01.21, RI.01.03.01, RI.01.03.03, RC.02.01.01 Question Question
As Is for Use
What is your informed consent process? ☐ ☐
What forms or education about informed consent do you share with patients? ☐ ☐
During the informed consent process, how do you discuss with patients their treatments and
procedures, including risks, benefits, and alternatives? Which staff are involved in these ☐ ☐
conversations, and who answers questions from the patient or family?
Do you provide informed consent explanations verbally only, or do you also provide printed
☐ ☐
information?
What are your organization’s policies and procedures regarding interpreters for the informed
☐ ☐
consent process?
Are your informed consent forms in English only? If so, how do you obtain informed consent from
patients with limited English proficiency? How do you determine if they have limited English ☐ ☐
proficiency?
How is patient education during the informed consent process documented in the patient record? ☐ ☐
Please provide the consent forms for the patient, including any for medications as well as imaging
☐ ☐
or surgical procedures.
To Patient: Did you sign a consent form? Who was present when you signed it? When was that
☐ ☐
done?
To Patient: What is your understanding of the informed consent process and form? Who
explained the treatment or procedure to you? Did the explanation include the risks and benefits ☐ ☐
as well as alternatives?
To Surgical Staff: What is your process for making sure that the informed consent was properly
☐ ☐
obtained? [CAH, HAP, and OBS only]
To Surgical Staff: Do you use a preoperative checklist? Does it include documentation about the
☐ ☐
patient’s informed consent? [CAH, HAP, and OBS only]


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Health Information and Technology: The Medical Record

5.4: The Medical Record

Relevant Standards: HR.01.05.03, HRM.01.05.01, RC.01.01.01, RC.01.02.01, RC.01.03.01, Use Adapt
RC.01.04.01, RC.01.05.01, RC 02.01.01, RC.02.01.03, RC.02.04.01, PC.02.01.21, PC.04.02.01 Question Question
As Is for Use
Is the medical record completely electronic or is it a hybrid of electronic and paper? If the medical
record is still partially paper, when are those documents scanned into the electronic record? Who ☐ ☐
is responsible for doing that?
What do you document in the patient’s medical record? What is your organization’s policy on
☐ ☐
what is included in the record?
Are prohibited abbreviations and dose designations (as defined by policy) absent from the
☐ ☐
medical record?
What training have you had regarding the use of unapproved abbreviations? ☐ ☐
Does the medical record contain the patient’s race and ethnicity? ☐ ☐
How do you document the care, treatment, and services you are providing to the patient? ☐ ☐
How is information in the medical record communicated to relevant staff for care planning
☐ ☐
purposes?
Is it clear in the medical record who made each entry? Are the entries timed and dated? ☐ ☐
Where in the medical record do you document education you provided the patient? ☐ ☐
When it is necessary to call the prescribing physician or other provider for new orders, how do
☐ ☐
you document it?
Please show me the clinical record of an individual receiving medication. Where do you document
☐ ☐
treatment and care planning related to medication?
How are the side effects and responses to medications taken (for example, weight gain, metabolic
☐ ☐
syndrome, and so on) documented and used?
If a patient has an adverse reaction to an injection, how is that noted in the medical record? ☐ ☐
Where in the patient’s medical record do you record the prescribed wound care orders and
☐ ☐
current medication list?

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Health Information and Technology: The Medical Record
How do you receive and implement orders from the surgeon and the anesthesiologist? How are
those orders documented? [CAH, HAP, and OBS only]
☐ ☐
If an operative or other high-risk procedure was performed, was the complete report written or
dictated in the time frame defined by your policy? If not, was an immediate progress note ☐ ☐
written?
Does the operative or other high-risk procedure report or progress note in the medical record
include this information? [N/A for BHC, NCC, or OME]
• Name(s) of practitioner(s) performing the procedure and any assistants
• Procedure(s) performed
• Description(s) of the procedure(s) ☐ ☐
• Findings of the procedure(s)
• Any estimated blood loss
• Any specimen(s) removed
• Postoperative diagnosis
For planned recurring outpatient visits, was a summary list* started for the patient by the third
☐ ☐
visit? [N/A for BHC, NCC, OBS, or OME]
Does the patient’s summary list* contain this information? [N/A for BHC, NCC, OBS, or OME]
• Any significant medical diagnoses and conditions
• Any significant operative and invasive procedures ☐ ☐
• Any adverse and allergic drug reactions
• Any current medications, over-the counter medications, and herbal preparations
Is the patient’s summary list* updated whenever there’s a change in diagnoses, medications and
allergies to medications, and whenever a procedure is performed? [N/A for BHC, NCC, OBS, or ☐ ☐
OME]
Can practitioners access the summary list* information quickly and easily? [N/A for BHC, NCC,
☐ ☐
OBS, or OME]
Did you provide written discharge instructions* in a way that allowed the patient and/or the
☐ ☐
patient’s family, significant other, or caregiver to understand them?
Does the medical record contain a concise discharge summary* that includes this information?
• Reason for the inpatient stay
• Care, treatment, and services provided, including any procedures ☐ ☐
• Patient’s condition and disposition at discharge
• Information provided to the patient, family, and significant others
• Provisions for follow-up care
How often are medical records audited in your organization? ☐ ☐
What is your record retention policy? ☐ ☐

* Note: Summary lists and discharge summaries aren’t required in every patient setting for every visit. In some cases, final
progress notes or transfer summaries are sufficient; see your Joint Commission accreditation manual for more
information).


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Health Information and Technology: Verbal Orders

5.5: Verbal Orders Use Adapt
Relevant Standards: RC.02.03.07, MM.04.01.01, PC.02.01.03 Question Question
As Is for Use
How do orders come into your organization? Is there any variation among
departments/units/locations?
☐ ☐
How do you manage orders given verbally, including those by telephone? Is record and read back
part of your process?
☐ ☐
Are all verbal orders taken by a practitioner who is authorized to receive and record such orders,
per your policy?
☐ ☐
If an order was given verbally, was it authenticated within the time frame defined by policy? ☐ ☐
Does the authentication include the signature of the practitioner and the date and time of the
order?
☐ ☐
How often does your organization use verbal orders? ☐ ☐


6
AND CONTROL
PREVENTION
INFECTION
DOWNLOAD
Infection Prevention and Control: Infection Control Program
Infection Prevention and Control You may wish to

6.1: Infection Control Program

Relevant Standards: HR.01.05.03, HRM.01.05.01, IC.01.01.01, IC.01.02.01, IC.01.03.01, Use Adapt
IC.01.05.01, IC.02.01.01, IC.03.01.01 Question Question
As Is for Use
Who is responsible for infection prevention and control in your organization? What training and
☐ ☐
education do these leaders receive on infection prevention and control?
What oversight do you have in place to manage your infection prevention and control activities? ☐ ☐
If you have an infection prevention and control committee, how does that committee function? ☐ ☐
How often does your committee meet? What kind of representation is on it? ☐ ☐
What disciplines or departments are represented on the infection prevention and control
committee? Why? How are they educated to the requirements of infection prevention and ☐ ☐
control?
Is infection prevention and control represented in other forums in the organization (such as
☐ ☐
environmental, pharmacy, or performance improvement committees)?
How do you prepare for and make modifications to existing or new policies? How are these
☐ ☐
implemented?
Can you describe your infection prevention and control processes in the organization? ☐ ☐
What processes do you have in place to review the effectiveness of your existing infection
☐ ☐
prevention and control processes and systems?
How do you train staff on infection prevention and control processes? Who is responsible for the
☐ ☐
training? How is this documented?
How do you ensure that staff understand and follow procedures related to infection prevention
☐ ☐
and control?
What infection prevention and control competency activities do you provide to staff? How is this
documented and tracked? How about infection prevention and control orientation for new staff?
☐ ☐
Are infection prevention and control concerns integrated into your information management
☐ ☐
planning?

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What types of infection prevention education are provided to patients? What is required by the
☐ ☐
state, in terms of infection prevention education? [N/A for LAB]
Do you document patient education on infection prevention and control? If so, where and how is
☐ ☐
it documented? [N/A for LAB]
How are patients and families educated on informing you about any infection prevention and
☐ ☐
control concerns they may have, such as signs of an infection? [N/A for LAB]
How do you accommodate the cultural and linguistic needs of patients and families in the
☐ ☐
education you provide on infection prevention and control? [N/A for LAB]
What specific infection prevention and control issues do you need to consider in your setting? ☐ ☐
What have you identified as your greatest infection risks? ☐ ☐
What infection prevention and control risk assessments have you performed? When and where?
☐ ☐
Can you show me the documentation?
How are infection prevention and control risks monitored? How is this communicated to staff? ☐ ☐
How do you prioritize infection prevention and control risks to plan for? How is this documented? ☐ ☐
How does the staff research the infectious disease risks for the population it serves? ☐ ☐
What additional resources do you use to identify prevalent infection risks in your population? ☐ ☐
How does the staff research the possible infection risks due to common behaviors in your
population (drug use, sexual activity, etc.)?
☐ ☐
How has the literature regarding infectious risk in your population base been considered? What
about special populations among your patients?
☐ ☐
Were any other characteristics of your population considered in the design of your infection
☐ ☐
prevention and control program or education activities?
In instances in which you have identified an infection prevention and control risk, what was your
☐ ☐
performance improvement plan? How were staff informed about the plan?
How do you select preventive infection control activities? Do you address all the National Patient
☐ ☐
Safety Goals related to infection prevention and control?
How did you roll out the infection prevention and control performance improvement plan
☐ ☐
throughout the organization? How are you monitoring progress?
How do you report and evaluate an infection control improvement? ☐ ☐
What kinds of improvement initiatives is your infection prevention and control committee
currently implementing? How did you select these initiatives? How did you prioritize these ☐ ☐
initiatives? What types of activities are involved in each?
How have you educated and trained staff on these improvement initiatives? How are you ☐ ☐

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monitoring progress? How are you reinforcing the project in an ongoing manner?
How do you submit data on reportable diseases? ☐ ☐
What are your monthly infection rate statistics? ☐ ☐
What tool do you use to identify an infection? ☐ ☐
What is the internal process for reporting staff infections? ☐ ☐
What is your planned response to a potential influx of infectious patients? [N/A for LAB] ☐ ☐
Have you conducted any drills around a potential influx of infectious patients? How have you
engaged staff in the process? Have you analyzed the effectiveness of response to these drills? ☐ ☐
Have you made improvements based on this analysis? [N/A for LAB]
Describe a recent outbreak and what your staff did to bring it under control. What was the source
of the outbreak? How many people were affected by the outbreak? How did you determine when ☐ ☐
the outbreak had been contained? [N/A for LAB]
What types of care related to infection control are provided for any therapeutic animals in your
facility? What happens if one of those animals becomes ill? Please provide copies of the animals’ ☐ ☐
health records. [BHC only]
What are the organization’s policies on infectious waste disposal? Who develops these policies?
☐ ☐
How often are these policies reviewed?
What training does the organization provide to staff on infectious waste policies? ☐ ☐
What infection control precautions should be taken for a child suspected of having pertussis?
Please provide a copy of the policy and procedures for pertussis infection control. [N/A for BHC ☐ ☐
and LAB]
Does the organization have an antimicrobial stewardship program? If not, how do you ensure that
antimicrobial agents are used properly? If so, what are the antimicrobial stewardship activities? ☐ ☐
Describe the process and its outcomes.
What training have you received that qualifies you to serve on the antimicrobial
stewardship team?
☐ ☐
Does the antimicrobial stewardship team track the use of vancomycin? How does it use that
information?
☐ ☐
How often do you tour your physical environment for infection control–related issues? ☐ ☐
Are you involved in the selection of products for infection prevention equipment, devices, or
supplies?
☐ ☐
What is the infection prevention leader’s role in the risk management related to construction,
☐ ☐
demolition, and remodeling projects?


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Infection Prevention and Control: Infection Control NPSGs

6.2: Infection Control NPSGs

Relevant Standards: HR.01.05.03, HRM.01.05.01, NPSG.07.01.01, NPSG.07.03.01, NPSG.07.04.01, Use Adapt
NPSG.07.05.01, NPSG.07.06.01 Question Question
As Is for Use
What guidelines does the organization follow for infection prevention and hand hygiene? ☐ ☐

Please provide a copy of your organization’s hand hygiene policy and infection control plan. ☐ ☐
What are your goals for improving hand hygiene? How are you implementing those goals? ☐ ☐
What training and orientation have you received regarding hand hygiene? Can you tell me what is
☐ ☐
required?
When you conducted your baseline assessment of hand hygiene compliance, what did you review
☐ ☐
or assess? How did you use the results to make conclusions?
How do you monitor hand hygiene compliance? ☐ ☐
What types of risk assessments are you performing to identify risks from health care–associated
☐ ☐
infections (HAIs) due to multidrug-resistant organism (MDROs)? [CAH and HAP only]
Please describe the evidence-based practices you use to control HAI risks from MDROs. [CAH and
HAP only]
☐ ☐
What protocols do you use to prevent central line–associated bloodstream infections

(CLABSIs)? [CAH, HAP, and NCC only]
☐ ☐
How do you educate and train staff about prevention of central line–associated bloodstream
infections (CLABSIs) [CAH, HAP, and NCC only]
☐ ☐
How do you educate and train patients and their families about prevention of central line–
associated bloodstream infections (CLABSIs) [CAH and HAP only]
☐ ☐
What do your policies include about prevention of central line–associated bloodstream

infections (CLABSIs)? [CAH and HAP only]
☐ ☐
What evidence-based practices have you implemented to reduce surgical site infections? [AHC,
CAH, HAP, and OBS only]
☐ ☐

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Infection Prevention and Control: Infection Control NPSGs
What kind of staff education and training do you provide regarding preventing surgical site
infections? How are physicians and other providers educated and involved in the process? [AHC, ☐ ☐
CAH, HAP, and OBS only]
Please show me where in your policies you address reducing the risk of surgical site infections.
☐ ☐
[AHC, CAH, HAP, and OBS only]
What is the policy on documenting presurgical assessment, particularly in relation to preventing

☐ ☐
surgical site infections? [AHC, CAH, HAP, and OBS only]
With relation to any improvement efforts to prevent catheter-associated urinary tract infections
☐ ☐
(CAUTIs), what kind of staff education and training do you provide? [CAH, HAP, and NCC only]
Describe the processes for catheter-associated urinary tract infection (CAUTI) prevention, and
☐ ☐
provide a written copy of those processes. [CAH, HAP, and NCC only]
In what ways do you use evidence-based guidelines to prevent catheter-associated urinary tract
☐ ☐
infections (CAUTIs)? [CAH, HAP, and NCC only]
How do you educate patients and their families about preventing catheter-associated urinary
☐ ☐
tract infections (CAUTIs)? [CAH, HAP, and NCC only]
How do you measure and monitor improvement efforts designed to prevent catheter-associated
☐ ☐
urinary tract infections (CAUTIs)? [CAH, HAP, and NCC only]
What is the CAUTI rate for your particular unit? [CAH, HAP, and NCC only] ☐ ☐
When was the last CAUTI-reduction initiative? [CAH, HAP, and NCC only] ☐ ☐


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Infection Prevention and Control: Reprocessing Medical Equipment, Devices, and Supplies

6.3: Reprocessing Medical Equipment, Devices, and Supplies

Relevant Standards: IC.02.02.01, HR.01.05.03, HR.01.06.01, HR.01.07.01, HRM.01.05.01, Use Adapt
HRM.01.06.01, HRM.01.07.01 Question Question
As Is for Use
Please provide a copy of the policy and procedures for reprocessing. ☐ ☐
Please describe your reprocessing activities from point-of-use in the procedure room to
☐ ☐
decontamination, high-level disinfection/sterilization, and then to storage.
What is involved in your risk assessment for reprocessing? Is risk assessment conducted in all
☐ ☐
locations that conduct high-level disinfection and sterilization?
How do you assess competency in following reprocessing policy and procedure, including
competency of frontline staff that conduct high-level disinfection and sterilization? How do you ☐ ☐
assess competency of those with managerial/supervisory oversight that sign off on competencies?
How often are staff given refresher training on reprocessing? What does the training include? ☐ ☐
May I see the documentation on training for reprocessing? ☐ ☐
How does your training differ for items labeled as single-use disposable versus items that may be
☐ ☐
reprocessed for repeated use?
Describe your process of cleaning medical equipment, devices, and supplies before any further
☐ ☐
disinfection or sterilization.
How do you ensure that cleaning and disinfection are performed in a consistent and effective
☐ ☐
manner?
How do you ensure that manufacturer’s guidelines for the type of high-level disinfectant solutions
☐ ☐
used are available to staff?
What is the testing efficacy of disinfectant solutions? When are the solutions changed? ☐ ☐
How often do you clean the toys and furniture in the waiting room? How is this cleaning
documented? What products are used for disinfection in general and when a patient has been ☐ ☐
identified as posing a high risk of infection?
How do you ensure that manufacturer’s instructions are followed for automated endoscope
☐ ☐
reprocessers? [N/A for BHC]

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Infection Prevention and Control: Reprocessing Medical Equipment, Devices, and Supplies
What would happen if a scope were dropped during use or reprocessing? [N/A for BHC] ☐ ☐
Please describe your process for storing clean scopes. [N/A for BHC] ☐ ☐
What information regarding reprocessing services is reported to your facility’s infection control
☐ ☐
committee?
What are your quality monitoring parameters for sterilization? How are physical, chemical, and
biological indicators performed and documented? Is this done per evidence-based guidelines and ☐ ☐
manufacturer’s instructions for use?
What are your quality monitoring parameters for high-level disinfection, such as the correct use of
test strips, monitoring the temperature and time of the disinfection, and so on? How do you ☐ ☐
ensure procedures are following manufacturer’s instructions for use?


