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Additional References

You are here: Home / Resources / Additional References

Free compliance and tracer tools, links, and other resources that we found can be valuable to your organization. Click on Reference link in the table below to either download a file or visit a website to learn more.

CategoryReference TitleSummaryLinkhf:tax:reference_category
Patton Proprietary

Health Care Equity 2023

Learn more about the Health Equity Requirements. The PowerPoint guides the reader on the new Health Equity standards for 2023.

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Patton Proprietary

Emergency Management Plan Evaluation – Post COVID-19

A Patton after-action evaluation tool designed to critique a disaster response.

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Patton Proprietary

Performance Improvement Mandatories

A Patton self-assessment readiness tool based on Joint Commission’s mandatory PI requirements.

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OR Manager

OR Manager 2019 – February

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OR Manager

OR Manager  2019 – January

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OR Manager

OR Manager 2018 – January

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OR Manager

OR Manager  2016 – December

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COVID-19

Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment

An American Institute of Ultrasound Medicine (AIUM) official statement on safe preparations of transducers. Includes changes due to COVID-19.

covid-19 view-all
AHRQ (Agency for Healthcare Research and Quality)

Hospital Survey on Patient Safety Culture

An AHRQ 2018 User Database Report comparing hospitals on the Surveys on Patient Safety Culture™ Hospital Survey.

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PSJ (Patient Safety Journal)

Wrong-Site Surgery in Pennsylvania During 2015–2019

A Patient Safety Journal article summarizing 368 events reported by 178 facilities identifying the most problematic procedures and body parts.

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COVID-19

Vaccine Storage and Handling Toolkit

CDC’s updated vaccine storage and handling information toolkit with addendum added February 2021.

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FDA (Food and Drug Administration)

Transition to Duodenoscopes with Innovative Designs to Enhance Safety

An FDA Safety Communication recommendation for hospitals and other facilities who perform endoscopies to transition to innovative designs.

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CMS (Centers for Medicare and Medicaid Services)

Texting of Patient Information Among Healthcare Providers

CMS memo clarifying their position on texting in hospitals to have approved secure, encrypted platform to protect HIPAA confidentiality.

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CMS (Centers for Medicare and Medicaid Services)

State Operations Manual: Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals

CMS update to the 12/29/17 version with an entirely new section of Tag A-1500 on swing beds.

cms-centers-for-medicare-and-medicaid-services view-all
USP (United States Pharmacopeia)

Role and Applicability of USP General Chapter <800> Related to Safe Handling of Hazardous Drugs

USP resource on compendial applicability.

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CMS (Centers for Medicare and Medicaid Services)

Revisions to State Operations Manual (SOM) Hospital Appendix A

CMS clarifying guidance defining “Hospital” for smaller specialty hospitals, those with multiple EDs, those with limited inpatient capacity and more.

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COVID-19

Revised COVID-19 Focused Survey Tool

A CMS survey tool to assess compliance with new testing requirements for long-term care (LTC) facilities.

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CMS (Centers for Medicare and Medicaid Services)

Requirements to Reduce Legionella Risk in Healthcare Facility Water Systems

CMS memo providing the facility requirements to prevent Legionnaires’ Disease (LD) and other Legionella Infections.

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OSHA (Occupational Health and Safety Administration)

Requirements for Covered Beverages at Nurses’ Stations

An OSHA letter response to a New York RN regarding their regulations on drinks in nurse stations.

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CMS (Centers for Medicare and Medicaid Services)

Report to Congress; Review of Oversight of Accrediting Organizations; Clinical Laboratory Improvement Amendments Program

CMS memo including FY 2016 RTC, additional AO oversight initiatives, and the CLIA validation program.

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CMS (Centers for Medicare and Medicaid Services)

Regulatory Provisions; Fire Safety Requirements; Hospitals and Critical Access Hospital Changes

CMS final rule on Medicare regulations for healthcare providers and suppliers published in the Federal Register.

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Other Useful Resources

Patient Safety Standards, Materials, and Systems Guidelines

The New York State Office of Mental Health guidance on patient safety for inpatient psychiatric environments.

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COVID-19

Optimizing Personal Protective Equipment (PPE) Supplies

CDC FAQs, quick references, and other resources on how to optimize the supply of PPE during coronavirus.

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EPA (Environmental Protection Agency)

Management Standards for Hazardous Waste Pharmaceuticals

An EPA final rule to establish cost-saving and streamlined standards for organizations who handle hazardous waste.

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Other Useful Resources

Malignant Hyperthermia Association of the United States

A nonprofit organization providing information about treatment recommendations and precautions of general anesthetics or succinylcholine.

