Joint Commission Hospital Accreditation Checklist
This comprehensive Joint Commission accreditation checklist helps hospitals prepare for surveys and maintain continuous compliance. Covers National Patient Safety Goals (NPSGs), Environment of Care (EC), Life Safety (LS), Infection Prevention and Control (IC), Medication Management (MM), and Emergency Management (EM) standards. Aligned with CMS Conditions of Participation (CoP), CDC guidelines, and OSHA healthcare requirements. Designed for tracer methodology preparation, mock surveys, and ongoi
- Industry: Healthcare
- Frequency: Monthly / Pre-survey
- Estimated Time: 60-90 minutes
- Role: Quality Director / Accreditation Coordinator / Chief Nursing Officer / Safety Officer
- Total Items: 45
- Compliance: The Joint Commission, CMS CoP, NPSG, CDC, OSHA Healthcare
National Patient Safety Goals (NPSG)
Current hospital NPSGs address critical patient safety issues.
- NPSG.01: Two patient identifiers used consistently?
- NPSG.02: Critical test results communicated timely?
- NPSG.03: High-alert medications managed safely?
- NPSG.06: Clinical alarm management effective?
- NPSG.07: Healthcare-associated infections reduced?
- NPSG.15: Suicide risk identified and addressed?
- Universal Protocol followed for procedures?
- Fall reduction program implemented?
Environment of Care (EC)
Safe, functional, and supportive environment for patients, staff, and visitors.
- Safety management plan in place?
- Security management program effective?
- Hazardous materials safely managed?
- Fire safety program compliant?
- Medical equipment managed properly?
- Utility systems maintained reliably?
- Life Safety Code compliance verified?
- Construction risks assessed (ICRA/PCRA)?
Infection Prevention and Control (IC)
Reduce the risk of developing and transmitting infections.
- Infection prevention program comprehensive?
- Surveillance for HAIs conducted?
- Hand hygiene program robust?
- Standard precautions consistently applied?
- Transmission-based precautions followed?
- Central line insertion bundle used?
- Urinary catheter bundle implemented?
- Instrument reprocessing compliant?
- Outbreak response capability in place?
Medication Management (MM)
Safe medication use throughout the organization.
- Medication management plan documented?
- Medication storage secure and appropriate?
- Controlled substances managed properly?
- High-alert medications identified?
- Look-alike/sound-alike meds addressed?
- Medication labeling compliant?
- Medication reconciliation complete?
- Smart pump drug library used?
Emergency Management (EM)
Effective response to emergencies and disasters.
- Emergency management program comprehensive?
- Emergency operations plan current?
- Hospital Incident Command System adopted?
- Exercises conducted as required?
- Surge capacity plan in place?
- Backup communication systems available?
- Continuity of operations addressed?
- Community partnerships established?
Initial Safety Assessment
Preliminary safety and compliance verification
- Work area safe and hazard-free?
- Required PPE available and in good condition?
- Emergency exits clear and marked?
- First aid supplies accessible?
Related Health Services Checklists
- Sterile Processing Checklist
- Patient Fall Risk Assessment
- Hand Hygiene Compliance Audit
- UK CQC Healthcare Compliance Checklist
- Ambulance Vehicle Inspection
- Funeral Home Regulatory Compliance Inspection Checklist
- Daily Clinic Opening Checklist
- Medication Storage & Handling Checklist
Related Clinical Compliance Checklists
- Sterile Processing Checklist - FREE Download
- Patient Fall Risk Assessment - FREE Download
- Hand Hygiene Compliance Audit - FREE Download
- UK CQC Healthcare Compliance Checklist - FREE Download
- Australia ACSQHC Healthcare Safety Checklist - FREE Download
- India NABH Hospital Accreditation Checklist - FREE Download
Why Use This Joint Commission Hospital Accreditation Checklist?
This joint commission hospital accreditation checklist helps healthcare teams maintain compliance and operational excellence. Designed for quality director / accreditation coordinator / chief nursing officer / safety officer professionals, this checklist covers 45 critical inspection points across 6 sections. Recommended frequency: monthly / pre-survey.
Ensures compliance with The Joint Commission, CMS CoP, NPSG, CDC, OSHA Healthcare. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Joint Commission Hospital Accreditation Checklist cover?
This checklist covers 45 inspection items across 6 sections: National Patient Safety Goals (NPSG), Environment of Care (EC), Infection Prevention and Control (IC), Medication Management (MM), Emergency Management (EM), Initial Safety Assessment. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed monthly / pre-survey. Each completion takes approximately 60-90 minutes.
Who should use this Joint Commission Hospital Accreditation Checklist?
This checklist is designed for Quality Director / Accreditation Coordinator / Chief Nursing Officer / Safety Officer professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.