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Infection Prevention and Control: Vaccination Program

6.4: Vaccination Program Use Adapt

Relevant Standards: IC.02.04.01 Question Question
As Is for Use
Describe your vaccination program. Who is in charge of managing the program? ☐ ☐
Do you have an annual influenza vaccination program that is offered to licensed independent
☐ ☐
practitioners and staff? How do you communicate information about the program?
Does the organization provide influenza vaccination at sites accessible to licensed independent
☐ ☐
practitioners and staff?
Does the organization include in its infection control plan the goal of improving influenza
☐ ☐
vaccination rates?
Does the organization set incremental influenza vaccination goals, consistent with achieving the
☐ ☐
rate established by the US Department of Health and Human Services?
How do you prepare and submit your vaccination data? ☐ ☐
Does the organization evaluate the reasons given by staff and licensed independent practitioners
for declining the influenza vaccination? Does this evaluation occur at least annually? Explain how ☐ ☐
the evaluation is performed. What changes have been made as a result of the data?
How do you ensure that your staff’s immunizations are up to date? How do leaders, coworkers,
☐ ☐
and patients know which employees have received the influenza vaccination for the current year?


7
MANAGEMENT
MEDICATION
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Medication Management: Medication Management System
Medication Management You may wish to

7.1: Medication Management System

Relevant Standards: HR.01.04.01, HR.01.05.03, HRM.01.03.01, HRM.01.05.01, MM.01.01.01, Use Adapt
MM.08.01.01, MM.09.01.01, NPSG.03.06.01, PI.01.01.01, PI.02.01.01, PI.03.01.01 Question Question
As Is for Use
Who is responsible for monitoring medication management? Who has overall oversight for the
system? What is the reporting process? What is the frequency of reporting?
☐ ☐
Tell me about your medication management system. How did you design it and who was
involved?
☐ ☐
What is your background related to medication management? What type of training related to
medication management have you had?
☐ ☐
What ongoing training in medication management do you receive? What type of training
resources are available to you?
☐ ☐
What is your role in the medication management system? ☐ ☐
How is pharmacy staff involved in the development of medication management policies? How is
pharmacy staff involved in training of staff involved in medication system processes?
☐ ☐
How often is the medication management process reviewed? ☐ ☐
How do you evaluate your medication management system? How often do you do this? ☐ ☐
What is your process to make modifications to the system, if appropriate or warranted? How is
this documented?
☐ ☐
What performance improvement activities related to medication management are in place? ☐ ☐
What evidence based guidelines or best practices inform changes and improvements to your
medication management system?
☐ ☐
What data do you collect relating to medication management? How do you use that data? ☐ ☐
What process do you have to collect, aggregate, analyze, and track data relating to medication
management?
☐ ☐
How do you analyze the data to identify trends and opportunities for improvement? ☐ ☐

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Please describe the nature of analysis of any recent medication management issues. What tool do
you use to analyze medication management issues and process them for reporting?
☐ ☐
What type of medication management interventions have you implemented? How are you
tracking results?
☐ ☐
What is your process to modify medication-‐related policies? ☐ ☐
How do you monitor your medication management system’s effectiveness? ☐ ☐
Describe the medication management system for the inpatient behavioral health units. [CAH and
HAP only]
☐ ☐
How do pharmacists and physicians interact to improve medication management processes in
behavioral health units? [CAH and HAP only]
☐ ☐
What types of data are collected to document the problems and to guide improvements to the
medication management processes in behavioral health units? [CAH and HAP only]
☐ ☐
Have any improvements been made to the medication management system in behavioral health
units in the past year? How are these improvements sustained? [CAH and HAP only]
☐ ☐
How do pharmacists and anesthesia providers interact to improve medication management
processes? [CAH and HAP only]
☐ ☐
What types of data are collected to document the problems and to guide improvements to the
medication management processes in the operating room (or perioperative services)? [CAH and ☐ ☐
HAP only]
How are psychotropic medications managed? How are narcotics managed? ☐ ☐
Explain the protocols you use to prescribe multiple psychotropic medications. ☐ ☐
What is the medication management process for an opioid treatment program? [BHC only] ☐ ☐
How do you educate staff and licensed independent practitioners (LIPs) on the medication
management system? What do you do to orient new staff and LIPs? How are they educated or ☐ ☐
updated on changes to processes in the system? How is this documented?
What patient education do you provide related to the medication management system? What
specific information do you provide in certain cases, such as vaccinations for pediatric patients?
☐ ☐
How do you document processes in the medication management system, such as administration
and monitoring?
☐ ☐
How do you stay apprised of any new or developing medication safety issues? How is this
information reported to staff and licensed independent practitioners?
☐ ☐
Provide an example of an everyday medication safety step you perform that explicitly adheres to
your organization’s medication safety policy.
☐ ☐

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What process or method do you use to track medications from procurement through monitoring? ☐ ☐
How do you plan for specific medication issues, such as recalls and shortages, and having an
accurate and current list of medications?
☐ ☐
What are the high-‐risk areas you have identified in your medication management system
processes? How have you identified them?
☐ ☐
What improvements have been made to the medication management system for high-‐alert
medications? How are these improvements sustained? How do you know?
☐ ☐
What processes does the team use to manage the patient’s medications? Does your organization
use any analgesic or medication management algorithm as part of your care planning?
☐ ☐
Explain the process used to obtain accurate and complete medication histories from patients.
How do you know that this process is being carried out?
☐ ☐
What is the process for developing a list of discharge medications? ☐ ☐
Are patients encouraged to maintain a medication profile and to bring it to each visit? ☐ ☐
How are medication errors reported? What procedure does the organization follow if an error is
caught before it reaches the patient? Have you ever reported an error or a near miss?
☐ ☐
What kinds of adverse events or close calls related to medications do you track? ☐ ☐
Have you ever been involved in a situation where there was a close call or adverse event related
to medications? What was your response?
☐ ☐
What policies have been implemented specifically to control unwanted issues surrounding
“problematic” medications, such as insulin?
☐ ☐
Do you believe that the data you’ve collected so far on medication errors are accurate and useful?
Why or why not?
☐ ☐
What does the data analysis show about the possible causes of medication errors? ☐ ☐
What happens with reported medication errors? ☐ ☐
What medication management work-‐arounds are you aware of in your units that could be
considered security risk points?
☐ ☐
What training has been provided to the nursing staff/licensed independent practitioners
regarding high medication error rates related to overrides?
☐ ☐
What education do patients receive when being provided with sample medications? Are written
instructions provided?
☐ ☐
What issues have been identified regarding control, labeling, security, and documentation of
sample medications?
☐ ☐

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Has patient access to sample medications been identified as a safety risk, and if so, what has been
done to minimize this risk?
☐ ☐
What improvements have been implemented to correct any problems related to management of
sample medications?
☐ ☐
Does each patient and/or family receive a complete list of medications at discharge (or at the end
of an episode of care)? How is this process documented?
☐ ☐
When patients return to refill medications, how do you check with them to find out if they are
complying with instructions?
☐ ☐
Are processes related to comfort kits part of the evaluation of the medication management
system? [OME Hospice only]
☐ ☐
How does the organization assess whether comfort kits are safe in the patient’s home? [OME
Hospice only]
☐ ☐
What are the policy and processes for the use of comfort kits? [OME Hospice only] ☐ ☐
How are staff made aware of DEA and state regulations for the use of comfort kits? [OME Hospice
only]
☐ ☐
Describe what you know about the ordering and creation of comfort kits. [OME Hospice only] ☐ ☐
How is patient compliance with the use of the medications in the kits evaluated? [OME Hospice
only]
☐ ☐
How are patients/caregivers educated on each medication in the kit? [OME Hospice only] ☐ ☐
How is the patient's/caregiver's retention of the educational activities in the comfort kit
evaluated? [OME Hospice only]
☐ ☐
How is the effectiveness of the kit’s medications monitored? [OME Hospice only] ☐ ☐
What is done if a patient dies and the comfort kit has not been used? [OME Hospice only] ☐ ☐
What procedures are used to ensure that the comfort kits are compliant with DEA and state
regulations and organization policy? [OME Hospice only]
☐ ☐
How has leadership supported antimicrobial stewardship? ☐ ☐
What patient are educated about antimicrobial stewardship? ☐ ☐
What policies or protocol does your organization have on antimicrobial stewardship? ☐ ☐
What data is your organization collecting and analyzing regarding antimicrobial stewardship? ☐ ☐
Has your organization made any improvement in antimicrobial stewardship? ☐ ☐


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Medication Management: Medication Procurement, Ordering, and Dispensing

7.2: Medication Procurement, Ordering, and Dispensing

Use Adapt
Relevant Standards: HR.01.06.01, HRM.01.06.01, MM.04.01.01, MM.05.01.01, MM.05.01.09
Question Question
How do you procure and receive medications in the facility? Who is responsible for this? How are
☐ ☐
these processes reviewed?
Is there a pediatric formulary? If so, are prescribers and nurses aware of the medications on this
☐ ☐
list? What emergency medications do you have specifically for the pediatric population?
In relation to medication management, do you have any special medications you need to have on
☐ ☐
hand?
How are medications prescribed? What policies are in place related to prescribing? [N/A for OBS] ☐ ☐
How are medications prescribed for your current patients? [N/A for OBS] ☐ ☐
What is the prescription process for medications that have doses based on weight of the patient?
[N/A for OBS]
☐ ☐
Discuss the process of ordering the medications your patients currently receive. [N/A for OBS] ☐ ☐
What is the protocol for changing an individual’s medication? How changes to medication are
communicated to other staff members? [N/A for OBS]
☐ ☐
What types of medications are most often prescribed in the nursing units? Name about 10 of
☐ ☐
them. Which on this list are considered by the organization to be “problematic”? [N/A for OBS]
Does your organization use “signed and held” medication orders? If so how are these medication
orders implemented?
☐ ☐
Please describe your organization’s approach for medication range orders. Do you allow range
☐ ☐
orders and if so, under what circumstances?
Have you considered developing a formal list of medications associated with falls, like blood
pressure medications, sedating medications, diuretics, and analgesics—opiates and muscle ☐ ☐
relaxants in particular? [N/A for OBS]
As part of your falls assessment process, do you review medication profiles for medications that
☐ ☐
have the potential to cause falls? [N/A for OBS]

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How are medication orders reviewed for accuracy? What are the elements of a complete order?
Do you have a written policy defining this? [N/A for OBS]
☐ ☐
How are medication orders reviewed for appropriateness? What are the elements of the review?
☐ ☐
[N/A for OBS]
What are your systems for quality control when medication orders are filled? ☐ ☐
Does a pharmacist review all prescriptions? ☐ ☐
Has your pharmacy provided training regarding the error-reduction potential of a pharmacist
☐ ☐
review of medication orders?
How is assessment information—specifically, medications and patient allergies/sensitivities—

☐ ☐
shared with the pharmacy? [N/A for OBS]
What processes are in place to validate allergy information for medications that have an increased
☐ ☐
potential for producing adverse drug events? [N/A for OBS]
Does the pharmacy communicate with each patient to verify his or her allergy status? [N/A for
☐ ☐
OBS]
Can you tell me about an instance in which there was an adverse reaction to a medication? Were
processes for validating allergy information and analyzing adverse drug events followed in this ☐ ☐
instance? [N/A for OBS]
What is the process for ordering narcotics? What is the process to enter the narcotics into the
main inventory after the narcotics package has arrived at the organization?
☐ ☐
How is medication dispensed? What comes from the pharmacy? ☐ ☐
What is the process for anesthesia providers to obtain narcotics/controlled substances? If the
anesthesia provider or nurse (in the case of moderate sedation) obtains controlled substances for ☐ ☐
more than one patient, what is the reconciliation process? [AHC, CAH, HAP, and OBS only]
What do you do if you do not receive a needed medication from the pharmacy? ☐ ☐
What is the policy regarding returns of medication to the pharmacy? ☐ ☐
What is the controlled substances counting process? What drugs are considered controlled
☐ ☐
substances at your organization?
Do you contract with a pharmacy or pharmacist for oversight? If so, how do you communicate and
interact with that pharmacy/pharmacist? What are the pharmacist responsibilities? How often is ☐ ☐
the contract reviewed? How is that review documented?
Does the pharmacist generate a report after reviewing the medication management process?
How many charts does the pharmacist audit for diversion? Does the pharmacist audit sedation
charts for diversion? May I see the data? What is the process for the information from the
☐ ☐
reports to be evaluated by the governing body?
Please provide your policies on compounding. ☐ ☐


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May I observe your medication compounding process? ☐ ☐
May I see the infusion bag label for the medication that was just compounded? ☐ ☐
Please explain the type of environmental control unit or device that you use when compounding
☐ ☐
sterile medications.
How do you evaluate the competency of your sterile compounding staff? How often is this done? ☐ ☐
How often do you perform environmental sampling of your sterile compounding facilities and
☐ ☐
equipment? Please provide me with the documentation of the testing for the past year.
What medications are parts of floor stock? If you need to prepare a dose of medication, what is
☐ ☐
the process for doing so? Where is the medication prepared?
How are medications provided for pediatric patients? Who prepares them? ☐ ☐
Does the pharmacy have the capability to prepare medication like epinephrine in the appropriate
☐ ☐
dosage forms if not available from the manufacturer?
What is your process for labeling prepared medications? What if the medication is not going to be
immediately administered?
☐ ☐
Does the pharmacy make special provisions for high-risk patients in its on-call process? ☐ ☐
When the pharmacy is closed, what are your processes for making sure that a new medication
☐ ☐
order is properly reviewed prior to administration?
Under what circumstances would a nurse need to call a pharmacist after hours? ☐ ☐
Are nursing and licensed independent practitioners aware of the on-call policies for the
☐ ☐
pharmacy?
What are your organization’s policies and procedures on use of an automatic dispensing cabinet?
☐ ☐
[N/A for OBS]
Are there specific or unique steps to follow in withdrawing heparin or other high-alert
☐ ☐
medications from an automatic dispensing cabinet? [N/A for OBS]
Describe in detail the steps you take in restocking the automatic dispensing cabinet. [N/A for OBS] ☐ ☐
Describe the entire process you use from receipt of heparin orders through stocking the
☐ ☐
automatic dispensing cabinet. [N/A for OBS]
Does your organization have a policy on the types of medication overrides that will be reviewed
for appropriateness and the frequency of the reviews when automatic dispensing cabinets are ☐ ☐
used?


