Additional References

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.

Restraint and Seclusion Reduction Psychological Services

An article describing the implementation of a systematic plan to reduce the use of restraints while also reducing expenditures and staff injuries in large public psychiatric hospitals.

Health Care Equity 2023

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

Emergency Management Plan Evaluation – Post COVID-19

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

Performance Improvement Mandatories

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

OR Manager 2019 – February

OR Manager  2019 – January

OR Manager 2018 – January

OR Manager  2016 – December

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.

Hospital Survey on Patient Safety Culture

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

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.

Vaccine Storage and Handling Toolkit

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

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.

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.

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.

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

USP resource on compendial applicability.

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.

Revised COVID-19 Focused Survey Tool

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

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.

Requirements for Covered Beverages at Nurses’ Stations

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

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.

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.

Patient Safety Standards, Materials, and Systems Guidelines

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

Optimizing Personal Protective Equipment (PPE) Supplies

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

Management Standards for Hazardous Waste Pharmaceuticals

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

Malignant Hyperthermia Association of the United States

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

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.

Insanitary Conditions at Compounding Facilities Guidance for Industry

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

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.

Health Care Provider After Action Report Improvement Plan

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

Fire Safety Survey Report – Life Safety Code Healthcare

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

Federal Disaster Resources

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

Essential Elements of a Reprocessing Program for Flexible Endoscopes

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

Emergency Use Authorization (EAU)

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

Emergency Preparedness Rule

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

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

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

Design Guide for the Built Environment of Behavioral Health Facilities

The Facility Guidelines Institute Patient Safety Risk Assessment Tool.

COVID-19 Resources for Health Care Facilities

ASHE resource page with their Top COVID-19 Resources.

COVID-19 Guidance on Ventilation in the Workplace

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

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

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

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

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

Concurrent and Overlapping Surgeries: Additional Measures Warranted

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

Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge

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

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

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

Behavioral Health Design Guide

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

Clinical Hyperbaric Facility Accreditation Manual

The Undersea and Hyperbaric Medical Society manual.

Clarification of Ligature Risk Policy

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

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 .

ASHRAE Air Handling FAQs

ASHRAE’s technical resources healthcare FAQs on air handling.

­­After Action Report / Improvement Plan

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