The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

• A time-out is performed before the procedure.
• Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.01.01 for hand hygiene guidelines.
• Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
• Leaders create and maintain a culture of safety and quality throughout the organization.
• Organization leaders allocate needed resources for infection prevention and control activities.
• Staff and licensed independent practitioners performing waived tests are competent.
• Staff are competent to perform their responsibilities.
• The organization addresses the safe use of look-alike/sound-alike medications.
• The organization defines and verifies staff qualifications.
• The organization evaluates staff performance.
• The organization evaluates the effectiveness of its infection prevention and control activities.
• The organization evaluates the effectiveness of its medication management system. Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information)
• The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
• The organization identifies risks for acquiring and transmitting infections.
• The organization implements infection prevention and control activities.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The organization inspects, tests, and maintains medical equipment.
• The organization manages risks related to hazardous materials and waste.
• The organization performs quality control checks for waived testing on each procedure. Note: Internal quality controls may include electronic, liquid, or control zone. External quality controls may include electronic or liquid.
• The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
• The organization respects the patient's right to participate in decisions about his or her care, treatment, or services.
• The organization safely manages emergency medications.
• The organization safely stores medications.
• The organization selects and procures medications.
• Those who work in the organization are focused on improving safety and quality.