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If you have questions or concerns about achieving clinical and operational improvements toward safe, quality patient care, we can help. We encourage you to contact us for a confidential discussion of your needs.
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.read more
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.read more
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.read more
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.read more
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.read more
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...read more
Moderate sedation, commonly known as conscious sedation, is a drug-induced depression of consciousness. When moderate sedation is administered, patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Interventions are not required to maintain a patent airway; spontaneous ventilation continues to be adequate; and cardiovascular function is maintained.
Reducing variability in your Moderate Sedation Program is key to patient safety! Let’s look at the requirements in the TJC standards and some strategies for compliance.read more
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.read more
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.read more
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.read more