Readiness Services

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

OSHA

Focuses on compliance to safety and health legislation.

Targeted Consultation

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 respond in mock survey conditions while identifying opportunities for targeted improvement.

EMTALA

Focuses on areas such as: Emergency department, obstetrics, and behavioral services.

Focused Standards Assessment

We provide expert resources to complete your Focused Standards Assessment (FSA) or to validate one prepared internally. Assessments include: Cleaning and high-level disinfection; sterilization processes; behavioral health patients in the ED assessments; and Environment of Care areas.

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.  

 

Contact Us

Compass Clinical Consulting works with your organization to craft ongoing readiness and survey preparation activities. We focus on mitigating deficiencies prior to survey, refocusing staff attention and arming managers with a response plan to launch when surveyors arrive, coach and mentor staff and managers on survey activities and educate boards and executives on the latest trends in accreditation and their implications.

To find out more about our Compliance and Accreditation services, contact us or call our office at (800) 241.0142.

Happy Healthcare Quality Week!

Happy Healthcare Quality Week!

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...

Accreditation Options Update: Going Bare — The State Option as an Alternative to Accreditation

Accreditation Options Update: Going Bare — The State Option as an Alternative to Accreditation

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.

Increased Focus on Ligature Risks

Increased Focus on Ligature Risks

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.

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