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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.
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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Does your Moderate Sedation Program measure up to the standards?
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.
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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.
read more 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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The Future of Infection Prevention: Looking Ahead to Improve Patient Outcomes and Decrease Hospital Acquired Infections (HAIs)
As infection prevention challenges evolve—such as emerging infectious organisms and resistance—healthcare organizations must focus on preventing hospital acquired infections and ensuring better patient outcomes. To achieve these goals, Infection Prevention professionals must be involved in all decisions affecting the delivery of patient care. Healthcare is ever-changing, and innovative approaches are critical as we look to the future of infection prevention.
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The Hospital Utilization Management Committee (UMC) – CMS Condition of Participation (CoPS) Requirement
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?
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Becker’s Healthcare Names 100 Great Community Hospitals
Congratulations to Becker’s Healthcare’s 100 great community hospitals in 2018! Many of the hospitals have been recognized for their clinical quality, operational excellence and economic impact on the surrounding areas.
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