Access complimentary regulatory and accreditation resources, tools, tracers, policy checklists and other key aids to facilitate ongoing success for Healthcare Professionals.
1:1 Monitoring for Suicidal Risk Patient Competency Checklist
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Accu-Check II Cleaning and Disinfecting Competency Tool
Failure to properly clean and disinfect your Blood Glucose Monitoring equipment can result in Immediate Threat level findings. This competency tool is designed to assess staff’s ability to properly manage the Accucheck-II equipment.
Adult Intravenous Access Insertion Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Anesthesia Technician Competency Tool
Designed to promote the assessment and documentation of competency, this tool contains core skills typically assigned to the role of Anesthesia Technician.
Anesthesia Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Anesthesia Management of the Patient.
ASHE ICRA 2.0
Designed to promote the assessment and documentation of competency, this tool contains core skills typically assigned to those individuals responsible for the administration of medications.
ASHE ICRA 2.0 Form for Infection Control Risk Assessment
This Infection Control Risk Assessment tool helps hospitals audit Infection Control precautions for construction and renovation projects.
This downloadable PDF matrix worksheet tool will help Infection Control hospital team members perform a risk assessment and ensure proper precautions are in place to reduce the risk of infection related to hospital construction, renovation and operations projects.
The four-step process provides guidance and best practices on how to:
- Identify the activity type.
- Identify the Patient Risk Group(s) that will be affected.
- Match Patient Risk Group to Construction Activity Project Type.
- Assess potential risk to areas surrounding the project.
Blood Transfusion Competency
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Blood Transfusion Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for the Management of the Patient having a Blood Transfusion.
Breast Milk Management Competency Assessment Tool
This tool template is designed to be integrated into your competency assessment program or the management of breast milk. Established indicators are designed to address key quality and safety areas.
Cardiac Cath Lab Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for a patient undergoing a Cardiac Cath Procedure.
CareFusion Surgical Clippers Cleaning & Disinfecting Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
CDC Essential Elements of a Reprocessing Program for Flexible Endoscopes – Recommendations of the HICPAC
Flexible endoscope cleaning is a highly complex, essential process. Organizations must have a reliable system for endoscope reprocessing which minimizes infection risks. This guidance document from the CDC will assist your organization in establishing a step-by-step robust process that reduces or mitigates rick of infection and improves patient outcomes.
Changes in Patient Condition Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Chemotherapy Tracer Tool
Utilize this tool to assess your organizations delivery of chemotherapy services to patients and determine your compliance with the CMS Conditions of Participation.
Clinical Contract Evaluation Tool
Our most requested tool in 2022, the Contract Evaluation Tool captures all of the key elements of the contract evaluation process all on one page.
CMS Immediate Jeopardy Removal Plan Tool
This tool provides guidance to organizations regarding what to expect should the organization face an “IJ” finding and how to organize your response.
Competency Assessment Template
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Competency Program Review and Human Resource File Review Tool
Competency Programs are one of the most important influencers of patient safety. Targeting key topics for discussion with Organizational Leaders, this tool is designed to help prepare your Human Resource/ Education and other key Leaders on key topics that lead to a successful Competency Program and Management of.
Computer Tomography (CT) Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s Cat Scan(CT) Services based upon the CMS Hospital Conditions of Participation and Accrediting organization requirements.
Considerations Malignant Hyperthermia Drills
This tool is designed with a touch of assessing risk and stimulating thought for when you are designing your malignant hyperthermia drill process. |
Contracting for Care, Treatment & Services Policy Template
This policy is designed to ensure your policy addresses all of the required elements per The Joint Commission Standards. Download the tool and personalize it for your organization.
Crash Cart Tracer Tool
Understanding and complying with your organization’s Crash Cart Management Process is vital to patient safety. Use this tool to trace compliance within your organization.
Data, Infection Control, and Medication Management Session
This tool is designed specifically to assist the Quality, Infection Control, Nursing and Pharmacy to respond to questions during the Data-IC-MM Session with the surveyors.
Dialysis Environment of Care Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for the Dialysis Environment of Care.
Dialysis Patient Care Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s delivery of patient care service within Dialysis Services based upon the CMS Hospital Conditions of Participation and Accrediting organization requirements.
Dialysis Patient Record Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Documentation on a Dialysis Patient.
Dialysis QAPI Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for a successful QAPI Program in Dialysis.
Emergency Management Program Review Tool
CMS and Accrediting Organizations recently revised the requirements for Emergency Management – Use this tool to ensure your program meets the expectations.
