Post on 22-Aug-2020
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Accreditation Ambulatory ................................................................................................................................................... 3
Behavioral Health .......................................................................................................................................... 4
Critical Access Hospital ................................................................................................................................. 5
Home Care .................................................................................................................................................... 6
Hospital ......................................................................................................................................................... 7
Hospital - Continued ..................................................................................................................................... 8
Laboratory ..................................................................................................................................................... 9
Nursing Care Center .................................................................................................................................... 10
Certification
Disease Specific Care................................................................................................................................... 12
Comprehensive Cardiac Center .................................................................................................................. 12
Integrated Care ........................................................................................................................................... 12
Health Care Staffing Services ...................................................................................................................... 12
Medication Compounding .......................................................................................................................... 12
Palliative Care ............................................................................................................................................. 13
Patient Blood Management ........................................................................................................................ 13
Perinatal Care .............................................................................................................................................. 13
Advanced Disease Specific Care
Acute Stroke Ready Hospital ....................................................................................................................... 15
Chronic Kidney Disease ............................................................................................................................... 15
Chronic Obstructive Pulmonary Disease ..................................................................................................... 15
Comprehensive Stroke Center .................................................................................................................... 15
Heart Failure ............................................................................................................................................... 16
Inpatient Diabetes....................................................................................................................................... 16
Lung Volume Reduction Surgery ................................................................................................................. 16
Primary Stroke Center ................................................................................................................................. 16
Total Hip and Total Knee Replacement ...................................................................................................... 17
Ventricular Assist Device ............................................................................................................................. 17
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Accreditation
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Ambulatory Abuse Screening Low-Level Disinfection of Equipment
Accreditation Participation Requirements (APR) Library
Medical Record Audit
Assessment & Reassessment Medication Management - Ordering
Blood Transfusion Medication Management - Storage
Cardiac & Pulmonary Rehab Medication Management (MM) Library
Clinic or Physician Office Medication Management Question Library
CT Checklist National Patient Safety Goals (NPSG) Library
Dental Clinic Moderate Sedation
Diagnostic Imaging Checklist MRI Checklist
Emergency Management (EM) Library Nuclear Medicine Checklist
Environment of Care (EC) Library PET Checklist
Hand Hygiene Performance Improvement (PI) Library
High-Level Disinfection Primary Care Medical Home
HR File Review Provision of Care, Treatment, and Services (PC) Library
Human Resources (HR) Library Record of Care, Treatment, and Services (RC) Library
Hyperbaric Oxygen Therapy Rights and Responsibilities of the Individual (RI) Library
Infection Prevention and Control (IC) Library Sterilization – Ambulatory Setting
Information Management (IM) Library Surgery or Procedure
Laser Safety in OR Transplant Safety (TS) Library
Leadership (LD) Library Waived Testing (WT) Library
Life Safety (LS) Library Wound Care Center
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Behavioral Health Addiction Services – Record Review Medication Management (MM) Library
Accreditation Participation Requirements (APR) Library
Medication Management - Ordering
Care, Treatment, and Services (CTS) Library Medication Management – Storage
Eating Disorders Medication Management Question Library
Elopement Mental Health Services - Record Review
Emergency Management (EM) Library National Patient Safety Goals (NPSG) Library
Environment of Care (EC) Library Opioid Management
