Posts Currently viewing the category: "Accreditation & Compliance"

It is a frequent assumption that sterilization and high-level disinfection (HLD) are limited to the main OR and sterile processing departments (SPD). However, accrediting agencies are beginning to place a greater focus on hospital-based clinics and satellite practices that use instruments and equipment in their practice. For many newly acquired physician practices and…(Read More)

explore your Accreditation options

This decision to maintain accredited status with one particular source is rarely questioned, much less examined from a strategic perspective. But perhaps it is time for hospital leaders to evaluate the decision to pursue accreditation and view it as a key element of their hospitals’ strategies. This whitepaper explores some of the accreditation options available…(Read More)

Kevin Kiely, CHSP, CHFM, CPSO, HEM, senior consultant for Compass Clinical Consulting, is the featured in the August 1, 2017, edition of the Briefings on Accreditation and Quality Journal article, “High- and low-risk devices are all the same to surveyors; New maintenance standards could prove costly for hospitals.”  EXCERPT:  Many were shocked by The…(Read More)

Healthcare Facilities Accreditation Program Compass Clinical Consulting

HFAP is the accreditation process that has grown out of the former hospital approval process of the American Osteopathic Association. Founded in 1945, this accreditation program has experienced growth well beyond its traditional base of osteopathic hospitals to encompass over 200 acute-care hospitals, plus 200 other accredited entities…(Read More)

What is a CMS Systems Improvement Agreement: FAQ'S

The Systems Improvement Agreement between the hospital/healthcare organization and CMS binds the organization to engage in a series of improvement activities to address multiple deficiencies in compliance with the CoPs with the assistance of a third-party monitor/consultant approved in advance by the CMS Regional Office. The agreement grants the organization additional time…(Read More)

The Joint Commission (TJC) is, by far, one of the biggest names in hospital accreditation. Formerly known for years as the Joint Commission on the Accreditation Healthcare Organizations, TJC’s mission still rings true today: “To continuously improve healthcare for the public in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to…(Read More)