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Medication Management: Medication Administration


7.3: Medication Administration

Relevant Standards: HR.01.05.03, HR.01.06.01, HR.01.07.01, HRM.01.05.01, HRM.01.06.01,
Use Adapt
HRM.01.07.01, MM.06.01.01, MM.06.01.03, NPSG.01.01.01, MM.05.01.09, MM.03.01.03,
Question Question
PI.01.01.01, PI.02.01.01, PI.03.01.01
As Is for Use
What policies are in place for the administration of medications? ☐ ☐
What is your process for medication administration? How is this documented? ☐ ☐
Please describe the process of distributing medications and your exact role in it. ☐ ☐
How do you work with the pharmacy and the physician or licensed independent practitioner
☐ ☐
when questions or concerns arise about administering medications?
Have medication error data collected been used to improve the medication administration
process? How are the data analyzed and reported? What interventions have been implemented in ☐ ☐
response to the data?
What types of medications are usually administered in this facility? ☐ ☐
How do you confirm the patient’s identity for medication administration? ☐ ☐
How do you verify that the correct medications are being administered to the correct patient at
☐ ☐
the proper time, in the prescribed does, and by the correct route?
Do you review the medication label to see whether it includes the required information? ☐ ☐
What are you checking for on the labels of medications before you administer them? ☐ ☐
How do you check expiration dates on medications you administer? ☐ ☐
How do you check for contraindications on medications you administer? [N/A for BHC] ☐ ☐
What are you looking for when you visually inspect medications? ☐ ☐
May I observe as you follow procedure to assess the patient prior to administering medication? ☐ ☐
What are the elements of your checking process when it comes to correct admixtures? ☐ ☐
How does the bar-code process work? How do you use it for stat medications or for partial doses ☐ ☐

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from vials or containers that are pulled from floor stock?
Are medication bar-code bypasses tracked? Please explain how. How are bypasses analyzed? ☐ ☐
What other safety checks are in place beyond the bar-code system? ☐ ☐
How are doses adjusted? Who adjusts doses? Are they adjusted according to protocol? ☐ ☐
How do you check dosing on doses for medications that need to be weight based? ☐ ☐
Do you use the same standardized approach (pounds or kilograms) for all patients in determining
☐ ☐
the weight scheduling of their medication? How often is each patient’s weight record updated?
Provide details regarding your approach to adjusting doses according to the responses of critically
☐ ☐
ill patients.
What does your policy say about titrating doses? ☐ ☐
How are titrated doses calculated? Show me how you would calculate a dose for this patient. ☐ ☐
What processes are involved in administering radioactive pharmaceuticals used for diagnostic
☐ ☐
purposes? [AHC, CAH, HAP only]
For radioactive pharmaceuticals used for diagnostic purposes, what else do you do before
☐ ☐
administering the drug? [AHC, CAH, HAP only]
How do you record and monitor opioid administration in this program? [BHC opioid treatment
☐ ☐
programs only]
What processes do you put in place to monitor medication administration and usage for
☐ ☐
psychiatric patients, particularly when monitoring for suicide risk?
In what locations do you administer vaccinations? Do you need a physician order to administer
☐ ☐
vaccinations? How is this order obtained?
Please show me any used vials and diluents for medications administered to this patient today. ☐ ☐
How are medication containers labeled when medications are prepared but not immediately
☐ ☐
administered? How are they labeled when the medications are prepared on the sterile field?
How can you tell if a medication is for single use or multidose use? ☐ ☐
What is the organization’s policy regarding the expiration dating of opened vials? ☐ ☐
Are opened multidose vials without new beyond-use dates (BUDs) routinely available for use on
patients?
☐ ☐
What is the correct beyond-use date (BUD) for opened multidose vials? ☐ ☐
What is the policy regarding the opening and storing of vials of medication without beyond-use
dates (BUDs)? Are multidose vials used for more than one patient when accessed in a patient care ☐ ☐
area, such as at the patient bedside?

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What is the policy regarding the opening and storing of vials of medication without beyond-use
dates (BUDs)?
☐ ☐
Have you received training on applying expiration dates on opened vials? ☐ ☐
Please show me how you prepare a PICC line for medication administration. [CAH and HAP only] ☐ ☐
May I see the competency reviews for the pharmacy technician and/or the nurse? ☐ ☐
How do you administer warfarin to inpatients? [N/A for BHC] ☐ ☐
How do you administer heparin to inpatients? [N/A for BHC] ☐ ☐
Are there special requirements for infusing heparin? Explain the steps in the administration
☐ ☐
process. [N/A for BHC or OME]
How are new staff members educated on the standard protocol for warfarin dosing? How is
☐ ☐
compliance monitored? [N/A for BHC]
Please describe the kind of equipment you use for administering anticoagulants and how you
monitor it. What safety measures are in place to ensure safe administration and dosing? How do ☐ ☐
you ensure that the INR and PTT results are accurate? [N/A for BHC]
If you use equipment, such as an infusion pump, how do you maintain the equipment? What do
☐ ☐
you do in the event of a problem with the equipment? [N/A for BHC]
How do you determine that a patient is safely able to tolerate the infusion? [N/A for BHC] ☐ ☐
How do you ensure that you are administering the infusion at the correct rate? [N/A for BHC] ☐ ☐
What is the process for administration of a dose using a smart pump? Please show me how you
☐ ☐
set up a smart pump. Do you take any special precautions? [N/A for BHC]
What is the process for administering insulin? ☐ ☐
Do you ever make infusions in the ICU? What about emergent first doses? Where are these
☐ ☐
prepared? How do you know what concentrations to prepare? [CAH and HAP only]
Please describe the spinal or epidural process. What is the prep process for the lower spinal area?
What is the process for ensuring that correct medications are being used for the spinal or ☐ ☐
epidural? [CAH and HAP only]
Do the nurses change out the cartridges for labor epidural infusions? Who begins the infusion for
the parturient’s labor epidural infusions? How are the orders checked for accuracy? Do the ☐ ☐
nurses administer epidural medication boluses?
What are the policies and training for epidurals? What safety protocols are in place? What is the
☐ ☐
training for these activities?
Describe the policies and procedures that guide the self-administration of medications. [N/A for
AHC and OBS]
☐ ☐

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How is a patient’s self-administration of medications supervised? [N/A for AHC and OBS] ☐ ☐
What training have you received related to observing a patient’s self-administration of

☐ ☐
medications? [N/A for AHC and OBS]
How are reactions to medications monitored? As standard practice, do you tell patients what side
☐ ☐
effects to watch for?
What policies and procedures exist for monitoring of the effects of medications on patients? ☐ ☐
How do you monitor a patient for effects of the medications administered during transport? [CAH
☐ ☐
and HAP only]
Are you certified in advanced cardiac life support? If you are certified, what medications may you
☐ ☐
administer without a physician’s order? [CAH and HAP only]
Please explain how you mix and administer an IV for a cardiac patient. [CAH and HAP only] ☐ ☐
What special training do you have to qualify you to administer sedation to patients? How often is
competency evaluated? What methods are used to evaluate competency?
☐ ☐
What special training do you have to qualify you to administer sedation to patients? ☐ ☐
What medications are available to reverse sedation, if necessary? ☐ ☐
How are patients monitored while sedation is administered? ☐ ☐
What is the organization’s policy for emergency medication dosage forms (for example, single
☐ ☐
use, pediatric dose, vials, syringes)?
What are the acquisition methods for obtaining emergency medication dosage in the appropriate
☐ ☐
form in the event of a shortage?
What is the organization's policy regarding the provision of emergency medications in their most
☐ ☐
ready-to-administer forms?
What alternative methods are used to obtain emergency medications in their most ready-to-
☐ ☐
administer form if they are not commercially available?
What is the organization’s policy for emergency medication dosage forms? ☐ ☐
What are the acquisition methods for obtaining emergency medication dosage forms in the event
☐ ☐
of a shortage?
Has the pharmacy provided any staff training regarding the application of expiration dates to
☐ ☐
emergency medication vials when they are opened?
Are the nurses allowed by law/regulation to carry emergency medications? ☐ ☐
How do you monitor medication use for youth/pediatrics? ☐ ☐


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Medication Management: Medication Storage and Security


7.4: Medication Storage and Security

Use Adapt
Relevant Standards: CTS.04.01.03, MM.03.01.01, MM.05.01.19, PC.02.03.01
Question Question
Where are medications—including any sample medications—stored? ☐ ☐
How do you ensure that all medications are correctly labeled or stored? Who is responsible for
☐ ☐
stocking medications?
How do you ensure the medications are stored per manufacturer’s recommendations? Per your
☐ ☐
policies?
How do you ensure that the correct temperature is maintained in the medication refrigerator? ☐ ☐
What do you do if you discover that the medication refrigerator temperature was not
maintained? Who is responsible for placing a beyond-use date on medications taken out of the ☐ ☐
refrigerator to be stored at room temperature?
What guidelines do you follow for the storage of vaccines? ☐ ☐
How do you ensure that the storage area is secure? ☐ ☐
How does the organization prevent unauthorized access to medications? How often are the logs
☐ ☐
associated with medications reviewed?
What is your process to prevent diversion? ☐ ☐
Who audits the charts and narcotic logs for diversion? ☐ ☐
What is your process for the safe disposal of medications? ☐ ☐
What do you do with expired, damaged, or contaminated medications? ☐ ☐
How do you dispose of chemotherapy waste? ☐ ☐
What are your processes to secure medications during emergencies? ☐ ☐
What type of emergency backup does your organization have for maintaining the proper storage
of essential medications, including those that need to be stored within proper temperatures? ☐ ☐
Does your organization have a policy relate to this?
Where do you store medications that are transported to and used in patients’ homes? ☐ ☐

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Medication Management: Medication Storage and Security

Do you know if possessing unlabeled prescription drugs is legal in your state? Do you know if
organizational policy and/or state law allows you to store and transport medications in your car ☐ ☐
trunk in such a manner?
How do you ensure that the medications you transport are kept at proper temperatures? ☐ ☐
Have you made medication storage a part of your patient and caregiver education? If you have,
☐ ☐
how do you impart that information?
How are medications managed in the operating area? Who has access to the medication cart and
☐ ☐
how is that monitored and controlled?


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Medication Management: High-Alert and Hazardous Medications


7.5: High-Alert and Hazardous Medications

Relevant Standards: HR.01.02.07, HR.01.05.03, HR.01.07.01, HRM.01.01.03, HRM.01.05.01, Use Adapt
MM.01.01.03, HRM.01.07.01, MM.01.01.03, MM.07.01.03, PI.03.01.01 Question Question
As Is for Use
What are the high-alert and hazardous medications you keep in the facility? ☐ ☐
Please provide a list of the high-alert medications and hazardous medications that your
☐ ☐
organization handles.
What high-alert and hazardous medications are handled in this pharmacy? ☐ ☐
What specific high-alert drug is most commonly used at your organization? What is the most
☐ ☐
commonly used hazardous medication at your organization?
Where are high-alert and hazardous medications stored? ☐ ☐
How do you ensure that medications are not placed in the wrong locations? How do you monitor
☐ ☐
for this?
What do you do when you do not have enough space to store all your medication supplies? In
☐ ☐
such a situation, what do you do with high-risk items such as injection needles?
How does the organization prevent unauthorized access to high-alert and hazardous medications?
☐ ☐
How often are the logs associated with these medications reviewed?
Where are high-alert and hazardous medications labeled? ☐ ☐
How are high-alert and hazardous medications marked on the shelf? ☐ ☐
How does the organization define a high-alert or hazardous medication? ☐ ☐
How are staff made aware of the medications identified as high-alert and hazardous? ☐ ☐
Is the high-risk designation documented in the medical record for patients on high-alert
☐ ☐
medications?
What education and training do you provide to staff regarding medication safety and issues
related to high-alert and hazardous medications? Does it include all the components of the ☐ ☐
organization’s policy?

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Medication Management: High-Alert and Hazardous Medications

What is the process for providing additional training for high-alert and hazardous medications as
☐ ☐
they are added to the formulary?
What would you do if you had questions about a high-alert or hazardous medication? ☐ ☐
How are the staff selected to care for patients receiving high-alert or hazardous medications? ☐ ☐
How would management know if a staff member without the required training was assigned to
☐ ☐
care for a patient receiving a high-alert or hazardous medication?
What improvements have been made to the medication management system for high-alert and
☐ ☐
hazardous medications? How are these improvements sustained? How do you know?
Are you aware of any adverse drug reaction reports concerning the use of high-alert medications
☐ ☐
in the past year? If so, what follow-up has been done?
How is insulin stored? [N/A for BHC] ☐ ☐
Are any special precautions required for insulin storage? [N/A for BHC] ☐ ☐
What is the organization’s policy regarding proper storage of insulin? [N/A for BHC] ☐ ☐
What high-risk processes related to insulin have been identified? [N/A for BHC] ☐ ☐
What processes are in place to minimize mix-ups of different types of insulin? [N/A for BHC] ☐ ☐
Is unfractionated heparin a high-alert medication identified for this organization? How did you
decide on that designation? How did you decide which of the various heparin preparations should ☐ ☐
be available in this organization?
Please show me how and where you store heparin in the pharmacy. ☐ ☐
Where are the nearest spill kits located? What does a kit contain? What are the procedures
☐ ☐
regarding use of the kit for hazardous medication spills?
What is organization policy regarding the use of personal protective equipment (PPE) during
☐ ☐
chemotherapy administration?
How are staff who work in this area trained and deemed competent for the administration of
☐ ☐
chemotherapy medications? Please show documentation of this assessment.
What part do you play in making sure chemotherapy is used safely in this organization? ☐ ☐


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Medication Management: Look-Alike/Sound-Alike Medications


7.6: Look-Alike/Sound-Alike Medications

Use Adapt
Relevant Standards: HR.01.05.03, HRM.01.05.01, MM.01.02.01, MM.04.01.01, MM.07.01.03
Question Question
How has the use of look-alike/sound- alike medications been made a part of your policies and
☐ ☐
procedures?
How did you develop your look-alike/sound- alike medication list? How often do you review and,
☐ ☐
if warranted, update the list?
What precautions and practices are in place to prevent medication errors when look-alike/sound-
☐ ☐
alike medications are ordered?
How do you store look-alike/sound-alike medications? What about sample medications that are
☐ ☐
look-alike/sound-alike?
What is your process to verify that the correct look-alike/sound-alike medications are
☐ ☐
administered?
What training and information do you share with staff about look-alike/sound-alike medications? ☐ ☐
What data has your organization collected on adverse events related to look-alike/sound-alike
medications? What has been done in response to that data? Are improvements in place to ☐ ☐
manage risks?


