A straightforward, hands-on resource, the 2023 Hospital Compliance Assessment Workbook engages staff and leadership in accreditation activities with questions, templates, and tools to identify areas of noncompliance and plan to address them. The workbook includes ALL hospital standards and elements of performance (EPs), including those used for deemed status purposes and primary care medical home certification in the hospital setting.
A color-coded compliance matrix allows you to capture manually (in the hard copy) or digitally (in the PDF site license) your compliance level with each EP and the evidence you used to assess standards compliance. Clear questions correlated directly to each EP help your hospital assess whether you are meeting standards—a "No" or "ITL" (Immediate Threat to Life") answer should prompt action from your accreditation team. Downloadable, adaptable tools and templates help you identify and prioritize needed improvements and maintain continuous survey readiness. For example, you'll use the Plan of Action Follow-Up worksheets to develop and prioritize next steps to bring noncompliant EPs back into compliance. The Required Documentation worksheets help you to track how your hospital meets those EPs with Required Written Documentation icons in the E-dition®/Comprehensive Accreditation Manual for Hospitals (CAMH).
Hospitals need resources when preparing for a Joint Commission survey to ensure they are compliant and ready for survey. The 2023 Hospital Compliance Assessment Workbook allows you to self-assess compliance with all hospital requirements and plan and implement corrective actions before surveyors arrive onsite, focusing compliance efforts and simplifying where possible. A PDF site license allows you to download a copy to a central, secure location so your accreditation prep team can capture and share these learnings and data across the organization.
The 2023 version includes all standards updates that occurred over the past year, including changes to the Accreditation Participation Requirements (APRs), new environment of care requirements for water management programs, new information management requirements related to the electronic exchange of patient health information, new life safety requirements for mitigating fire and smoke hazards and events.
If you're looking for a self-assessment option that takes you beyond the simplicity of E-dition/CAMH but is more budget friendly than Tracers with AMP®, the 2023 Hospital Compliance Assessment Workbook is for you. Buy a hard copy for each member of your accreditation team or a PDF site license for all to share!
Standards assessment and compliance
Application of the SAFER® Matrix
Questions to assess each element of performance in the E-dition/CAMH as of January 1, 2023
Downloadable, adaptable tools and templates for standards assessment and compliance
Writable PDFs (site license only)
Standards: All hospital standards effective January 1, 2023
Setting: Organizations accredited under the Hospital Accreditation Program, including general, acute psychiatric, pediatric, medical/surgical specialty, long-term acute care, and rehabilitation hospitals
Key Audience: Accreditation managers, quality improvement managers, physician and nurse leaders, chapter leaders, and department heads