Environment of Care for Secured Behavioral Units
Opioid Treatment Program - Clinical Record Audit
Human Resources Management (HRM) Library
Performance Improvement (PI) Library
Human Resources File Review Record of Care, Treatment, and Services (RC) Library
Infection Prevention and Control (IC) Library Restraint & Seclusion -Comprehensive
Information Management (IM) Library Restraint & Seclusion - Implementation & Staff Training
Leadership (LD) Library Rights and Responsibilities of the Individual (RI) Library
Life Safety (LS) Library Suicide Inpatient - Brief
Mental Health Services – Record Review Suicide Inpatient - Comprehensive
Medical Record Audit Violence
Waived Testing (WT) Library
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Critical Access Hospital Accreditation Participation Requirements (APR) Library
Life Safety – Frequently Cited
Ambulatory Surgery or Procedure Life Safety (LS) Library
Antibiotic Stewardship Medical Record Audit
Clinical Alarm Safety – Telemetry Medical Staff (MS) Library
Critical Care Medication Management - Storage
CT Checklist Medication Management (MM) Library
Diagnostic Imaging Moderate Sedation – Procedural
Emergency Department MRI Checklist
Emergency Management (EM) Library National Patient Safety Goals (NPSG) Library
Endoscopy with High-Level Disinfection Nuclear Medicine Checklist
Environment of Care (EC) Library Nursing (NR) Library
Environment of Care Documentation Outpatient Clinic or Physician Office
Environment of Care Rounds Pain Assessment & Reassessment
Fall Risk Pediatric Inpatient
Hand Hygiene Pediatric Safety & Security
High-Level Disinfection Performance Improvement (PI) Library
HR File Review PET Checklist
Human Resources (HR) Library Primary Care Medical Home
Infection Prevention and Control (IC) Library Provision of Care, Treatment, and Services (PC) Library
Information Management (IM) Library Record of Care, Treatment, and Services (RC) Library
Inpatient Tracer – Comprehensive Rights and Responsibilities of the Individual (RI) Library
Laser Safety in OR Transplant Safety (TS) Library
Leadership (LD) Library Waived Testing (WT) Library
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Home Care Accreditation Participation Requirements (APR) Library
Leadership (LD) Library
Assessment Life Safety (LS) Library
Blood Transfusion Medication Management (MM) Library
Contracted Services National Patient Safety Goals (NPSG) Library
DME – Patient Residence Oxygen Safety
Emergency Management (EM) Library Patient Education
Environment of Care (EC) Library Performance Improvement (PI) Library
Equipment Management (EQ) Library Provision of Care, Treatment, and Services (PC) Library
Fall Risk Record of Care, Treatment, and Services (RC) Library
Hand Hygiene Rights and Responsibilities of the Individual (RI) Library
Human Resources (HR) Library Top Non-Compliant
Infection Prevention and Control (IC) Library Waived Testing
Information Management (IM) Library Waived Testing (WT) Library
Lab Specimen Collection Wound Care
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Hospital Accreditation Requirements Library Labor & Delivery
Ambulatory Surgery or Procedure Laser Safety in OR
Antibiotic Stewardship Leadership Question Library – Part 1
Assessment & Reassessment – Inpatient Leadership Question Library – Part 2
Behavioral Health Care Inpatient Life Safety – Frequently Cited
Behavioral Health Care -Inpatient Environment of Care
Life Safety Question Library – Part 1
Blood Transfusion Life Safety Question Library - Part 2
Cardiac & Pulmonary Rehab Low-Level Disinfection of Equipment
CAUTI Prevention Medical Record Audit
Central Venous Catheter Audit Medical Staff – Initial Appointment with FPPE
Clinical Alarm Safety Medical Staff Question Library – Part 1
Clinical Alarm Safety – Telemetry Medical Staff Question Library – Part 2
CMS DC Planning Worksheet Medication Management – Ordering
CMS Infection Control Medication Management – Storage
CMS QAPI Medication Management Question Library
Complaint & Grievance – Deemed Status Moderate Sedation – Procedural
Contracted Services MRI Checklist
Critical Care (ICU) MRI Safety
CT Checklist National Patient Safety Goals Question Library
CT Scan Nuclear Medicine
Dental Clinic Nuclear Medicine Checklist
Diagnostic Imaging Nursing Question Library
Emergency Department Outpatient Clinic or Physician Office
Emergency Management Pain Assessment – Reassessment
Emergency Management Question Library Pain Management
Emergency Power Systems Patient Flow Emergency Department
EMTALA Pediatric Inpatient
EMTALA – Obstetric Patient Pediatric Safety & Security
EMTALA – Patient Transfer Medical Record Audit
Performance Improvement Question Library
Endoscopy PET Checklist
Endoscopy with High-Level Disinfection Pharmacy Inspection Medication Storage
Environment of Care Documentation Phlebotomy
Environment of Care Question Library – Part 1 Primary Care Medical Home
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Hospital - Continued
Environment of Care Question Library – Part 2 Provision of Care Question Library – Part 1
Environment of Care Rounds Provision of Care Question Library – Part 2
Environment of Care Rounds - Comprehensive Radiology
Fall Risk Record of Care Question Library
Fire Protection & Suppression Testing & Inspection
Restraints & Seclusion – Violent/Self-Destructive Deemed Status
Food & Nutrition Services Restraints Nonviolent – Deemed Status
Hand Hygiene Rights & Responsibilities of Individuals Question Library
Hemodialysis Sentinel Event Alert 54 – Safe Use of Health Technology
High Level Disinfection Sentinel Event Alert 55 - Fall Prevention
Hot Topics – Multiple Chapters Skin – Pressure Ulcer Care
HR File Review Skin – Pressure Ulcer Prevention
Human Resources Question Library Sleep Lab
Hyperbaric Oxygen Therapy Sterilization
Infection Prevention – Isolation Suicide - Brief
Infection Prevention & Control Question Library
Suicide Emergency Department - Comprehensive
Information Management Question Library Suicide Inpatient BHC - Comprehensive