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Medication Management: Anticoagulant Therapy
Accreditation Programs/Settings: AHC, CAH, HAP, NCC

7.7: Anticoagulant Therapy

Relevant Standards: HR.01.05.03, HR.01.07.01, NPSG.03.05.01, MM.07.01.03, PC.02.03.01,
PI.03.01.01 Use Adapt
Question Question
Accreditation Programs/Settings*: AHC, CAH, HAP, NCC As Is for Use
*For organizations that provide anticoagulant therapy and/or long-‐term anticoagulation
prophylaxis where the clinical expectation is that the patient’s laboratory values for coagulation
will remain outside normal values
Who has oversight in making sure policies and procedures regarding the management of
anticoagulants are followed?
☐ ☐
What is your organization’s policy on safe anticoagulant therapy? ☐ ☐
What are the organization’s policies and procedures for anticoagulant therapy? How were these
policies developed? What evidence-‐based guidelines were used? Who was involved in the ☐ ☐
development?
How is compliance with anticoagulant policies evaluated? What improvements have been made
as a result of evaluation?
☐ ☐
How do you monitor patients on anticoagulant therapy? ☐ ☐
What is the monitoring frequency for anticoagulants? ☐ ☐
What is the organization’s policy for monitoring patients on anticoagulants? ☐ ☐
What is your approach to medication management as it relates to high-‐risk processes such as
anticoagulant therapy?
☐ ☐
How are orders for anticoagulant medications reviewed for accuracy? ☐ ☐
Are standing orders for anticoagulants allowed, per your policy? ☐ ☐
How is anticoagulant medication dispensed? Is heparin provided in manufacturer-‐prepared
premixed infusions? Is warfarin provided in unit-‐dose tablets in exact doses?
☐ ☐
How are doses adjusted? Who adjusts doses? Are they adjusted according to protocol? ☐ ☐
How do you ensure that new staff is aware of the standard protocol for warfarin dosing? How is
compliance with protocol monitored?
☐ ☐

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Medication Management: Anticoagulant Therapy
Accreditation Programs/Settings: AHC, CAH, HAP, NCC
How do you determine a patient’s baseline coagulation status for warfarin? Where in the medical
record is that documented? May I see it, please?
☐ ☐
Are there special requirements for infusing heparin? Explain the steps in the administration
process.
☐ ☐
What steps has your organization taken to reduce anticoagulant compounding and
labeling errors?
☐ ☐
How might a patient receive heparin in error? What processes are in place to prevent this? ☐ ☐
What resources are you using to help manage potential food and drug interactions with
anticoagulants?
☐ ☐
How do you educate patients on anticoagulation therapy? ☐ ☐
Patient: Has someone on staff talked with you about the proper way to take warfarin? ☐ ☐
Patient: Has someone on staff talked with you about taking other medications while you are
taking warfarin and the potential for interactions?
☐ ☐
Patient: What information have you received about your diet and its effect on the anticoagulant
medication you’ll be taking after discharge?
☐ ☐
Patient: Have you been trained in recognizing the symptoms and implications of bleeding? What
should you do if bleeding or clotting occurs?
☐ ☐


8
TRANSPLANTS,
AND IMAGING
TESTING,
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Testing, Transplants, and Imaging: Test Orders and Results
Testing, Transplants, and Imaging You may wish to

8.1: Test Orders and Results

Use Adapt
Relevant Standards: DC.01.01.01, DC.01.02.01, NPSG.02.03.01, IM.02.01.03, PC.01.02.15, Question Question
PC.02.01.21, PC.02.03.01, PI.01.01.01, PI.02.01.01, PI.03.01.01 As Is for Use
Who orders tests and makes referrals in your organization? How do you document when a test
☐ ☐
order is made?
How are patients informed of any necessary tests or referrals? How are patients educated about
☐ ☐
the test or referral?
How do orders get communicated to the laboratory? Is there any variation between
units/departments or providers in how this is done? Must all orders be written? If there are verbal ☐ ☐
orders, how are they validated?
What kind of system is used to communicate test results between the laboratory and the areas of
☐ ☐
the organization that order the tests?
What tracking system do you have in place to follow up on tests and results? Who is responsible
☐ ☐
for this? Who has access to your tracking system?
Who interprets the test results, and how are they sent to the ordering practitioner or provider? ☐ ☐
What actions take place after a result or report has come back from the lab? How do you monitor
☐ ☐
that tests are performed as ordered?
What happens if the result is abnormal? How do you document an abnormal result? What
☐ ☐
happens if the result is normal? How do you document a normal result?
How are patients informed of an abnormal result? How are patients informed of a normal result? ☐ ☐
What is your process for stat tests? How do the orders come into the lab? How do you ensure that
☐ ☐
all orders are completed? How is delivery acknowledged? How are results shared?
How are physicians informed when a stat test result is transmitted to the emergency department? ☐ ☐
What interventions are you using to reduce risk in the communication process between the
☐ ☐
laboratory and the unit/department/provider ordering the test?
What procedures are in place to protect health information transmitted between the laboratory
☐ ☐
and other areas of the organization?


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Testing, Transplants, and Imaging: Laboratory Procedures and Equipment
Accreditation Programs/Settings: LAB

8.2: Laboratory Procedures and Equipment

Relevant Standards: HR.01.05.03, HR.01.06.01, HR.01.07.01, QSA.01.01.01, QSA.01.02.01, Use Adapt
DC.01.01.01, DC.02.01.01, EC.02.01.01, EC.02.04.01, EC.02.04.03, HR.01.05.03, LD.04.05.09, Question Question
NPSG.02.03.01 As Is for Use
Please provide the laboratory policies and procedures related to this test. ☐ ☐
What is the organization’s required time line for reporting critical results/values? ☐ ☐
How do you ensure that the critical values you report are accurate? Where are the reference
☐ ☐
ranges for your test results?
May I see your policy identifying critical values? ☐ ☐
How do you ensure the privacy of test results? What process is in place to secure your electronic
☐ ☐
records?
How do you document the quality control for each laboratory test? How do you monitor it for
completeness? What type of external reporting do you have in place? What reports do you ☐ ☐
receive?
Do you have provider-performed microscopy testing? How are physicians trained to perform
☐ ☐
these tests?
Please show me your written laboratory equipment inventory. How do you select equipment to
☐ ☐
add to your inventory? How is staff involved?
What documentation do you have in relation to laboratory instrument maintenance? How long do
you keep the records for performance maintenance and function checks? How long do you keep ☐ ☐
the records for repairs and parts replacements?
What records do you keep for laboratory equipment quality control, calibration, calibration
verification, and correlation? Do they include records for automated volumetric equipment? Can
you please show those records? ☐ ☐
What is your process for responding to a product recall on a piece of equipment? ☐ ☐
May I review the laboratory procedures, quality control, calibration, calibration verification, and
☐ ☐
maintenance and temperature records in the clinical laboratory for the hematology analyzers?

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Testing, Transplants, and Imaging: Laboratory Procedures and Equipment
Where are blood warmers located and how are they maintained to ensure they are ready for use
☐ ☐
as needed?
How does your laboratory obtain blood products for testing? ☐ ☐
What are the laboratory policies and procedures for emergency release of blood? ☐ ☐
How do you monitor the blood utilization and criteria for transfusion? ☐ ☐
How does your laboratory perform the quality control in the transfusion services? ☐ ☐
How do you monitor temperature-controlled spaces and equipment in the laboratory? ☐ ☐
Will you please show me the temperature logs for your storage refrigerators? ☐ ☐
What backups are in place in case the refrigerator or freezer fails? ☐ ☐
How are the blood products stored? May I see the refrigerator used for this? ☐ ☐
What is your policy regarding storage of nonlaboratory items in the laboratory, including the
☐ ☐
refrigerators?
What personal protective equipment is required for laboratory personnel? ☐ ☐
What would you do if you splashed a chemical in your eye during laboratory work? ☐ ☐
May I review a specimen tube label? ☐ ☐
How do you provide reports for proficiency testing of laboratory staff? May I please see
☐ ☐
documentation of proficiency testing?
How might a discrepancy exhibited in the proficiency test results have affected patient results?
☐ ☐
How should your current process be modified, based on the proficiency test results?


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Testing, Transplants, and Imaging: QSA Cytology Procedures

8.3: QSA Cytology Procedures

Relevant Standards: DC.01.01.01, DC.02.04.01, HR.01.02.03, HR.01.05.03, HR.01.06.01, Use Adapt
HR.01.07.01, LD.04.05.01, PI.01.01.01, PI.02.01.01, PI.03.01.01, QSA.01.01.01, QSA.01.02.01, Question Question
QSA.08.01.01, QSA.08.02.01, QSA.08.03.01, QSA.08.04.01, QSA.08.05.01, QSA.08.06.01, As Is for Use
QSA.08.06.03, QSA.08.07.01, QSA.08.08.01, QSA.08.09.01, QSA.02.11.01
Who oversees the cytology department of the laboratory? ☐ ☐
Who is responsible for establishing and updating laboratory policies and procedures for cytology? ☐ ☐
What data and statistics do you collect or produce in relation to your cytology service? How is this
☐ ☐
reported and documented? How is this data used for performance improvement?
What quality improvement processes have you incorporated to improve the cytology service? ☐ ☐
How do you set workload limits and parameters for cytology, particularly for primary slide
☐ ☐
screening? Where is this documented? How do you determine maximum 24-‐hour limits?
How do you monitor workload limits and how often do you evaluate and modify them? ☐ ☐
May I please see the laboratory policies and procedures for cytology specimen collection,
☐ ☐
identification, preservation, transport, and evaluation?
How do your processes of staining, interpretation, and review differ for gynecologic and
☐ ☐
nongynecologic specimens? Who performs the reviews?
How are cytology results sent to whomever ordered the test or will be using the results? ☐ ☐
What happens when an incorrect test is reported? How is this response documented? ☐ ☐
How are your cytology slides stored, maintained, and preserved? ☐ ☐
How long do you retain cytology reports? ☐ ☐
Who determines the qualifications and number of staff? ☐ ☐
How do you provide reports for proficiency testing of laboratory staff in cytology? ☐ ☐
What staff training and education do you provide in relation to cytology? ☐ ☐


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Testing, Transplants, and Imaging: Waived/Point-of-Care Testing

8.4: Waived/Point-of-Care Testing

Use Adapt
Relevant Standards: HR.01.06.01, HR.01.07.01, DC.01.01.01, WT.01.01.01, WT.02.01.01, Question Question
WT.03.01.01, WT.04.01.01, WT.05.01.01, NPSG.01.01.01 As Is for Use
Who is responsible for maintaining your CLIA certificates? Who has oversight responsibility for all
☐ ☐
testing in the organization, including waived testing?
What oversight responsibility does the laboratory have in relation to point-of-care testing? ☐ ☐
How do you identify patients before testing? ☐ ☐
Can you please describe your policies and procedures in relation to waived testing? How is
☐ ☐
implementation of these monitored and, as needed, modified or improved?
How do you know when waived testing is needed? What is your process to communicate and
☐ ☐
respond to orders for these tests?
How do you receive an order for a point-of-care testing specimen? ☐ ☐
How do the laboratory and the nursing staff communicate with one another for point-of-care
☐ ☐
testing concerns?
Please show me how you perform a point-of-care test at the bedside. ☐ ☐
What information do you communicate with the patient during point-of-care testing? ☐ ☐
Where are levels taken during point-of-care testing recorded? How are they reported? ☐ ☐
What type of competency assessment have you received for waived testing? ☐ ☐
Please provide the annual competency for blood glucose waived testing. ☐ ☐
Please provide the facility’s waived testing policy related to monitoring blood glucose. ☐ ☐
What is your quality control process? What are these processes based upon? ☐ ☐
May I review the quality control records/logs? ☐ ☐
What is the difference between the quality control process you perform for noninstrument-based
☐ ☐
waived testing and instrument-based waived testing?


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Testing, Transplants, and Imaging: Tissue Handling and Tracking

8.5: Tissue Handling and Tracking

Use Adapt
Relevant Standards: HR.01.05.03, TS.01.01.01, TS.02.01.01, TS.03.01.01, TS.03.02.01, Question Question
TS.03.03.01 As Is for Use
How does your organization work with tissue banks, eye banks, and organ procurement
☐ ☐
organizations? Do you have a written agreement?
Who developed your organ donation policy? What is included in that policy? ☐ ☐
How is staff educated about tissue and organ donations? ☐ ☐
Who is the person designated by the organization to talk to patients and families about tissue and
organ donations? What are that person’s responsibilities and how is that person trained to ☐ ☐
perform them?
Please describe the process for accepting and storing tissue. How much variation is allowed in the
☐ ☐
process?
May I please see the tissue log? ☐ ☐
How is tissue transported to the surgical area? Who transports it and by what means? ☐ ☐
How does the tissue get taken to the surgical area? Who takes it and by what means? ☐ ☐
Where do you store tissue in the surgical area? May I see your storage equipment, please? ☐ ☐
How do you monitor tissue for proper tissue storage? What happens if the tissue storage
☐ ☐
equipment temperature rises above acceptable limits?
What happens if the tissue storage equipment fails? What backup processes are in place, if any? ☐ ☐
May I see tissue storage equipment temperature records/logs that document the time the tissue
☐ ☐
was placed in inventory to the time the tissue was implanted?
What happens if the tissue storage equipment temperature rises above acceptable limits? ☐ ☐
What happens if the tissue storage equipment fails? ☐ ☐
May I see tissue storage equipment temperature records from the time the tissue was placed in
☐ ☐
inventory until the tissue was implanted?