Endoscope Cleaning-Disinfecting-Storage Tracer Tool
Utilize this tool to assess your Sterile Processing Department for compliance with the CMS Conditions of Participation and Accrediting Organization Requirements related to the care of surgical instruments.
Essential Contract Addendum Template for Healthcare Providers
Organizations continue to work on embedding performance expectations into their contracts. This tool condenses all of accreditation/regulatory requirements into one easy to use contract addendum potentially eliminating the need to renegotiate an entirely new contract.
Exergen Temporal Thermometer Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Eyedrop Instillation Competency
This tool is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Focused Professional Performance Evaluation (FPPE) Policy Template
This policy template is designed to address the CMS Condition of Participation requirements related to Focused Physician Performance Evaluation (FPPE) in an easy to use, easy to customize format.
Food Service and Nutrition checklist
Designed to guide you through tracing both the physical plant of food services, including the kitchen and other food/nutrition storage areas in addition to tracing the clinical nutrition process for patients.
Glucometer Management Tracer Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Hazardous Chemical Use Tracer Tool
Proper management of hazardous chemicals keeps patients, staff and visitors safe. This tool will help you to assess compliance with the most current requirements.
Human Resources File Review Checklist
The HR File Review Checklist is designed to provide you with a comprehensive list of the documents needed to substantiate compliance with regulatory and accreditation standards.
Hyperbaric Therapy Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s Hyperbaric Services based upon the CMS Hospital Conditions of Participation, Accrediting organization requirements and applicable guidelines.
Imaging Xray-Fluoroscopy Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Patients Undergoing a X-ray Procedure.
Last Minute Survey Checklist
Our last-minute survey checklist contains many of the most common survey findings that are easily correctable. Use this list as a last-minute survey checklist or as a guide to daily survey readiness operations.
Leadership Guidance Tool
Targeting key topics for discussion with Organizational Leaders, this tool is designed to help prepare your Leadership team for interactions with your Accrediting Organizations or CMS Survey team.
LLD, HLD and Instrument Processing
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Malignant Hyperthermia Cart Content Tool
This tool provides a list of the recommended contents for Malignant Hyperthermia carts.
Malignant Hyperthermia Competency Tool
Management of Malignant Hyperthermia takes honed skills that are not often used, This tool is designed with the core elements of Malignant Hyperthermia in the tool for ease of use.
Managing Fail Cycles, Spills and Maintenance of the Trophon Competency Tool
Proper skills in the maintenance of your Trophon equipment is essential to patient safety. This tool provides the detailed criteria to which staff must be competent in order to safely use the Trophon.
Maternal Hemorrhage Safety Program Checklist
Designed to promote the assessment and documentation of competency, this tool contains core skills typically assigned the responsibility of cleaning ultrasound probes.
Maternal Hemorrhage Tracer Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Medical Equipment Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s Medical Equipment Management Process based upon the CMS Conditions of Participation and Accrediting organization requirements.
Medical Staff Credentialing File Checklist
Utilize this tool to ensure that your Medical Staff Credentialing/ Privileging documentation is compliant with the CMS Conditions of Participation.
Medical Staff Credentialing/Privileging Program Review Tool
Targeting key topics related to the management of the Medical Staff, this tool is designed to help prepare your Leadership team for interactions with your Accrediting Organizations or CMS Survey team.
Medication Administration Competency Skill Checklist
Designed to promote the assessment and documentation of competency, this tool contains core skills typically assigned to those individuals responsible for the administration of medications.
Medication Administration Observation
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel, this tool is designed to be used as a staff observation tool to ensure the Medication Administration Process is compliant with the CMS Conditions of Participation and Accrediting organization requirements.
Medication Management Tracer Tool
Utilize this tool to assess your Medication Management Operations for compliance with the CMS Conditions of Participation and Accrediting Organization requirements. This tool does not include an assessment of the Medication Administration Processes.
Moderate Sedation Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Patients Undergoing Moderate Sedation.
Mother-Baby ServicesTracer Tool
Designed to support your organization in assessing the care processes related to care of patients in your Mother-Baby; Post-Partum Care Settings.
MRI Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s MRI Services based upon the CMS Hospital Conditions of Participation and Accrediting organization requirements.
Negative Pressure Wound Therapy Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Non-Violent, Non-Self-Destructive Behavior Restraint Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Non-Violent/ Non-Self-Destructive Restraint use and monitoring, previously known as Medical Use of Restraints.
Nuclear Medicine Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s Nuclear Medicine Services based upon the CMS Hospital Conditions of Participation and Accrediting organization requirements.
Ongoing Physician Performance Evaluation (OPPE) Policy Template
This policy template is designed to address the CMS Condition of Participation requirements related to Ongoing Physician Performance Evaluation (OPPE) in an easy to use, easy to customize format.