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AHRQ (Agency for Healthcare Research and Quality)

Making Informed Consent an Informed Choice

Training Modules for Health Care Leaders and Professionals training exercise aimed at improving the Informed Consent process in hospitals.

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FDA (Food and Drug Administration)

Insanitary Conditions at Compounding Facilities Guidance for Industry

FDA Final Guidance Document and Federal Register Notice on insanitary conditions for compounding facilities.

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AHRQ (Agency for Healthcare Research and Quality)

Improving Patient Safety in Hospitals: A Resource List for users of the AHRQ Hospital Survey on Patient Safety Culture

An AHRQ list of references available to give guidance on patient safety.

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HHS (Health and Human Services)

Health Care Provider After Action Report Improvement Plan

ASPR TRACIE article with links to a 2009 CMS evaluation template.

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CMS (Centers for Medicare and Medicaid Services)

Fire Safety Survey Report – Life Safety Code Healthcare

CMS form 2786R. 2012 Life Safety Code; Form Approved OMB Exempt.

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COVID-19

Federal Disaster Resources

CMS federal resources and disaster preparedness toolkits for emergencies and disasters such as COVID-19.

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CDC (Centers for Disease Control and Prevention)

Essential Elements of a Reprocessing Program for Flexible Endoscopes

CDC recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC).

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COVID-19

Emergency Use Authorization (EAU)

An FDA discussion of the EAU process and the Public Readiness and Emergency Preparedness (PREP) Act.

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CMS (Centers for Medicare and Medicaid Services)

Emergency Preparedness Rule

CMS Federal Register publishing establishing national emergency preparedness requirements to plan for disasters.

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CDC (Centers for Disease Control and Prevention)

Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings

A CDC practical guide to implementing industry standards to prevent Legionella infections.

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FGI (Facility Guidelines Institute)

Design Guide for the Built Environment of Behavioral Health Facilities

The Facility Guidelines Institute Patient Safety Risk Assessment Tool.

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COVID-19

COVID-19 Resources for Health Care Facilities

ASHE resource page with their Top COVID-19 Resources.

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COVID-19

COVID-19 Guidance on Ventilation in the Workplace

An OSHA Alert providing tips to reduce the risk of coronavirus exposure through adequate ventilation.

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COVID-19

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

A CMS list of all blanket waivers effective during the national emergency.

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COVID-19

COVID-19 Compounding EC Resources (BUDs, PPE, etc.)

USP Healthcare Quality & Safety EC Resources on sterile compounding during the pandemic.

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Other Useful Resources

Concurrent and Overlapping Surgeries: Additional Measures Warranted

A United States Senate Finance Committee Staff Report on concurrent, overlapping, or simultaneous surgeries.

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COVID-19

Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge

A CMS press release outlining steps to increase healthcare capacity amid COVID-19 hospitalizations.

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CMS (Centers for Medicare and Medicaid Services)

CMS – Quality, Certification, and Oversight Reports (QCOR)

Results of CMS surveys for all states in a searchable format.

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FGI (Facility Guidelines Institute)

Behavioral Health Design Guide

The Facilities Guidelines Institute Design Guide on adult inpatient behavioral health care facilities.

fgi-facility-guidelines-institute view-all
Other Useful Resources

Clinical Hyperbaric Facility Accreditation Manual

The Undersea and Hyperbaric Medical Society manual.

other-useful-resources view-all
CMS (Centers for Medicare and Medicaid Services)

Clarification of Ligature Risk Policy

CMS memo giving guidance on ligature risks in psychiatric hospitals and psychiatric units of general hospitals.

cms-centers-for-medicare-and-medicaid-services view-all
Other Useful Resources

As One Chapter Ends, Another Begins – A Story About Preparing Tc-99m Red Blood Cells Under USP <797>

Cardinal Health explaining some of the changes and implications of USP .

other-useful-resources view-all
COVID-19

ASHRAE Air Handling FAQs

ASHRAE’s technical resources healthcare FAQs on air handling.

covid-19 view-all
CDC (Centers for Disease Control and Prevention)

­­After Action Report / Improvement Plan

A Homeland Security Exercise and Evaluation Program (HSEEP) after-action evaluation template.

cdc-centers-for-disease-control-and-prevention view-all
AHRQ (Agency for Healthcare Research and Quality)

Action Planning Tool for the AHRQ Surveys on Patient Safety Culture

An AHRQ Action Planning Tool to help hospitals design a goal directed improvement plan based on the results reported at your organization.

ahrq-agency-for-healthcare-research-and-quality view-all

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