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Testing, Transplants, and Imaging: Tissue Handling and Tracking
How are tissue implant products handled? ☐ ☐
Please describe the tracking mechanism for tissue implants. ☐ ☐
What are the procedures for reviewing tissue tracking in case of adverse outcomes? ☐ ☐
How do you sequester tissue that may be compromised or a source of infection? ☐ ☐
How do you verify that the tissue supplier has a current federal and state tissue-bank license? ☐ ☐


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Testing, Transplants, and Imaging: MRI Suite Processes

8.6: MRI Suite Processes

Use Adapt
Relevant Standards: EC.02.01.01, EC.02.04.01, EC.02.04.03, HR.01.05.03, HR.01.06.01, Question Question
HR.01.07.01, PC.01.02.15, PI.01.01.01, PI.02.01.01, PI.03.01.01 As Is for Use
Who is in charge of MRI safety in your organization? ☐ ☐
What qualifications are required for the MRI technologists? How do you verify staff qualifications? ☐ ☐
What guidelines are the imaging protocols based upon? Who reviews and approves them? How
☐ ☐
are they kept current?
How are orders for MRIs communicated to the diagnostic imaging area/center? ☐ ☐
How are MRI results communicated to the ordering provider? ☐ ☐
What is the policy regarding sedation of MRI patients? Please provide the policy for review. ☐ ☐
What does the MRI patient prescreening include? How is it different for pediatric patients? How is
☐ ☐
staff screened? What if the patient responds affirmatively to any of the screening questions?
What is your process for managing patients with anxiety or claustrophobia? ☐ ☐
How are the safety zones marked in the MRI suite? How do you control access to the MRI area? ☐ ☐
What sort of training have you received regarding safety in the MRI suite? ☐ ☐
Did your training for the MRI suite include processes for caring for non-English-speaking patients? ☐ ☐
What sort of training have you received for emergency MRI shutdowns? ☐ ☐
How do you respond to patient emergencies in the MRI suite? Can you provide examples? ☐ ☐
What quality control activities do you perform on the MRI equipment to ensure that it is
☐ ☐
functioning properly?
Please provide the quality control documentation and the annual physicist’s report for review. ☐ ☐
How do you use data collected on adverse events in the MRI suite? ☐ ☐


9
ENVIRONMENT
THE PHYSICAL
DOWNLOAD
The Physical Environment – EC: EC Management and Risk Management
The Physical Environment – Environment of Care You may wish to

9.1: EC Management Plans and Risk Management

Use Adapt
Relevant Standards: EC.01.01.01, EC.02.06.01, EC.04.01.01, EC.04.01.03, EC.04.01.05, PI.01.01.01, Question Question
PI.03.01.01 As Is for Use
Who is responsible for risk management activities in the organization? Is this person also
responsible for intervening in cases of threat to life, health, or damage to equipment or buildings? ☐ ☐
If not, who is responsible for that? [N/A for OBS and OME]
Please describe the process for creating the environment of care management plans. [N/A for OBS
☐ ☐
and OME]
Who is responsible for creating the environment of care management plans? Is an

☐ ☐
interdisciplinary team involved? If so, who is on the team? [N/A for OBS and OME]
Does your organization have environment of care management plans covering all of the
☐ ☐
environment of care functional areas, such as fire safety and utilities? [N/A for OBS and OME]
How do your environment of care management plans focus on risk management? [N/A for OBS
☐ ☐
and OME]
Do the environment of care management plans include objectives, performance monitors, and
scope definitions? Do they cover all organization sites, including any leased sites? Do they explain ☐ ☐
briefly how relevant standards and EPs are met? [N/A for OBS and OME]
Do your environment of care management plans identify those responsible for completing specific
☐ ☐
tasks within required time frames? [N/A for OBS and OME]
How does your organization evaluate your environment of care management plans? How often
do you perform an evaluation? Who participates in the evaluation? Does your organization ☐ ☐
document the date of evaluations? [N/A for OBS and OME]
How does your organization ensure that the evaluation process occurs in a timely way? [N/A for
☐ ☐
OBS and OME]
Does your organization compare the evaluations of the environment of care management plans
☐ ☐
against the minutes of your improvement committee? [N/A for OBS and OME]
How do environment of care leaders communicate the results of the management plan evaluation
process to organization leadership? [N/A for OBS and OME]
☐ ☐
How do environment of care leaders use the environment of care management plan evaluations
☐ ☐
as a starting point for further conversation? [N/A for OBS and OME]

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The Physical Environment – EC: EC Management and Risk Management
Senior Leader: How do you feel about the environment of care management plan evaluations?
Are the environment of care management plan evaluations easy to read and understand? What
conversations occur about environment of care issues, based on the environment of care
☐ ☐
management plan evaluations? [N/A for OBS and OME]
Senior Leader: Describe the organization’s main environment of care issues. Are those part of the
☐ ☐
management plans? [N/A for OBS and OME]
How do you monitor the environment of care to ensure a safe, functional environment? ☐ ☐
What data do you collect on environment of care issues? ☐ ☐
How do incidents get reported? Who receives incident reports? What is the process to enter data
☐ ☐
from the report for the purposes of data use?
Where is the incident report form located? If you cannot access an electronic version, do you have
☐ ☐
a paper version? If so, where is that located?
How do you analyze data on environment of care issues? [N/A for OBS] ☐ ☐
Are there any external agencies that you must report to? What kinds of reports do you submit?
☐ ☐
How frequently do you provide them?
What types of improvement activities have you undertaken recently to address environment of
☐ ☐
care issue? [N/A for OBS and OME]


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The Physical Environment – EC: Safety and Security

9.2: Safety and Security

Relevant Standards: EC.02.01.01, EC.02.01.03, EC.02.06.01, EC.03.01.01, EC.04.01.01, Use Adapt
EC.04.01.03, HR.01.05.03, HR.01.06.01, HRM.01.05.01, HRM.01.06.01, PI.01.01.01, PI.03.01.01 Question Question
As Is for Use
Do you feel the organization creates a safe and secure environment in which you can work? ☐ ☐
What type of education and procedures are in place to address workplace violence? ☐ ☐
How does the organization assess for safe workplace practice controls (ergonomics, safety
☐ ☐
equipment, personal protective equipment)?
What is the process for reporting safety and security issues? Does this information get reported to
☐ ☐
an environment of care committee and if so, how often?
Where are organizational policies regarding the environment of care located and are they
☐ ☐
available to staff?
Please describe the organization’s environment of care risk assessment process. ☐ ☐
Please provide a copy of the most recent environment of care risk assessment. ☐ ☐
How frequently does the organization review environmental data collected, committee meeting
☐ ☐
minutes, and incident reports? What do you do with the information gleaned from this review?
What interventions do you put in place to ensure that your environment is safe when the floor is
☐ ☐
being cleaned or there is inclement weather?
What are the organization’s processes for managing snow removal? ☐ ☐
When you have inclement weather, what is your response plan? Who has responsibility for
☐ ☐
carrying it out? Who is responsible for tracking and implementing the plan?
How do you secure outside equipment? ☐ ☐
How do you ensure that your signage is correct and safe for patients, staff, and visitors? ☐ ☐
How many security staff members monitor the organization during the day and evening? What
☐ ☐
is your approach to patrolling the facilities and grounds?

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Please show me where your major entrances are for the organization. How do you monitor
security at entrances and exits?
☐ ☐
How do you secure the facility? Do you lock the doors at any time? If so, why? Do you do so in a
☐ ☐
way that allows for safe egress?
Please provide documentation of any departments in which it is required to log in visitors or

☐ ☐
nonauthorized personnel.
Please show me documentation on logging of access to secure areas of the organization. ☐ ☐
What areas are designated as security-sensitive? Please take me to tour these areas. ☐ ☐
Who has access to security-sensitive areas? What do you do in the event that a staff member
☐ ☐
loses an access card or key?
What additional security measures do you put in place in security-sensitive areas? ☐ ☐
How does the unit ensure the security of the elevators in security-sensitive areas like obstetrics
☐ ☐
and pediatrics?
Will you please show me any documentation you have to demonstrate training for security staff? ☐ ☐
Where are medication carts stored? How is the room secured? Does it allow safe egress? ☐ ☐
Where are your generators located? How have you secured your generators from unauthorized
access?
☐ ☐
What risks have you identified with the generators in relation to an adverse event, such as
☐ ☐
a terrorist attack or sabotage?
Have you considered the security risk implications in how you identify the generator room? ☐ ☐
Who has access to the generator? How do you control access? ☐ ☐
Please show me where your exterior generator is located. How have you secured this
☐ ☐
generator from unauthorized access or vandalism? Who has access to the exterior generator?
How do you control access to other critical utility systems? ☐ ☐
Are any of the doors in the mechanical areas unmarked? Is the door that leads to the roof
☐ ☐
identified as such?
How do you mitigate risk from potential hazards in the mechanical rooms? ☐ ☐
In the event of a security problem, such as an attack or accident, how do you secure the building?
☐ ☐
What is your response?
What are the emergency lockdown procedures for all of the facilities that provide patient care? ☐ ☐
What are security staff members trained to do in the event of an active shooter? ☐ ☐

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Has the organization conducted an emergency response exercise that initiated the organization’s
☐ ☐
Emergency Operations Plan? If so, when did this exercise take place?
During the emergency response exercise, did you monitor management of safety and security? ☐ ☐
How do you analyze the results of your emergency response exercises? Who is responsible for this
☐ ☐
analysis? How are the results communicated?
What types of data do you collect in relation to environmental safety? Who is responsible for
collecting environmental safety data? What methods do you use for collection and analysis? Who ☐ ☐
analyzes the data?
What environmental safety issues have you discovered and addressed as a result of your data
☐ ☐
collection and aggregation?
Who is responsible for planning and designing improvements resulting from environmental risk
assessments? How do you implement the improvements? How are staff members educated about ☐ ☐
the improvements? How are you monitoring results?
How do you mitigate risk from potential hazards in the mechanical rooms? ☐ ☐
How do you train to protect workers from workplace injuries? ☐ ☐
What training do you offer on safe lifting? ☐ ☐
Please describe how wheelchairs used by discharged patients get returned from the main
entrance to their proper storage area. How do you check the entrances for potential equipment ☐ ☐
blockages such as this?
Please show me where the wheelchairs are stored. Are any patient rooms being used for
equipment storage? If so, why? How do you ensure security for the equipment in that room?
☐ ☐
What environmental factors have you identified that could increase the risk of successful suicide
☐ ☐
or self-harm attempts in behavioral health areas? In other areas?
What kinds of environmental interventions have you put in place? How do you secure the
☐ ☐
environment to mitigate suicide and self-harm risk in behavioral health areas? In other areas?
What education do you provide to patients and families about home environment hazards? ☐ ☐
What processes are in place for responding to a patient elopement? May I see your written
☐ ☐
response plan? [NCC only]
How do you communicate the patient elopement to staff and the patient’s family? How is local
☐ ☐
law enforcement informed and involved? [NCC only]
How do you communicate and facilitate product recall (equipment, food, devices, utilities)? ☐ ☐


DOWNLOAD
The Physical Environment – EC: Infant and Pediatric Security

9.3: Infant and Pediatric Security

Use Adapt
Relevant Standards: EC.02.01.01, EC.02.01.03, EC.03.01.01, EC.04.01.01, EC.04.01.03, Question Question
HR.01.05.03 As Is for Use
Who is responsible for ensuring the security of infants and pediatric patients in this organization? ☐ ☐
Has the organization conducted a risk assessment on infant/pediatric security and abduction?
☐ ☐
What were the results of this risk assessment?
What are your concerns about infant/pediatric security in the organization? ☐ ☐
How does the organization preserve security for infants and pediatric patients in this area? ☐ ☐
Patient or Family: Please tell me about what you have been told regarding infant/pediatric patient
☐ ☐
security.
What additional security measures do you put in place in security-sensitive areas, such as the
☐ ☐
obstetrics department?
Who has access to the obstetrics department and pediatric units? How does the organization
☐ ☐
control access to these areas?
How do you track and monitor access to security-sensitive areas like obstetrics and pediatrics? ☐ ☐
What do you do when the electronic system for controlling access to infant/pediatric care units
fails? Does the unit have manual systems in place for controlling access? Is the security system for ☐ ☐
obstetrics connected to emergency power?
How do you know if an infant/pediatric patient has been abducted? ☐ ☐
Do you use a Code Pink process or similar process to alert staff to an infant/pediatric abduction? If
☐ ☐
so, please describe that process. Which staff members are involved in the process?
What is your responsibility when a Code Pink or similar process is called? What is the
☐ ☐
responsibility of your peers in this situation?
What is the role of local law enforcement in your organization’s response to an infant/pediatric
abduction? How would they be contacted if it became necessary? Who would contact them?
☐ ☐
Has the organization ever done an infant/pediatric abduction exercise? If so, in what areas of the
☐ ☐
organization? Who was involved?

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The Physical Environment – EC: Infant and Pediatric Security
How often are exercises on infant/pediatric abduction response conducted? Please provide a copy
☐ ☐
of the most recent exercise evaluation.
Has the organization involved outside law enforcement in infant/pediatric abduction exercises? ☐ ☐
How does the unit identify potentially disruptive family situations (such as estrangement or a
custody battle) that might create risk for an infant/pediatric abduction? How is that information
shared with staff on the relevant unit? How does the unit increase security around a child
☐ ☐
involved in such situations?
What processes does the organization have in place for releasing a child to a noncustodial parent? ☐ ☐
How does the emergency department preserve the safety of infants and pediatric patients? ☐ ☐
How do you determine if a child is missing in the emergency department? ☐ ☐
How do you respond if a child is missing in the emergency department? Who do you notify first?
☐ ☐
Who else do you notify?
How does the organization notify internal and external security if a child is missing in the
☐ ☐
emergency department?
Does the organization lock down the emergency department in response to a missing child? If so,
how? How is the lockdown communicated to patients, families, and staff?
☐ ☐
Has the organization done exercises for children missing in the emergency department? What
deficiencies did the organization identify in those exercises? What changes have resulted in ☐ ☐
response to those exercises?
What type of education and training does the organization provide staff about infant/pediatric
security and incident response? How often is it offered? Can you please provide documentation of ☐ ☐
this education and training?


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The Physical Environment – EC: Hazardous Materials and Waste

9.4: Hazardous Materials and Waste

Relevant Standards: EC.02.02.01, HR.01.05.03, HR.01.06.01, HRM.01.05.01, HRM.01.06.01, Use Adapt
IC.02.01.01, MM.01.01.03, PI.01.01.01, PI.03.01.01, QSA.13.15.01, QSA.19.01.01, QSA.19.02.01 Question Question
As Is for Use
How do you inventory your hazardous materials and waste? What do you keep on the inventory?
☐ ☐
May I see your hazardous materials and waste inventory? [N/A for BHC and OBS]
How do you check and update the inventory? How often is this done? How do you prioritize
updating the inventory? What happens when a new hazardous material is brought into ☐ ☐
the organization? [N/A for BHC and OBS]
Who has responsibility for the inventory? Who is responsible for updating it? How do you track
this responsibility? [N/A for BHC and OBS]
☐ ☐
Where is the inventory kept? Do you have any backups for it? [N/A for BHC and OBS] ☐ ☐
Do you use any kind of safety data sheets (SDSs) in the organization? If so, where do you store
them? [N/A for BHC and OBS]
☐ ☐
Do staff members know how to access safety data sheets (SDSs)? How do staff members access
an SDS when the computer is not available? [N/A for BHC and OBS]
☐ ☐
How do you update the safety data sheets (SDSs)? How do you communicate any changes or
☐ ☐
updates? [N/A for BHC and OBS]
What organization processes and procedures exist for handling hazardous material and waste? ☐ ☐
What is your organization’s policy on hazardous waste management? ☐ ☐
What regulatory bodies control the organization’s storage, labeling, and handling of hazardous
materials and waste?
☐ ☐
What kind of documentation do you maintain in relation to hazardous waste and materials
management? What monitoring logs or checklists do you maintain?
☐ ☐
How do you secure hazardous materials—for example, those stored on a housekeeping cart? ☐ ☐

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Where do you store hazardous materials for use? ☐ ☐
How do you label containers of hazardous materials? How do you label containers of cleaning
products with hazardous materials? What do you do if you find an unlabeled product?
☐ ☐
How do you check to see if your hazardous materials are expired? ☐ ☐
How are hazardous waste products handled? How are they stored for disposal? How often are
they removed from the facility?
☐ ☐
How does the organization collect data on hazardous materials and waste spills? Are these data
☐ ☐
available for specific locations, such as the laboratory? How often do you review these data?
What kinds of data do you collect on hazardous materials and waste use and adverse events? ☐ ☐
Has there been any recent incident involving hazardous materials or waste? If so, please describe
that incident.
☐ ☐
How do you report an incident involving hazardous materials or waste? ☐ ☐
What training does the organization provide on responding to an incident involving hazardous
materials or waste?
☐ ☐
Are you required to report hazardous materials and waste reports to any external agencies? If so,
what kinds of reports do you submit? How frequently do you provide them?
☐ ☐
What do you do in the event of an accidental ingestion of a hazardous material? ☐ ☐
What are the risks involved in splashing chemicals? What training have you had on the proper
response to a chemical splash? If a chemical splashes in your eye, what do you do?
☐ ☐
Does your organization have eyewash stations? If so, where are they located? ☐ ☐
What training does the organization provide on use of eyewash stations? ☐ ☐
Who is responsible for testing the eyewash stations? What do you test in the eyewash stations
and how do you test it? What do you do when the testing shows that an eyewash station is not ☐ ☐
functioning properly? Who do you contact to fix the eyewash station?
How often do you test the eyewash stations? Where do you keep testing records for the eyewash
stations?
☐ ☐
What hazardous materials do you work with? What risks are associated with the hazardous
materials? What training and education have you had on these materials? How do you access the ☐ ☐
safety data sheets (SDS) for this material? [N/A for BHC and OBS]
What personal protective equipment (PPE) do you wear to protect yourself from hazardous
materials and waste?
☐ ☐

