1

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

2

Accreditation

3

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

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

Certification

12

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!

13

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

14

Advanced Disease Specific Care

15

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

16

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

17

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