Craft Your Compliance Competency

CORE Competency Framework: Compliance Logo

Health care facilities managers oversee the health care physical environment and ensure compliance with associated regulatory requirements in a way that ensures patient care and safety is the foremost priority for the entire facility management team. 

This is demonstrated through, but not limited to, possessing a comprehensive working knowledge of health care physical environment-related regulatory requirements for accreditation at the federal/state/local levels, as well as an understanding of the actions required to ensure compliance through:

  • Policy/procedure development
  • Documentation of integrated life safety inspection
  • Compliance-related testing, maintenance and documentation of facility-related systems
  • Identification of the responsible facility authority for medical gas systems
  • Maintaining the appropriate permits for work programs (ex. above ceiling, medical gases, hot work, etc.)

Featured Resources

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Understanding Health Care Compliance: The Facilities Manager’s Handbook

Available for Pre-Sale! A comprehensive overview of health care facilities compliance that maps the complex regulatory landscape and shares best practices in compliant facilities management.

Two coworkers view a clipboard as they walk inside a health facility.

Physical Environment Survey Readiness

Leverage continuous code compliance and reduce survey mistakes. Explore upcoming dates for Life Safety, Emergency Management and The Care Environment modules.

Hazard Vulnerability Assessment Tool

Hazard Vulnerability Assessment Tool

Use this tool to score your emergency preparedness using the all hazards approach and identify the potential hazards that need the most attention for exercise, mitigation and/or planning.

Training and Resources

Compliance Education

Cover Image: construction hat and traffic cone

NFPA 101: Chapter 43 Building Rehabilitation

24/7 on demand

Understand Chapter 43 of NFPA 101, which provides clarification on levels of building renovations and when compliance with new construction would be required.

Medical Gas Cylinder Storage

Medical Gas Cylinder Storage

e-Learning

Understand the storage and use of medical gas cylinders with the 2012 Edition of NFPA 99 in mind.


Cover Image: NFPA 99 - Medical Gas and Vacuum Systems

NFPA 99 - Medical Gas and Vacuum Systems

e-Learning

Learn NFPA 99’s (2012 edition’s) minimum health care facilities requirements related to medical gas and vacuum systems, covering a broad spectrum of applications.

Cover Image: Major Proposed Changes to NFPA 101 - 2024 Edition

Major Proposed Changes to NFPA 101 - 2024 Edition

Webinar

CMS currently enforces the 2012 Edition of NFPA 101 — explore the changes in the 2015, 2018, 2021 Editions, and anticipated changes in the 2024 Edition.

Cover Image: Managing Life Safety Program

Managing Life Safety Program

e-Learning

Experts provide advice on how to protect patients, staff and visitors from fire-related hazards by correctly applying NFPA 101 code requirements.

Cover Image: CMS Conditions of Participation (CoP) and Codes

CMS Conditions of Participation (CoP) and Codes

Video

Get a step-by-step explanation of how the Conditions of Participation for Hospitals, the State Operations Manual and accrediting organizations standards all tie together.

Compliance Publications and Tools

Cover Image: Physical Environment Provisions of USP <797>

Physical Environment Provisions of USP <797>

Monograph

Review the certification process and ongoing requirements for the physical environment provisions of compounded sterile preparations (CSPs) in USP.

Cover Image: ANSI/ASHRAE/ASHE Standard 170-2021, Ventilation of Health Care Facilities

ANSI/ASHRAE/ASHE Standard 170-2021, Ventilation of Health Care Facilities

Guide/Report

Standard 170 offers ventilation guidance, regulation and mandates to designers and operators of health care facilities.

Cover Image: Managing Hospital Electrical Shutdowns

Managing Hospital Electrical Shutdowns

Monograph

Improve your hospital’s electrical infrastructure, power system reliability, and staff training with the utility management program approach.

Cover Image: Hospital CMS Tag Checklists and Crosswalks

Hospital CMS Tag Checklists and Crosswalks

Tool

These tools outline how accreditation standards and codes applicable to most hospitals align with CMS’s Conditions of Participation and Code of Federal Regulations.

Cover Image: Health Care Facility Manager's Guide to Smoke Control

Health Care Facility Manager's Guide to Smoke Control

Monograph

Get insights into the regulatory requirements and maintenance recommendations for smoke control systems in hospitals.

Cover Image: Focus on Compliance: Fire door checklist

Focus on Compliance: Fire door checklist

Tool

This checklist can help health care facilities professionals inspect fire doors to ensure compliance with The Joint Commission standard LS.02.01.10.