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What would happen if someone spilled hazardous materials? How would the spill be cleaned and
disinfected? What personal protective equipment (PPE) would be necessary when cleaning up the ☐ ☐
spill?
What is the housekeeping department’s role in cleaning up spills, specifically those related to
hazardous cleaning materials such as bleach?
☐ ☐
How would you notify other staff, patients, and leadership about a hazardous materials spill? ☐ ☐
How would you respond to individuals exposed to hazardous spill materials? How would you
prevent exposure to others in the organization? Would you need to evacuate the area of the spill?
☐ ☐
What training and education have you received on hazmat spill response? ☐ ☐
Who would you call to address a really large hazmat spill? When do you notify outside authorities,
such as the fire department? What is the organization’s relationship with the fire department ☐ ☐
regarding hazmat response?
Do you have a hazmat response team? Who is on the hazmat response team? ☐ ☐
How are hazmat team members trained? What is the team’s response to a hazmat spill? ☐ ☐
Has the organization ever done a hazmat spill response drill? ☐ ☐
Has the organization ever done a hazmat drill that included an individual who needs
decontamination?
☐ ☐
Please describe the general storage requirements for the chemicals in the mechanical rooms. ☐ ☐
Are the boiler and air-handling equipment rooms typically where the chemicals needed for
maintaining the equipment are stored? If so, how was it determined that these chemicals could ☐ ☐
be stored in the same area as the equipment?
How is the maintenance staff supervised when working with or stocking the chemicals stored in
the mechanical rooms?
☐ ☐
Who keeps the safety data sheets (SDSs) on chemicals needed for maintaining equipment? Please
provide the SDSs on the chemicals stored in the mechanical rooms. [N/A for BHC and OBS]
☐ ☐
How do you inform staff of the SDS requirements for chemicals stored in the mechanical rooms?
☐ ☐
What type of refresher education is held? [N/A for BHC and OBS]
Do you conduct regular inspections for spills or leakage of chemicals in the mechanical rooms? Do
you have documentation of those inspections?
☐ ☐
Please show me your written procedures regarding spills of chemicals in the mechanical rooms. ☐ ☐

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Do you know what to do in the case of a chemical spill? What is the special code to call if a
chemical spill occurs?
☐ ☐
Do you know whether any specific chemicals require specialized handling in case of a spill? ☐ ☐
Where is the protective equipment for handling chemical spills in the mechanical rooms? ☐ ☐
What are the organization’s policies on infectious waste disposal? Who develops these policies?
How often are these policies reviewed?
☐ ☐
What training does the organization provide to staff on infectious waste disposal policies? ☐ ☐
What are the risks associated with infectious waste? ☐ ☐
What is the proper way to discard infectious waste, such as a used syringe or soiled gauzes? ☐ ☐
What personal protective equipment (PPE) should you wear when handling infectious waste? ☐ ☐
What training does the organization provide on infectious waste? How often does that training
occur? How does the organization measure whether that training is effective?
☐ ☐
Where do you usually pick up bags of infectious waste? What types of materials are in the bags? ☐ ☐
What personal protective equipment (PPE) do you wear when you handle a hazmat bag of
infectious waste? How do you ensure infection control when transporting the bag? What training ☐ ☐
and education have you received on infectious waste disposal?
How does the organization store infectious waste until the contracted infectious waste hauler
arrives for pickup?
☐ ☐
How do you document when infectious waste arrives? How do you document when the
contractor picks up the infectious waste for disposal?
☐ ☐
Who is the organization’s hauling contractor for infectious waste? How did the organization
choose that contractor?
☐ ☐
Has the organization done a risk assessment on radiation safety? If so, what were the results of
☐ ☐
that assessment? [N/A for BHC, OME, NCC, and OBS]
How do you remove radioactive material from the facility? How do you dispose of such material?
What personal protective equipment (PPE) do you wear when removing and disposing of ☐ ☐
radioactive material? [N/A for BHC, OME, NCC, and OBS]
How does a dosimeter badge work? How do you interpret the information on the badge? [N/A for
BHC, OME, NCC, and OBS]
☐ ☐

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The Physical Environment – EC: Fire Response

9.5: Fire Response*

Relevant Standards: EC.02.03.01, EC.02.03.03, EC.02.03.05, HR.01.05.03, HR.01.06.01, Use Adapt
HRM.01.05.01, HRM.01.06.01, PI.01.01.01, PI.03.01.01 Question Question
As Is for Use
May I please see your written fire response plan? How often do you review and update it? ☐ ☐
How does the organization create and maintain the fire response plan? Who is involved in this
☐ ☐
process?
Who is on the organization’s fire response team? ☐ ☐
How is the fire response team notified about a fire? ☐ ☐
What is the role of the fire response team in the fire response? ☐ ☐
What is the organization’s approach to fire response? How often is this approach tested? ☐ ☐
Whom do you contact when there is a fire? ☐ ☐
How does the organization interact with the fire department? ☐ ☐
When would the unit make the decision to evacuate? Who would make that decision? ☐ ☐
How would the unit horizontally evacuate? How would the unit vertically evacuate? Where would
the unit meet up after the evacuation?
☐ ☐
How is the staff directed to maintain communication with family members and other organization
☐ ☐
staff during a fire evacuation?
What are the expectations of staff in responding to a fire? ☐ ☐
What training and education does the staff receive on the fire response plan? How often is that
☐ ☐
training provided? Is that training documented?
How often are staff understanding and familiarity with the plan tested? ☐ ☐
If there were a fire in the organization right now, what would you do? How would you ensure the
☐ ☐
safety of patients, visitors, and staff? What would you do about items stored in the corridor?
What would your response be if the fire were on a different floor from yours? ☐ ☐

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The Physical Environment – EC: Fire Response
When was the last fire drill for your work area? Please show me your log of fire drills. Who is
☐ ☐
responsible for tracking and updating this information?
Describe a recent fire drill in which you participated and what the outcomes of that drill were. ☐ ☐
Are fire drills usually announced in advance? ☐ ☐
Did the organization involve the fire department in the drill? Does the organization notify the fire
department before the drill so it doesn’t respond?
☐ ☐
How did you evaluate the success of the drill? What did the organization learn from the drill? ☐ ☐
How does the organization evaluate its fire drills? ☐ ☐
Who is in charge of evaluating the drills? ☐ ☐
What does the organization do with the information gleaned from fire drill evaluations? Does the
☐ ☐
organization use the information for performance improvement?
In the last fire drill, what was something the organization learned? What corrective actions were
☐ ☐
taken as a result of the drill? Who followed through on those corrective actions?
In the event of an unexpected response or outcome to a fire drill or fire incident, how do you
☐ ☐
implement an improvement? Can you please give me an example of this?
Where is the closest fire alarm? Where is the closest fire extinguisher? ☐ ☐
Where are the visual and audible fire alarms located? Please show me an example. How often is
the equipment tested?
☐ ☐
What equipment does the fire response team use to help contain a fire? Where does the team
☐ ☐
access that equipment?
Please show me where your fire safety equipment is. Where do you label dates and
☐ ☐
other information about recent testing and monitoring on the equipment?
Where do you document your testing of fire safety equipment? ☐ ☐
May I see the policy for smoke detector testing, maintenance, and battery replacement? Please
☐ ☐
provide the documentation indicating that you have followed this policy.
* Fire safety and life safety are both terms that relate to fire protection, but they differ for the purposes of Joint Commission
requirements: Fire safety requirements are in the “Environment of Care” chapter and refer to fire protection—and fire
response—that is dependent on human intervention (fire drills and fire safety equipment, maintaining means of egress and
fire exits). Life safety requirements are in the “Life Safety” chapter and refer to fire protection dependent on building
features (alarm and sprinkler systems, construction, building design, hardware). The standards in the “Life Safety” chapter are
based on the 2012 edition of the Life Safety Code, issued by the National Fire Protection Association. Life Safety Code® is a
registered trademark of the National Fire Protection Association, Quincy, MA.


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The Physical Environment – EC: Medical Equipment

9.6: Medical Equipment

Relevant Standards: EC.02.04.01, EC.02.04.03, EQ.01.01.01, EQ.01.02.01, EQ.01.03.01,
Use Adapt
EQ.01.04.01, EQ.01.05.01, EQ.01.06.01, HR.01.05.03, HR.01.06.01, HRM.01.05.01, HRM.01.06.01,
Question Question
LD.04.03.09, PI.01.01.01, PI.03.01.01
As Is for Use
NOTE: HRM standards are for BHC only. EQ standards are for OME only.
Who is primarily responsible for medical equipment in the organization? ☐ ☐
May I see your medical equipment inventory? How does the organization create its medical
equipment inventory? Who is involved?
☐ ☐
How does the organization determine which medical equipment to include in its inventory? ☐ ☐
How often does the organization review and update the inventory? ☐ ☐
How has the organization identified medical equipment that is considered high-risk? ☐ ☐
Do you have defined activities and frequencies for maintaining, inspecting, and testing all medical
equipment on the inventory?
☐ ☐
How has the organization identified whether medical equipment is maintained per
manufacturers’ recommendations or an alternative equipment maintenance (AEM) program? ☐ ☐
[CAH and HAP only]
For equipment that is required to be maintained per manufacturers’ recommendation, please

☐ ☐
provide documentation that those activities and frequencies are being met.
For equipment that is maintained through an AEM program, please provide documentation by a
☐ ☐
qualified individual of the written criteria used to develop this program. [CAH and HAP only]
Where do you store and manage your medical equipment? ☐ ☐
What is your process to safely store, label, and handle medical equipment? ☐ ☐
What safety guidelines and processes do you follow for specific types of medical equipment? ☐ ☐
How do you handle medical equipment use issues in your organization? ☐ ☐
What process do you follow for staff to report any issues with medical equipment (missing,
☐ ☐
needing repair, and so on)?

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Please describe your processes for initial inspection of equipment and inspection after major
repair.
☐ ☐
Have you ever had issues of lost or missing medical equipment? If so, what is your process to
☐ ☐
resolve it?
Where do you keep documentation for maintenance, inspection, and testing of medical
☐ ☐
equipment?
How does the organization ensure that all medical equipment is appropriately maintained? ☐ ☐
How does the organization track medical equipment maintenance schedules and information? ☐ ☐
What training is provided to the individuals charged with maintaining the equipment? ☐ ☐
How do you communicate with the staff in charge of medical equipment maintenance? ☐ ☐
How do you communicate with medical equipment users about equipment maintenance? ☐ ☐
How does the organization handle medical equipment that is serviced off-site? ☐ ☐
Who is the contractor the department uses to maintain the equipment? How do you
☐ ☐
communicate with this contractor?
How do you get the equipment to the contractor? What do you do to ensure that equipment
☐ ☐
returned to your location is in working order?
How does the organization ensure that the contractor is doing a good job? ☐ ☐
Staff Member: Could you point to a key piece of equipment that you use regularly? How often is it
used and what maintenance is performed on it? How would you know if there is a need to repair ☐ ☐
anything? What kind of competency training have you had to use this piece of equipment?
Who do you contact with questions about medical equipment functions and malfunctions? ☐ ☐
If you use medical equipment, such as an infusion pump in the home environment, how do you
maintain the equipment? How are the supplies for medical equipment delivered to the patient in
☐ ☐
the home? Who checks whether there are expiration dates on the supplies? What do you do in
the event of a problem with the equipment? [OME only]
What kind of patient education and training materials do you provide in relation to medical
☐ ☐
equipment used in the home? [OME only]
Patient: What has your experience been with this home medical equipment organization? Have
☐ ☐
you been able to get help with answers to your concerns or questions? [OME only]
What is the organizational process when patients bringing their own medical equipment, such as
CPAPs (Continuous Positive Airway Pressure)? What kind of training have you received to help you ☐ ☐
check the equipment, if necessary?
What is the organizational process when medical equipment failure leads to a poor patient
☐ ☐
outcome? How do you secure the equipment? How do you isolate the equipment?

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How does the clinical staff know who to notify about the medical equipment failures? ☐ ☐
How do you maintain the safety of patients during failure of medical equipment? ☐ ☐
What training have you had on emergency clinical interventions during medical equipment
☐ ☐
failures?
Describe an event in which a piece of medical equipment failed. What circumstances led to the
☐ ☐
event? What was the immediate response to the incident? What was the long-term response?
Are you satisfied with responses to medical equipment failures? How well do the various
individuals and/or departments work together during such events? What have you learned from ☐ ☐
such incidents to prevent future equipment failures?
Does your organization report incidents of medical equipment failure? If so, who creates the
☐ ☐
report and how? To whom is it submitted?
Has the organization ever used the data in the medical equipment database to track
☐ ☐
performance? If so, how has that data been used to improve performance?
Is sterilizer maintenance part of the organization’s overall medical equipment management

☐ ☐
program? [N/A for BHC]
Do the defined activities and frequencies not only include testing, inspection, and maintenance
☐ ☐
but also cleaning procedures?
How does the organization document maintenance activities, including cleaning? ☐ ☐


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The Physical Environment – EC: Utility Systems

9.7: Utility Systems

Relevant Standards: EC.02.05.01, EC.02.05.03, EC.02.05.05, EC.02.05.07, EC.02.05.09, Use Adapt
HR.01.05.03, HR.01.06.01, HRM.01.05.01, HRM.01.06.01, PI.01.01.01, PI.03.01.01 Question Question
As Is for Use
Who is primarily responsible for utilities equipment in the organization? ☐ ☐
May I see your utility component inventory? How does the organization create its utility
☐ ☐
component inventory? Who is involved?
How does the organization determine which utility components to include in its inventory? ☐ ☐
How often does the organization review and update the inventory? ☐ ☐
How has the organization identified utility components that are considered high-risk? ☐ ☐
Do you have defined activities and frequencies for maintaining, inspecting, and testing all utility
☐ ☐
components on the inventory?
How has the organization identified whether utility components are maintained per
manufacturers’ recommendations or an alternative equipment maintenance (AEM) program? ☐ ☐
[CAH and HAP only]
For utility components that are required to be maintained per manufacturers’ recommendation,
☐ ☐
please provide documentation that those activities and frequencies are being met.
For utility components that are maintained through an AEM program, please provide
documentation by a qualified individual of the written criteria utilized to develop this program. ☐ ☐
[CAH and HAP only]
What kind of training and orientation does the organization provide in relation to utility systems? ☐ ☐
Please show me the organization’s written procedures for responding to utilities system
☐ ☐
disruptions or failures. Who creates these procedures? How often are they reviewed?
Are clinical staff trained on procedures for responding to utilities system disruptions or failures? ☐ ☐
What would you do in the event of a utility failure, such as a medical gas failure? ☐ ☐
How would you ensure the safety of patients during a utility failure? [N/A for LAB] ☐ ☐

