
Is Your Healthcare Team Suffering from Initiative Fatigue?
An abundance of initiatives can be a great sign of a vital organization with leaders who are committed to improving healthcare delivery. Unfortunately, there’s also a shadow side.
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The Impact of Electronic Health Records in Patient Safety
Is your organization’s electronic health record process truly survey-ready? Proactive risk assessments can be conducted to mitigate safety hazards and known risks. We recommend addressing three common risk areas.
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The Achilles Heel during Survey for Infection Prevention and Control: High-Level Disinfection and Sterilization
Many organizations struggle to properly disinfect or sterilize medical and surgical equipment or devices that are not single-use disposable. It may seem like a small or isolated problem, but like any Achilles heel, it can result in major failure.
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Lisa Waldowski, DNP, APRN, CIC, Joins Compass Clinical
We are thrilled to announce the addition of Lisa Waldowski, DNP, APRN, CIC, to the Compass Clinical Consulting team. Lisa joins us with deep expertise in infection prevention and control and accreditation and regulatory standards.
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The 90-Minute Life Safety Code Document Review
There’s nothing more frustrating to a Joint Commission Life Safety Code Surveyor than a document review that exceeds 90 minutes for a single building. A well-organized document review sets the tone for your survey. This article delves into a process for making that happen.
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CMS Announces Increased Oversight of Accrediting Organizations
The Centers for Medicare and Medicaid Services (CMS) has alerted both accrediting organizations (AOs) and healthcare organizations of increased scrutiny and oversight of the AOs. This means that state agencies and accrediting organizations contracted to assess...
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Tabitha Garbart, DNP, RN, Joins Compass Clinical
Tabitha Garbart, DNP, RN, has joined our staff as a Senior Consultant. Tabitha brings more than 19 years of experience in the industry and a commitment to helping healthcare organizations connect the dots and understand the “why” behind their work to use evidence-based practices to reduce harm and improve quality of care.
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Life Safety Code Deficiencies: Is There Low-Hanging Fruit in Your Hospital?
Did you know that most life safety code deficiencies that contribute to CMS condition-level deficiencies are “low-hanging fruit”? This means that many findings could be prevented if you would simply deal with the easy-to-address deficiencies on a routine basis. For the sake of this article, I’m going to pinpoint places where the life safety code low-hanging fruit are most commonly found in hospitals and offer simple practices for quick remediation.
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Eight Steps to A Successful Medicare Deficiency Follow-Up Survey
Your triennial accreditation survey just ended, and your TJC surveyor has informed you deficiencies were scored under the CMS Conditions of Participation, which will lead to a Condition-level Finding for your organization, meaning that you are a candidate for a Medicare deficiency follow-up survey.
That’s right, they’re coming back unannounced within 45 days to ensure your organization has met the identified Conditions of Participation. Follow these eight steps to get across the compliance finish line quickly for a successful Medicare Deficiency Follow-Up Survey.
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Ken Blackwell, LSCS, CHSP, Joins Compass Clinical Consulting
Compass is pleased to announce that Ken Blackwell, LSCS, CHSP, has joined the firm as a Senior Consultant, with a focus on Life Safety and the Environment of Care. A former Joint Commission surveyor, Ken has surveyed nearly 600 healthcare organizations, including military hospitals and Veterans Health Administration facilities. He brings to Compass nearly 20 years of experience in the healthcare industry, with expertise in the accreditation and regulatory standards and a commitment to continuous quality improvement.
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