Pain Management Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Patient at Risk Monitoring Audit Tool
This form is designed to ensure that documentation for the Patient at Risk meets all of the CMS Conditions of Participation and Accrediting Organization requirements.
Peri-Operative Outpatient Tracer
Utilize this tool to assess your processes for managing patients undergoing surgical/invasive procedures that do not require inpatient admission. Criteria is based upon the CMS Conditions of Participation and Accrediting Organization Requirements.
Personal Protective Equipment Donning-Doffing Competency Tool
Designed to promote the assessment and documentation of competency, this tool contains core skills associated with the donning and doffing of Personal Protective Equipment and can be used to assess these skills in any staff member.
Point of Use Cleaning Tracer Tool
A problematic area often cited on surveys, this tool is designed to walk the user through the process to be followed for cleaning equipment at the point of use.
QA-PI Plan Attachment- Gap Analysis and Risk Assessment Approaches
Assessing Risks and the risk assessment process is a staple of our QA-PI programs. This tool is designed to help you describe the process within your QA-PI Plan.
Rehabilitation Services Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s Rehabilitation Services based upon the CMS Conditions of Participation and Accrediting organization requirements.
Respiratory Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s Respiratory Services based upon the CMS Conditions of Participation and Accrediting organization requirements.
Risk Assessment Tool – Generic
Assessing risk is the latest strategy for organizations to utilize to set priorities. This tool is designed to facilitate that assessment regardless of the situation/ process you are evaluating.
Sample Educational Workplace Violence Template
This tool is designed specifically to assist the organization in designing an Education and Training Program for Workplace Violence and ensure that all of the CMS Conditions of Participation and Accrediting Organization requirements are met.
Sharps Use Tracer Tool
The Sharps Exposure Tracer Tool is designed to be used to conduct a comprehensive assessment to your Sharps Exposure plan.
Sleep Study Center Tracer Tool
Specifically designed to meet the needs of Quality and Accreditation/regulatory personnel to guide them through a thorough assessment of their organization’s Sleep Lab/Sleep Study Services based upon the CMS Conditions of Participation and Accrediting organization requirements.
Surgical Instrument InspectionTool
Utilize this tool to assess your Sterile Processing instrument inspection process to ensure compliance with the CMS Conditions of Participation and Patient Safety.
Survey Readiness Execution Checklist
This checklist accounts for 16 components and the necessary tasks required for survey readiness.
Surveyor Safety Briefing Template
To start your survey off on the right foot, use this template to develop the 5-minute Safety Briefing you will provide to your survey team upon their arrival to your organization.
Tissue System Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Patients having a Tissue Implant.
TJC Required Plans-Policies-Documents List
Formatted in an easy-to-use document, this list contains the most current documents that your organization must have ready for the surveyors from the moment they enter your organization.
Trophon Use Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Ultrasound Probe Cleaning Disinfecting Competency Tool
Designed to promote the assessment and documentation of competency, this tool contains core skills typically assigned the responsibility of cleaning ultrasound probes.
Ultrasound Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Patients Undergoing an Ultrasound Procedure.
SAMHSA Useful Resources on Opiod Overdose Prevention
This resource provides a summary of the Opioid Crisis Management Strategy set for by SAMHSA and can be used to determine and design your organizations focus area for fighting the Opioid Epidemic.
VHA Workplace Violence Prevention Program Policy
This Veteran Health Administration (VHA) directive establishes policy and responsibilities for the development, management and administration of the VHA Workplace Violence Prevention Program (WVPP). It assigns workplace violence prevention responsibilities to all levels of management and provides for a VHA Central Office point of coordination for these activities within the organization.
This purpose is consistent with VHA’s longstanding commitment to a culture of safety and security, and to adherence to existing safety and security regulations and standards, in all places where VHA work is conducted.
Violent Restraints and Seclusion Competency Tool
This tool template is designed to ensure that your competency assessment documentation meets the intent of the competency assessment process. Simply populate the tool with the key steps of the skills you are assessing and follow the directions on the form.
Violent, Self-Destructive Behavior Restraint/Seclusion Tracer Tool
This tool is designed specifically to address all of the CMS Conditions of Participation and Accrediting Organization requirements for Non-Violent/ Non-Self-Destructive Restraint use and monitoring, previously known as Behavioral Use of Restraints.
Workplace Violence Sample Education & Training Plan Design
This tool is designed specifically to assist the organization in designing an Education and Training Plan for Workplace Violence and ensure that all of the CMS Conditions of Participation and Accrediting Organization requirements are met.