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How would you communicate with the facilities management department during a utility failure? ☐ ☐
How are lighting, ventilation, and temperature controlled in the case of an electrical outage? ☐ ☐
How would you shut down a particular system on the utilities system map in the event of an
☐ ☐
emergency?
How would you notify staff in affected areas if a utility system needed to be shut down or was
☐ ☐
otherwise disrupted?
How does the organization obtain emergency repair services for utility systems disruptions? ☐ ☐
What training have you received about utilities system shutdowns? ☐ ☐
Who in the organization is qualified to shut down a utility during an emergency situation? ☐ ☐
How does the organization ensure that only qualified individuals can shut down utilities? ☐ ☐
Please show a sample of how the organization labels utilities system controls to facilitate partial
or complete emergency shutdowns. Who labels the controls? How are the labels changed if ☐ ☐
necessary? How often do you check these utilities for correct labeling?
Please show me where the shutoff panels are in this area. How can I verify whether the
☐ ☐
maintenance and labeling is up to date on the panels?
What would you do if you needed to shut off the electrical power or medical gas in this area? ☐ ☐
Who do you contact if you need to do an emergency shutdown or if you have a problem with a
☐ ☐
utility system?
What emergency planning have you conducted around utility system failures? What testing do
you do to help mitigate such failures?
☐ ☐
What failures, if any, occurred during recent testing of emergency power? How has the
☐ ☐
organization addressed those failures?
How does facility management communicate with patient care units about power outages and
☐ ☐
when power is expected to be restored? [N/A for LAB]
Please describe the plan for communication between the organization’s power plant and your
☐ ☐
area during a power outage.
What training and education regarding power outages have you received? Do you feel that this
☐ ☐
training and education adequately prepares you for power outages?
How does the staff ensure the safety of anyone in surgery at the time of a power outage? [CAH,
☐ ☐
HAP, and OBS only]
What training and education has operating room staff received on response to power outages? Is
☐ ☐
that training effective? How do you know? [CAH, HAP, and OBS only]

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Does the organization activate its incident command center during a power outage? If not, why
☐ ☐
not? If yes, how does the process work?
How does the organization communicate with the power company during a power outage? ☐ ☐
Does the organization have a memorandum of understanding with its power company and any
☐ ☐
generator vendors?
When was the last time you experienced a power outage? Please describe the incidents and the
events leading up to it. How did the organization respond to the power outage? What systems
☐ ☐
transferred to emergency power? How smooth was that transfer? Was anyone harmed as a result
of this outage?
Please show me your documentation on your emergency generators. Has any recent maintenance
☐ ☐
been done on them?
How does the organization initiate emergency generator tests? What does the organization do to
☐ ☐
prepare for a generator test?
How does the organization test its emergency generators? ☐ ☐
Why is it important to do a 30-minute test and a four-hour test for emergency generators? ☐ ☐
Under what load does the organization test each emergency generator? ☐ ☐
What does the organization do to test the emergency generator’s fuel oil? Track expiration dates?
☐ ☐
Replace stale fuel oil?
What training and education have staff in charge of emergency generator testing received? ☐ ☐
What is the process involved in ensuring that all emergency generator tests are accomplished in a
☐ ☐
timely manner?
What contingency plans does the organization have in place in case the emergency generator fails
☐ ☐
the test and the power goes out?
Does the organization restrict its services during an emergency generator test to minimize any
patient impact? [N/A for LAB]
☐ ☐
Do you have a secondary generator that can be in place before each four-hour generator test? ☐ ☐
How well does the organization communicate with staff about emergency generator tests? Why is
interdepartmental communication important before, during, and after these tests?
☐ ☐
How does the organization coordinate transfer switch testing with emergency generator testing? ☐ ☐
How does the organization ensure that every transfer switch is tested? ☐ ☐
How often does the organization test transfer switches? ☐ ☐
How recently has the organization tested the transfer switches for emergency power? Were there
☐ ☐
areas that were supposed to be under emergency power that weren’t?

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How did the organization ensure the proper design and installation of the ventilation system?
What regulations govern the design and installation of the ventilation system?
☐ ☐
How old is the ventilation system in this area? How can you tell if the ventilation system is
☐ ☐
working? What do you do if the ventilation system isn’t working?
What training and education does the organization provide on the ventilation system? ☐ ☐
In what areas does the ventilation system control airborne contaminants? Can you please show
☐ ☐
me the utility system drawings?
How does the organization set and maintain appropriate pressure relationships? ☐ ☐
How does the organization set and maintain appropriate air-exchange rates? ☐ ☐
How does the organization set and maintain appropriate filtration efficiencies? ☐ ☐
How does the organization set and maintain appropriate temperature and humidity? ☐ ☐
How does the automated HVAC system work? ☐ ☐
Who interprets the reports from the HVAC system? How do these people interpret the reports?
☐ ☐
How do they respond to those reports?
What happens if pressure relationships, air-exchange rates, filtration efficiencies, temperature,

☐ ☐
and humidity vary from the appropriate HVAC settings?
How does the organization’s HVAC alarm system work to warn of variations from appropriate
☐ ☐
system settings? How does the organization ensure that HVAC alarms are heard?
How would you respond to an HVAC alarm? ☐ ☐
Please describe your medical gas and vacuum systems: processes, maintenance, and emergency
management (including cylinders and manifold rooms).
☐ ☐
What education and training does the organization provide on medical gas and vacuum systems? ☐ ☐
What is your organization’s process for response to elevator entrapment? How do you manage
☐ ☐
risks related to elevator entrapment?
How do you instruct and train all staff involved in oxygen safe handling, use, and delivery? How is
☐ ☐
this documented?
Would you please show me a personnel record for a staff member who has undergone
☐ ☐
competency training in relation to oxygen safe handling?
What education do your delivery technicians provide to patients receiving special medical
equipment such as oxygen? [OME only]
☐ ☐

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The Physical Environment – EC: Construction

9.8: Construction*
Relevant Standards: EC.02.03.01, EC.02.03.03, EC.02.06.01, EC.02.06.05, HR.01.05.03, Use Adapt
HRM.01.05.01,LD.04.03.09 Question Question
As Is for Use
What is the construction plan? Please outline the details. ☐ ☐
Who was responsible for writing the construction plan? What staff members were involved in
☐ ☐
planning for it?
Do you follow any specific design guidelines for your construction plans? If so, what are they?
☐ ☐
[N/A for OBS]
Did your organization prepare a preconstruction risk assessment prior to construction? If so, may I
☐ ☐
see it? [N/A for LAB and OBS]
What risks were revealed in the preconstruction risk assessment? [N/A for LAB and OBS] ☐ ☐
Did you perform an infection control risk assessment (ICRA) prior to construction? [N/A for LAB
☐ ☐
and OBS]
How often do you evaluate your construction plan? Have you made changes to it? Were any of
the changes in response to a preconstruction risk assessment? How are those changes ☐ ☐
communicated? [N/A for LAB and OBS]
When did the project start? How long has the construction been under way? How long is it
expected to continue?
☐ ☐
Please show me the construction site. Who has oversight responsibility for this construction site?
What involvement does management at the construction site have in the ongoing activity?
☐ ☐
What changes to the environment have been put in place to accommodate the construction?
☐ ☐
How are you redirecting traffic?
Are any building exits compromised by the construction? What does the organization do to alert
staff, visitors, and patients about alternate exits? Are there signs showing alternate exits? Are ☐ ☐
patients and families ever confused when leaving the area?
What impact has the construction project had on patient care activities? ☐ ☐

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How does the organization conduct rounds of the construction site? Who participates in these
rounds? How long do the rounds take? How frequently do the rounds occur? Do you document ☐ ☐
information observed in these rounds?
What does the construction plan dictate should happen if there are changes at the construction
☐ ☐
site? What are the appropriate channels of communication in the event of a change?
Has the organization experienced any problems in the project that could threaten the safety of
☐ ☐
patients, staff, and visitors? If so, please describe them.
How do you report a safety issue with the construction project? To whom would you report this
☐ ☐
issue?
Do you perceive increased fire protection** risks associated with the project? ☐ ☐
General Contractor: How does the construction company preserve life safety on this site? ☐ ☐
General Contractor: How do you ensure that every construction worker understands the fire
safety risks present in the project and how to minimize those risks?
☐ ☐
Construction Worker: Please describe how you preserve fire safety in this area. ☐ ☐
Is there a “no smoking” policy for the area? How is that policy enforced? ☐ ☐
Does the organization do fire drills for this area? How often does the organization do them? When
was the last one?
☐ ☐
General Contractor: When was your most recent fire drill in this area? How did it go? ☐ ☐
What training and orientation does the organization offer to construction workers? What topics
are covered in that training? How is the training provided? How does the organization ensure that ☐ ☐
construction workers understand the training?
General Contractor: What education do you provide to construction workers before and during
☐ ☐
the project? Do you document that education? If so, how?
Construction Worker: What education have you received about this project? ☐ ☐
Please describe how the organization proactively looks for Life Safety Code† deficiencies on
☐ ☐
construction sites. [N/A for OBS]
Please describe what would happen if someone discovered a Life Safety Code† deficiency on a
☐ ☐
construction site. [N/A for OBS]
How does the organization educate staff on reporting any Life Safety Code† deficiencies
encountered on a construction site? [N/A for OBS]
☐ ☐
Maintenance Worker: Describe a possible Life Safety Code† deficiency that you may encounter in
or near the construction site. How would you respond to that deficiency? How would you report ☐ ☐
the deficiency? [N/A for OBS]

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Do you have an interim life safety measure (ILSM) policy? If so, how did the organization create its
☐ ☐
ILSM policy? Who was involved in creating this policy? Who approved this policy? [N/A for OBS]
Does your organization’s interim life safety measure (ILSM) policy involve more than just life
☐ ☐
safety deficiencies associated with construction? [N/A for OBS]
How would the organization activate the interim life safety measure (ILSM) policy? Please
☐ ☐
describe situations in which the ILSM policy would go into effect. [N/A for OBS]
How does the organization make staff members, such as maintenance personnel, aware of
the interim life safety measure (ILSM) policy, how to access the policy, and what the policy ☐ ☐
contains? [N/A for OBS]
How does the organization enforce its interim life safety measure (ILSM) policy? [N/A for OBS] ☐ ☐
Who is responsible for making decisions about the appropriate interim life safety measures
(ILSMs) for a particular project or situation? How would this person document what measures ☐ ☐
were to be used? [N/A for OBS]
How does the organization post information about the particular interim life safety measure
(ILSM) used to mitigate a deficiency? [N/A for OBS]
☐ ☐
How would the organization know to stop using an interim life safety measure (ILSM) when a
deficiency is resolved? [N/A for OBS]
☐ ☐
How does the organization notify patients, staff, and visitors about interim life safety measures
☐ ☐
(ILSMs)? [N/A for OBS]
Staff Member: What are interim life safety measures (ILSMs)? What ILSMs are in place on this
☐ ☐
construction site? Why are they in place? How do they affect your daily routine? [N/A for OBS]
What interim life safety measures (ILSMs) are in place? Will those be in place for the duration of
the construction? [N/A for OBS]
☐ ☐
How regularly do you check the site to ensure that appropriate interim life safety measures
(ILSMs) are in place? Have you used additional staff to help check and test whether the interim ☐ ☐
life safety measures are working? [N/A for OBS]
* Applies to demolition, construction, and renovation projects
† Fire safety and life safety are both terms that relate to fire protection, but differ for the purposes of Joint Commission
requirements: Fire safety requirements are in the “Environment of Care” chapter and refer to fire protection that is
dependent on human intervention (fire drills and fire safety equipment, maintaining means of egress and fire exits). Life
safety requirements are in the “Life Safety” chapter and refer to refer to fire protection dependent on building features
(alarm and sprinkler systems, construction, building design, hardware). The standards in the “Life Safety” chapter are based
on the 2012 edition of the Life Safety Code, issued by the National Fire Protection Association. Life Safety Code® is a registered
trademark of the National Fire Protection Association, Quincy, MA.


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The Physical Environment – EM: Emergency Management – EM Plans/EOP
The Physical Environment – Emergency Management You may wish to

9.9: EM Plans/Emergency Operations Plan

Relevant Standards: EM.01.01.01, EM.02.01.01, EM.03.01.01, EM.03.01.03, HR.01.05.03, Use Adapt
HR.01.06.01, HRM.01.05.01, HRM.01.06.01, PI.01.01.01, PI.03.01.01 Question Question
As Is for Use
Who is responsible in your organization for emergency management planning? How does
leadership support that individual or team in emergency preparedness activities throughout the ☐ ☐
organization?
May I see the Emergency Operations Plan manual and any other paperwork related to exercises
☐ ☐
or actual emergency responses?
How does the organization involve senior leadership in the emergency management planning? ☐ ☐
How does the organization involve community partners in the process of emergency planning? ☐ ☐
How do you ensure that your staff is aware of and understands the Emergency Operations Plan? ☐ ☐
What kind of training have you provided to your staff on emergency preparedness and response? ☐ ☐
Does this organization have an interactive relationship with community responders? If so, how
often do people from the organization and emergency responders get together to talk about ☐ ☐
emergency preparedness, response, and recovery?
How does your organization create its hazard vulnerability analysis (HVA)? ☐ ☐
How is the hazard vulnerability analysis (HVA) process documented? ☐ ☐
How is the hazard vulnerability analysis (HVA) used to define mitigation and preparedness
☐ ☐
activities?
What are the organization’s top prioritized risks as identified by the hazard vulnerability analysis
(HVA)? Give an example of how the organization would address each of the six critical areas of
emergency management during likely emergencies: communication, assets and resources, safety ☐ ☐
and security, staff responsibilities, utilities management, and patient clinical and support
activities.

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The Physical Environment – EM: Emergency Management – Communications and Community in Emergencies

9.10: Communications and Community in Emergencies*

Relevant Standards: EM.01.01.01, EM.02.01.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, Use Adapt
EM.02.02.09, EM.02.02.11, HR.01.05.03, HRM.01.05.01 Question Question
As Is for Use
Does the organization use an incident command system, such as NIMS or HICS, for
communication during an emergency? If so, please describe the incident command system the ☐ ☐
organization uses.
Who is on the incident command team? Which team members are stationed in the command
☐ ☐
center during an emergency?
How is the organization oriented to the purpose and functions of the Incident Command System? ☐ ☐
How does the incident command center connect to community responders? ☐ ☐
How does the organization activate the incident command center during an emergency response
☐ ☐
event/exercise? Set it up? Equip it?
Incident Commander: Describe your role as incident commander. ☐ ☐
Incident Commander: What training have you received about how to be an incident commander?
☐ ☐
Did that training help you during recent emergencies and exercises?
Incident Commander: Why did the organization choose you to be the incident commander? Is
☐ ☐
there a trained backup person in case you are unavailable?
Incident Commander: As incident commander, what do you do to prepare for an

☐ ☐
incident/emergency?
Incident Commander: Please show me the incident command center. Why did the organization
choose this location for the command center? Does the organization have a secondary location?
☐ ☐
Why did the organization choose that location? Has the organization ever done an emergency
management exercise using the alternative location?
Staff Member: Where is the incident command center? Who works there? ☐ ☐
How does security communicate during a phone outage? ☐ ☐
How do staff members communicate throughout the organization and between locations during a
phone outage?
☐ ☐

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The Physical Environment – EM: Emergency Management – Communications and Community in Emergencies
What plans are in place to ensure that medications are provided uninterrupted during an
emergency? How is the pharmacy included in this planning?
☐ ☐
What plans are in place to identify risks related to potential cyber emergencies (system failures or
system attacks) that could impact patient care? How are cyber failures or attacks detected? How
☐ ☐
are patient care services maintained when information technology service downtimes (scheduled
or unscheduled) occur?
What is the emergency management plan for monitoring the statuses of patients and their
locations in the event of a disaster requiring evacuation? How will you communicate patient ☐ ☐
status and needs to organizations/locations receiving evacuated patients?
What types of emergency supplies and equipment does the organization keep in this area? How
☐ ☐
will you communicate need for more during an emergency?
During the last emergency response, were the number and types of supplies in this area
☐ ☐
adequate? Was anything missing? If so, what?
What would the organization do if it projected that it could not receive support from the
community for 96 hours during an emergency? Please describe this scenario as it relates to the ☐ ☐
organization’s top three likely emergencies, as defined in your hazard vulnerability analysis (HVA).
* An emergency is an unexpected or sudden event that significantly disrupts the organization's ability to provide care, or the
environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's
services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a
combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity,
scope, or duration, threatens the organization's capabilities and requires outside assistance to sustain patient care, safety,
or security functions. Electrical system failures and power outages are addressed in tracer question sets covering utility
systems.

