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)
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)
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)
Compass Clinical Consulting’s Director Kate Fenner, PhD, RN, is featured in a series about Hospital Accreditation Options for Hospitals and Health Systems in Becker’s Hospital Review Magazine. Excerpt: The clear majority of hospitals seek voluntary accreditation, most through The Joint Commission (TJC) and now, several hundred through the Healthcare Facilities Accreditation Program (HFAP…(Read More)
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)
We work with a wide range of institutions—both in size and in resources. A significant portion of our effort focuses on hospitals experiencing close CMS examination. A review of these clients suggests that there are common traits that may predispose a healthcare organization to CMS compliance challenges…(Read More)
Victoria Fennel, PhD, RN-BC, CPHQ, Director of Accreditation and Clinical Compliance, Compass Clinical Consulting, will be hosting a webinar entitled, “Accreditation Organizations: What are the Options for Hospitals?” at The Centers for Disease Control and Prevention on December 13, 2016…(Read More)
How do you inspire, create and build an ongoing culture of readiness for the Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) Surveys for your hospital or health system…(Read More)
A significant portion of our effort focuses on hospitals experiencing close CMS examination. A review of these clients suggests that there are nine common traits that may predispose a healthcare organization to CMS compliance challenges…(Read More)
Did you know that, almost hidden away in the Conditions of Participation, there is an oft-overlooked requirement that is ideal for increasing medical staff involvement and improving practice evaluation…(Read More)
The threat of loss of accreditation is one that keeps survey coordinators and hospital leaders awake at night, but for most hospitals, it’s more of a bogeyman than an actual threat. There are many stages an organization must go through and fail before their accrediting bodies slam the hammer down. However, a recent case…(Read More)
Did you miss any of these top articles? “Understanding the Healthcare Facilities Accreditation Program (HFAP),”; “The Hospital Utilization Management Committee (UMC) – CMS Condition of Participation (CoPS) Requirement,”; “Improving Treatment of Mental Health Patients in the Emergency Department (ED),”; “Four Common EMTALA Vulnerabilities Hospitals Should Know … But Probably Don’t,”; and…(Read More)
When The Joint Commission comes in on a complaint finding, it’s not because of the humidity in the OR, but that digitalis wasn’t correctly administered or that a patient wasn’t informed of what was going to happen to her before she went to surgery…(Read More)
There are two types of expenses associated with accreditation: direct and indirect. Direct costs may include the survey fee (may be an annual survey fee or triennial registration fee) plus the travel expenses. Indirect costs may include survey preparation…(Read More)
The ED Psychiatric Patient Management System was developed by experts at Compass Clincial Consulting as a comprehensive approach to consistently deliver best practices in the care of psychiatric patients in the emergency department. This new system provides adaptable tools to ensure the ED staff is well prepared to address psychiatric patient needs and consistently use…(Read More)
What is the Healthcare Facilities Accreditation Progam (HFAP)? The 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…(Read More)
What does value-based purchasing have to do with accreditation? Turns out, a lot. According to the Centers for Medicare and Medicaid Services, “Hospital Value-Based Purchasing (VBP) is part of the Centers for Medicare & Medicaid Services’ (CMS’) long-standing effort to link Medicare’s payment system to a value-based system to improve healthcare…(Read More)
Dr. Cary Gutbezahl, CEO of Compass Clinical Consulting, was the featured guest on Health Professional Radio Network, the #1 global online radio station for health professionals ED & ER Mock Surveys Neal Howard: Dr. Gutbezahl, You have also served as a mock surveyor in preparing hospitals for regulatory surveys. Have you ever done anything similar…(Read More)
Corporate Offices
Recent Posts
- First Update of Surgical Site Infection (SSI) Guidelines by CDC in 18 years
- High and Low-risk Devices are all the Same to TJC Surveyors? New Maintenance Standards Could Prove Costly for Hospitals
- Understanding the Healthcare Facilities Accreditation Program (HFAP)
- Common Problems in the ED: Insights from Emergency Department Consulting
- Understanding the Joint Commission (TJC)
- Accreditation: A Hospital CEO’s Strategic Choice
- Regaining Conditions of Participation Compliance (CoPs) after Immediate Jeopardy & CMS Termination
- Hospital Leaders Like to Think that “Immediate Jeopardy Can’t Happen Here” — Until it Does
- FAQ: What is a CMS Systems Improvement Agreement?
- How to Evaluate the Financial Implications and Benefits of Hiring an Interim Healthcare Executive?
- The Treatment of Psych Patients in the ED: What You Need to Know – Part 1
- What is a Patient Safety Assessment?
Pages
- Accreditation Options:
A Guide for Hospital Leaders - Case Studies & Education Classes
- Clinical Operations Improvement, Redesign
- Clinical Operations Management System
- CMS Immediate Jeopardy
- CMS Systems Improvement Agreement (SIA)
- Contact
- Contact
- Expert Perspectives
- Home
- Hospital Compliance & Accreditation Consulting Services
- Immediate Jeopardy
- Interim Healthcare Management
- Knowledge Center
- Leadership
- News
- No Access
- Patient Safety Assessment
- Performance Improvement
- Profile in Healthcare Leadership, Peter Fine, CEO Banner Health
- Readiness Services
- Recruitment
- Response & Recovery Survey Services
- Safer Behavioral Health in the Emergency Department
- Sterilization and High-Level Disinfection Clinical Services
- Successful Departmental Transformation through Interim Leadership
- Surgical Services: Operating Room Management Solutions
- White Papers
- [White Paper] How Medicare Termination Can Push Your Hospital to the Brink of Closing
Categories
- Accreditation & Compliance (31)
- Behavioral Health (7)
- Case Management (8)
- Case Study (17)
- Clinical Improvement (32)
- Compass Clinical Consulting Corporate (10)
- Compass Clinical Institute (1)
- Compass in the Media & Press (1)
- Compliance Recovery (7)
- Emergency Department (7)
- Featured (26)
- Hospital Board (1)
- Hospital Cost Management (7)
- Hospital Leadership (78)
- Interim Healthcare Executives (20)
- News (23)
- Nursing Today (1)
- Patient Experience (4)
- Patient Safety (9)
- Profiles in Healthcare Leadership (47)
- Systems Improvement Agreement (1)
- The Joint Commission (2)
- Uncategorized (2)
- White Paper (7)