Information System Transplant Safety – Tissue
Inpatient Surgery: Pre-Intra-Post-Op Transplant Safety Question Library
Inpatient Tracer – Comprehensive Ultrasound
Kitchen Tour Ventilation - Air Pressure Relationships
Waived Testing Question Library
Wound Care Center
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Laboratory Accreditation Participation Requirements (APR) Library
Hematology - Pre - Analytic Phase
Blood & Blood Product Transfusion Human Resources (HR) Library
Calibration & Calibration Verification Infection Control
Chemistry - Analytic Phase Infection Prevention and Control (IC) Library
Chemistry - Comprehensive Information Management (IM) Library
Chemistry - Pre - Analytic Phase Leadership (LD) Library
Chemistry-Post-Analytic Phase National Patient Safety Goals (NPSG) Library
Competency Assessment – Technical Staff New Employee Orientation
Document and Process Control (DC) Library Performance Improvement (PI) Library
Emergency Management (EM) Library Phlebotomy Services
Emergency Release of Blood Provider Performed Microscopy (PPM)
Environment of Care (EC) Library Quality System Assessment (QSA)
Hematology - Analytic Phase Quality System Assessment for Non-waived Testing (QSA) Library
Hematology - Comprehensive Transfusion Reactions
Hematology - Post - Analytic Phase Transplant Safety (TS) Library
Waived Testing (WT) Library
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Nursing Care Center Accreditation Participation Requirements (APR) Library
Life Safety (LS) Library
Antibiotic Stewardship Medication Management (MM) Library
Emergency Management (EM) Library National Patient Safety Goals (NPSG) Library
Environment of Care (EC) Library Performance Improvement (PI) Library
Human Resources (HR) Library Provision of Care, Treatment, and Services (PC) Library
Infection Prevention and Control (IC) Library Record of Care, Treatment, and Services (RC) Library
Information Management (IM) Library Rights and Responsibilities of the Individual (RI) Library
Leadership (LD) Library Top Non-Compliant
Waived Testing (WT) Library
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Certification
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Disease Specific Care Certification Participation Requirements (CPR) Library
Medical Staff File Review
Clinical Information Management (DSCT) Library
Performance Measurement (DSPM) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Program Management (DSPR) Library
HR File Review Spine Surgery
Inpatient Diabetes Care Supporting Self-Management (DSSE) Library
Medical Record Review - THKR - Non-advanced Program
THKR
Comprehensive Cardiac Center Certification Participation Requirements (CPR) Library
Performance Improvement (CCCPI) Library
Comprehensive Cardiac Center Management (CCCM) Library
Provision of Care, Treatment, and Services (CCCPC) Library
Information Management (CCCIM) Library
Integrated Care Certification Participation Requirements (CPR) Library
Program Characteristics (ICPC) Library
Program Alignment (ICPA) Library Quality, Safety, and Culture (ICQS) Library
Health Care Staffing Services Coming soon!
Medication Compounding Coming soon!
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Palliative Care Certification Participation Requirements (CPR) Library
Program Management (PCPM) Library
Information Management (PCIM) Library Provision of Care, Treatment, and Services (PCPC) Library
Performance Improvement (PCPI) Library
Patient Blood Management Assessments: Internal and External (PBMAM) Library
Organization (PBMOR) Library
Certification Participation Requirements (CPR) Library
Process Control (PBMPC) Library
Deviations, Non-conformances and Adverse Events (PBMDN) Library
Process Improvement Through Corrective and Preventive Action (PBMPI) Library
Documents and Records (PBMDR) Library Resources (PBMRS) Library
Equipment (PBMEQ) Library Supplier and Customer Issues (PBMSC) Library
Facilities and Safety (PBMFS) Library
Perinatal Care Certification Participation Requirements (CPR) Library
Program Management (PNPM) Library
Information Management (PNIM) Library Provision of Care, Treatment, and Services (PNPC) Library
Performance Improvement (PNPI) Library
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Advanced Disease Specific Care
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Acute Stroke Ready Hospital Certification Participation Requirements (CPR) Library
Program Management (DSPR) Library
Clinical Information Management (DSCT) Library
Supporting Self-Management (DSSE) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Thrombolytic Therapy
Performance Measurement (DSPM) Library
Chronic Kidney Disease Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library
Chronic Obstructive Pulmonary Disease Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library
Comprehensive Stroke Center Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library
Detailed Requirements Thrombolytic Therapy
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Heart Failure Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library
Lung Volume Reduction Surgery Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library
Primary Stroke Center Certification Participation Requirements (CPR) Library
Program Management (DSPR) Library
Clinical Information Management (DSCT) Library
Supporting Self-Management (DSSE) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Thrombolytic Therapy
Performance Measurement (DSPM) Library
Inpatient Diabetes Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library
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Total Hip and Total Knee Replacement Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library
Ventricular Assist Device Certification Participation Requirements (CPR) Library
Performance Measurement (DSPM) Library
Clinical Information Management (DSCT) Library
Program Management (DSPR) Library
Delivering or Facilitating Clinical Care (DSDF) Library
Supporting Self-Management (DSSE) Library