
Compass Clinical Consulting Chief Executive Officer Cary D. Gutbezahl, MD, and Managing Director Kate Fenner, RN, PhD, will attend the American College of Healthcare Executives (ACHE) 2013 Congress on Healthcare Leadership. They will be looking to meet with seasoned CEOs thinking about their next career move. Contact us to set up an appointment to meet [...]

There were several core issues that helped bring this organization’s quality challenges to a head. First and foremost, there was a horrendous turnover rate in the nursing staff, and a high use of traveling and agency nurses. Their CNO was an interim, which can sometimes be a good thing, but in this case, an interim CNO was overseeing a temporary staff.

Physicians diagnose and order, and other professionals play integral roles in the delivery of care, but the lion’s share of work rests with nursing personnel. And it is from here that vulnerabilities most often spring, as nurses perform the significant majority of the “doing” in care delivery, and it is in the “doing” that lapses in compliance occur.

On May 31, 2012, an article on the Systems Improvement Agreement (SIA) by Kate Fenner, RN, PhD, was featured in Hospital and Health Networks (H&HN) Daily. The systems improvement agreement is a new tool available to the Centers for Medicare & Medicaid Services to aid compliance with the conditions of participation in federal programs. Hospitals [...]

It is not uncommon for hospital leaders to believe that Medicare termination is rare and could never occur at their facilities. Administrators often think, “We’ve always done well, why would this time be any different?” However, as both The Joint Commission (TJC) and CMS become more thorough in their survey processes, this thinking may represent false confidence. The following guidelines present a strategy for dealing with Immediate Jeopardy.

Physician dissatisfaction with the handling of patient care issues finally pushed one practitioner over the edge. Individual quality concerns were ignored and left to fester. Incidents went unreported or landed in a bottomless pit of quality and risk data that staff perceived would never see the light of day again.

The Centers for Medicare and Medicaid Services (CMS) has a new quality improvement tool to gain compliance from hospitals with repeat or multiple Immediate Jeopardy (IJ) findings on compliance or validation surveys: the Systems Improvement Agreement (SIA). The SIA allows hospitals to continue receiving CMS funding while a third-party monitors its policies, facilities, and patient care until the [...]












