Compass Clinical Consulting assists organizations in building or strengthening internal resources to maintain a culture of continuous readiness for surveys by The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS). Because TJC and CMS surveys are unannounced, preparation and ongoing readiness are critical. To keep your hospital continuously prepared, we provide high-leverage services and products to help your organization achieve survey success through proactive strategies.
The Need to Create a Culture of Continuous Readiness
TJC and CMS surveys are unannounced, preparation and ongoing readiness are critical. Compass assists organizations in building or strengthening internal resources to maintain a culture of continuous readiness for surveys by The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS).
Compass Can Help
To keep your hospital continuously prepared, we provide high-leverage services and products to help your organization achieve survey success through proactive strategies:
Continuous Readiness Packages
Control costs over time and combines preparation resources in a convenient package customized to your organization. These include an on-demand question and clarification support, webinars, and other educational services on CMS and TJC changes and interpretation.
CMS & TJC Survey Preparation
Prepares the organization for an unannounced validation survey through the intense scrutiny of state surveyors in a safe setting.
CMS Conditions of Participation (CoPs)
Applies to: acute care hospitals, critical access hospitals, psychiatric hospitals, home health, hospice, and ambulatory surgery centers.
The Joint Commission (TJC)
Applies to: acute care hospitals, critical access hospitals, psychiatric hospitals, physician practices, home health, hospice, ambulatory surgery centers, and laboratory.
Disease Management Certification
Focuses on compliance
On-site personalized consultation proactively examines processes and targets those with the highest leverage for a redesign to conserve resources.
Tracer Methodology Mock Surveys
Allows staff to
Focuses on areas such
Focused Standards Assessment
We provide expert resources to complete your Focused Standards Assessment (FSA) or to validate one prepared internally. Assessments
Life Safety Code and NFPA
Applies to: acute care hospitals, critical access hospitals, and ambulatory surgery centers.
College of American Pathology (CAP)
Includes laboratory services and waived testing.
The Compass Difference
When you hire Compass to work with you, we bring a small team of consultants in to learn about your organization. We don’t invade your hospital – we become part of it. By keeping our team small, your people will get to know us and trust us and will see us as part of your team. We believe transparency is a critical success factor for any project, so you will always know about project progress and obstacles in real time.
Compass Clinical Consulting works with your organization to craft ongoing readiness and survey preparation activities. We focus on mitigating deficiencies prior to
To find out more about our Compliance and Accreditation services, contact us or call our office at (800) 241.0142.
Restructuring Communication and Establishing Organizational Improvements in the Laboratory with Interim Leadership
A hospital in the Midwest needed to fill a leadership vacancy after struggling with performance issues from their previous Laboratory Director for several months. The organization’s leadership had been trying to collaborate with him, but the Director was unable to...
The Joint Commission announces updates to its emergency management requirements, effective November 15, 2017. These updates align with Centers for Medicare and Medicaid Services (CMS)’s final rule on emergency preparedness to ensure healthcare professionals and...
This week is Healthcare Quality Week. Compass recognizes that healthcare quality professionals serve important roles in improving efficiencies and maximizing an organization's output, all while maintaining a culture that establishes safe, quality care. While their...
Each state has a designated agency, usually the state department of health, contracted with CMS for supervision and evaluation of all participating hospitals. Most hospitals encounter a state survey following a complaint, but CMS also requires that states conduct a validation (follow-up to accrediting agency survey to assure comprehensiveness) of 5% of accreditation surveys.
Integral for the smooth functioning of a hospital, high patient experience scores are necessary for the satisfaction of all members within the facility. The patient experience starts with the leaders of a hospital, clinic, or other facility of a health system. Leaders...
More than 70 hospitals may currently be in or have received an accreditation decision of Preliminary Denial of Accreditation (PDA) so far this year, and it would appear that lack of compliance with the suicide prevention standards is one of the main reasons for this accreditation decision. Other areas that seem to be in the top citations are high-level disinfection and sterilization, and staff competencies.
Inadequate hand-off communication is a contributing factor to adverse events, including many types of sentinel events.
There are some basic guidelines that many healthcare leaders fail to follow in the process of selecting a qualified candidate to become part of their leadership team. As an HR professional, I can’t remember how many times I have taught classes and reminded executive...
Modern Healthcare recently posted the 16th annual publication of the 100 Most Influential People in Healthcare, an awards & recognition program which honors individuals in healthcare who are deemed by their peers and the senior editors of Modern Healthcare to be the...
Nan Tomsky, MN, RN, CPHRM, Principal Consultant at Compass Clinical Consulting, and Richard Curtis, RN, MS, HACP, CEO of the Center for Improvement in Healthcare Quality and a nationally recognized expert on the CMS Conditions of Participation (CoPs) and certification...