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The Physical Environment – EM: Emergency Response Exercises

9.11: Emergency Response Exercises

Relevant Standards: EM.01.01.01, EM.02.01.01, EM.03.01.03, HR.01.05.03, HR.01.06.01, Use Adapt
HRM.01.05.01, HRM.01.06.01, PI.01.01.01, PI.03.01.01 Question Question
As Is for Use
Has your organization conducted a recent exercise to test your emergency planning? If so, when
did this exercise take place?
☐ ☐
How do you evaluate and analyze the results of your emergency response exercises? Who is
responsible for this analysis? How is the analysis documented? How are results communicated?
☐ ☐
What does the organization do with the information gleaned from the evaluations? ☐ ☐
What deficiencies has the organization identified in recent emergency response exercises? How
has the organization responded to those deficiencies?
☐ ☐
Please tell me about some of the modifications you have made to your emergency plans in
response to recent emergency events/exercises.
☐ ☐
Staff Member: Whom did you report to during the last emergency response event/exercise? Did
you know you would report to that person before the event/exercise?
☐ ☐
Staff Member: What were your responsibilities during the last emergency response
event/exercise? Were you comfortable with those responsibilities?
☐ ☐
How does the organization address the six critical areas of emergency response during
events/exercises: communication, assets and resources, safety and security, staff responsibilities, ☐ ☐
utilities management, and patient clinical and support activities?
Do you plan for decontamination during events/exercises? If so, how did the decontamination
efforts go in the last event/exercise?
☐ ☐
Does your organization designate alternative care sites for use in an emergency? If so, how were
these sites chosen? In what situations would these sites be used? Has the organization ever done ☐ ☐
an exercise using an alternative care site?
Have you conducted any exercises around a potential influx of infectious patients? How have you
engaged staff in the process? Have you analyzed the effectiveness of response to these exercises? ☐ ☐
Have you made improvements based on this analysis? [CAH and HAP only]


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The Physical Environment – EM: Disaster Volunteers

9.12: Disaster Volunteers*

Relevant Standards: EM.02.02.13, EM.02.02.15, HR.01.05.03, HR.01.06.01, HRM.01.05.01, Use Adapt
HRM.01.06.01, LD.04.04.01 Question Question
As Is for Use
How does the organization grant disaster privileges to volunteer licensed independent
☐ ☐
practitioners and other volunteer practitioners?
Who is involved in the process for granting disaster privileges to volunteer licensed independent
practitioners and other volunteer practitioners? How does the organization document this ☐ ☐
responsibility, and where does it document it?
When can the organization grant disaster privileges? To whom can it grant such privileges? ☐ ☐
What type of information is the organization required to get before the privileged volunteer can
begin treating patients? How does the organization verify a volunteer’s licensure, certification, or ☐ ☐
registration required for particular practices?
How does the organization obtain primary source verification of licensure? When does this
happen? What would the organization do if it could not obtain primary source verification within ☐ ☐
72 hours?
How does the organization ensure oversight of the care, treatment, and services provided by a
☐ ☐
privileged volunteer?
How does the organization assess performance and determine whether to continue granting
☐ ☐
disaster privileges to an individual? Who is in charge of making this determination?
How does the organization distinguish volunteer licensed independent practitioners (LIPs) from
☐ ☐
other LIPs?
Staff Member: Have you ever worked with a privileged volunteer licensed independent
☐ ☐
practitioner during an emergency? If so, how did the experience go?
Staff Member: How was the volunteer’s performance monitored? How did you recognize this
☐ ☐
person’s privileging status?
* The use of disaster volunteers is not a requirement; it is at the discretion of the organization.

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The Physical Environment – LS: Fire and Smoke Protection Features
The Physical Environment – Life Safety You may wish to

9.13: Fire and Smoke Protection Features

Use Adapt
Relevant Standards: LS.01.01.01, LS.01.02.01, LS.02.01.10, LS.02.01.30, LS.02.01.35, LS.02.01.40, Question Question
LS.02.01.50; LS.03.01.10; LS.03.01.30; LS.03.01.35; LS.03.01.40 As Is for Use
Describe the organization’s approach to life safety* as fire and smoke protection, including how
that approach ensures compartmentation.†
☐ ☐
If you maintain a Statement of Conditions, how frequently do you review it? ☐ ☐
May I see your current life safety* floor plans (drawings)? Please point out to me the following:
• A legend/key that clearly identifies all features of life safety in the facility
• Areas of the building that are fully sprinklered (if the building is partially sprinklered)
• Locations of hazardous storage areas
• Locations of all fire rated barriers§, smoke barriers, and designated smoke compartments† ☐ ☐
• Indications of the size of the identified suites—both sleeping and nonsleeping
• Locations of chutes and shafts, such as those in elevators, laundry, and other vertical openings
• Any approved equivalencies or waivers
[For organizations designated as health care occupancy under the Life Safety Code™‡]
What are the fire ratings of the fire barriers§ in this area of the facility? In common walls between
or within buildings? In hazardous areas?
☐ ☐
What are the fire ratings of any vertical opening in your facility, including exit stairs? ☐ ☐
Do fire barriers§ extend from outside wall to outside wall, and from floor to ceiling or roof?
Specifically, do the fire barriers extend from the floor slab to the floor or roof slab above and from
the outside edge of the building to the opposing outside edge? Can you please show me examples
☐ ☐
of this?
What are the latching and closing abilities of fire barrier§ doors in this area? ☐ ☐
What is the fire rating for fire barrier§ door assemblies in this area? ☐ ☐
Please describe how your fire barrier§ doors close. ☐ ☐
What gap is allowed between fire barrier§ door pairs? What gap is allowed between the bottom
edge of the doors and the floor?
☐ ☐

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Please describe the purpose, size, and material of protective plates used on fire barrier§ doors. ☐ ☐
How do the fire barrier§ doors to the trash and laundry chutes and the doors to the chute
discharge within the chute discharge room work? What are the fire ratings of the trash and ☐ ☐
laundry chute walls and the chute discharge door within the chute discharge room?
Are there at least two smoke compartments† for every story in your facility that includes patient
sleeping or treatment rooms?
☐ ☐
Please describe the doors in smoke barriers§ in this area, including ability to close, spacing,
material, and protective plates.
☐ ☐
Do you limit access to barriers§ to avoid inadvertent breaches, such as holes (“penetrations”)?
Have you had any recent barrier breaches—accidental or purposeful? If so, how was the barrier ☐ ☐
repaired?
What is the fire rating of dampers used in ducts that penetrate your fire rated and smoke barrier§
walls and through floors?
☐ ☐
What fire-‐rated materials does your organization use to seal openings and joints in walls and
floors? Has that material been approved by a designated testing agency?
☐ ☐
Do you ever prop doors open or disable the latching mechanisms on doors? If so, under what
conditions?
☐ ☐
How often do you test your fire barrier§ doors? Where is documentation of that testing kept?
Who monitors the testing results? How are they reported and to whom? How do you document ☐ ☐
corrective action?
Please describe the fire and smoke protection features of your elevators. ☐ ☐
Please describe the fire and smoke protection features of your chute discharge rooms. ☐ ☐
Please tell me about your fire alarm system. How does it work with the fire extinguishing system? ☐ ☐
Where is the master fire alarm panel located? What protections for this panel are in place? ☐ ☐
Where are the smoke detectors in this area? ☐ ☐
Where are the sprinklers located in this area? What would you do when a sprinkler is damaged or
soiled?
☐ ☐
Is there appropriate space under all sprinkler heads? ☐ ☐
Is all sprinkler system piping safe, secure, and free of damage? How often are sprinkler systems—
including piping and heads—examined, maintained, and tested? Can you please show me where ☐ ☐
spare sprinkler heads are kept?
Are the water-‐flow and valve tamper devices in this area linked to the master fire alarm panel? ☐ ☐

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Please describe the sprinkler system, including sprinkler locations, within your trash and laundry
chutes.
☐ ☐
Are doors kept free from decorations, coverings, and other objects? ☐ ☐
Have you implemented any interim life safety* measures (ILSMs) recently? If so, for what reasons
and what types of ILSMs are you using?
☐ ☐
* Fire safety and life safety are both terms that relate to fire protection, but differ for the purposes of Joint
Commission requirements: Fire safety requirements are in the “Environment of Care” chapter and refer to
fire protection—and fire response—that is dependent on human intervention (fire drills and fire safety
equipment, maintaining means of egress and fire exits). Life safety requirements are in the “Life Safety”
chapter and refer to refer to fire protection dependent on building features (alarm and sprinkler systems,
construction, building design, hardware). The standards in the “Life Safety” chapter are based on the 2012
edition of the Life Safety Code,‡ issued by the National Fire Protection Association.
† Using barriers, doors, and corridors to create compartments that can contain fire and/or smoke is known
as compartmentation, or smoke compartmentation. It’s one of the most important features in the Life
Safety Code because it allows staff to do a horizontal evacuation to an adjacent compartment that’s
protected. Horizontal evacuation is often enough to ensure safety, and can prevent the need for you to
evacuate your entire facility.
‡ Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.
§ Barriers are separations for fire and smoke protection typically consisting of walls and the features within
walls (doors, windows), but not all walls are barriers. Smoke barriers contain smoke and restrict its
movement. Fire barriers protect occupants from fire itself and the products of combustion. Fire barriers
have a fire rating based on the length of time they’re effective in fire containment. Fire barrier doors occur
in fire barriers and are also fire-‐rated; they must also have self-‐closures or automatic-‐closing devices, and
those are required to latch. Smoke barrier doors occur in smoke barriers; they must have self-‐closures or
automatic-‐closing devices but ARE NOT required to latch—IF the wall in question is just a smoke barrier. If
the wall serves more than one purpose—smoke and fire barrier, it DOES have to latch.

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The Physical Environment – LS: Means of Egress
The Physical Environment – Life Safety You may wish to

9.14: Means of Egress Use Adapt

Relevant Standards: LS.01.01.01, LS.01.02.01, LS.02.01.20, LS.03.01.20 Question Question
As Is for Use
Are any doors in a means of egress locked on a regular basis? If so, please describe how they are
☐ ☐
able to be unlocked to maintain means of egress when needed.
Do fire barrier* doors swing in the correct direction in this area? What about smoke barrier
☐ ☐
doors?
Are exit stairs continuous from the highest level they serve to the outside of the building? ☐ ☐
What is the fire rating for outside exit stairs? ☐ ☐
How does the organization ensure proper signage in exit stairs? ☐ ☐
Does the stairwell exit discharge to a safe location? ☐ ☐
How does your organization keep its corridors free from clutter that impedes egress? ☐ ☐
What would you do about items stored in a corridor? Are any items allowed in a corridor? ☐ ☐
What is the width between walls in exit corridors? ☐ ☐
Please describe the doors in exit corridors. ☐ ☐
What types of carts can be stored in exit corridors? Can anything be stored in an exit enclosure? ☐ ☐
Are paths of egress adequately lit? What type of exit signage is present? Are all signs placed
☐ ☐
appropriately?
Please describe how your organization maintains egress for patients in sleeping suites. ☐ ☐
How does the organization maintain the exit through the passageway to a public way? ☐ ☐
* Barriers are separations for fire and smoke protection typically consisting of walls and the features within walls (doors,
windows), but not all walls are barriers. Smoke barriers contain smoke and restrict its movement. Fire barriers protect
occupants from fire itself and the products of combustion. Fire barriers have a fire rating based on the length of time
they are effective in fire containment. Fire barrier doors occur in fire barriers and are also fire-‐rated; they must also have
self-‐closures or automatic-‐closing devices, and those are required to latch. Smoke barrier doors occur in smoke barriers;
they must have self-‐closures or automatic-‐closing devices but ARE NOT required to latch—IF the wall in question is just a
smoke barrier. If the wall serves more than one purpose—smoke and fire barrier, it DOES have to latch.

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THE JOINT COMMISSION

Joint Commission Resources Mission

© 2017 The Joint Commission

MOCK TRACER FORM.......................................................................................................................... 4

SECTION 1: PERFORMANCE IMPROVEMENT

SECTION 3: STAFFING AND MEDICAL STAFF

SECTION 4: CARE OF THE PATIENT

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS III

SECTION 5: HEALTH INFORMATION AND TECHNOLOGY

SECTION 6: INFECTION PREVENTION AND CONTROL

SECTION 7: MEDICATION MANAGEMENT

SECTION 8: TESTING, TRANSPLANTS, AND IMAGING

SECTION 9: THE PHYSICAL ENVIRONMENT

IV THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS V

This Big Book coordinate the PI program with staff, PI committees,

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 1

2 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 3

4 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

Mock Tracer Form

Tracer Question(s) Relevant Standard(s)

Tracer Question(s) Relevant Standard(s)

Tracer Question(s) Relevant Standard(s)

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 5

Mock Tracer Form with SAFER™ Matrix

Tracer Question(s) Relevant Standard(s)

Tracer Question(s) Relevant Standard(s)

Tracer Question(s) Relevant Standard(s)

6 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

If you’re new to The Joint Commission or Joint Commission International (JCI),

Tracer Basics During a tracer, the surveyor interacts with leaders,

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 7

System tracers for data management: To perform Core Tracer Activities

8 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 9

Mock Tracer Basics Why Conduct Mock Tracers?

10 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 11

12 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 13

Performance Improvement You may wish to

1.1: Performance Improvement Data

What is your planning process for performance improvement data use? ☐ ☐

What kinds of data do you collect for performance improvement initiatives? ☐ ☐

What methods do you typically use to collect performance improvement data? ☐ ☐

How do you ensure that all data is collected as planned? ☐ ☐

Who identifies the frequency for performance improvement data collection? ☐ ☐

How is performance improvement data input? ☐ ☐

How often do you update and review performance improvement data? ☐ ☐

What methods of data collection are associated with specific monitors? ☐ ☐

THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS 17

How are these data shared with organization leadership? ☐ ☐

How do you usually track performance improvement data? ☐ ☐

How are you tracking sustained improvement? ☐ ☐

How do you plan for implementation of new data software? ☐ ☐

How do you decide on performance improvement data software and training? ☐ ☐

Are your data management processes responsive to organizational changes? ☐ ☐

How do you collect and report data on adverse events? ☐ ☐

18 THE JOINT COMMISSION BIG BOOK OF TRACER QUESTIONS

Performance Improvement You may wish to

1.2: Implementing Performance Initiatives