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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.
FAQ: What is a CMS Systems Improvement Agreement?
The Systems Improvement Agreement between the hospital/healthcare organization and CMS binds the organization to engage in a series of improvement activities to address multiple deficiencies in compliance with the CoPs with the assistance of a third-party monitor/consultant approved in advance by the CMS Regional Office. The agreement grants the organization additional time to make sustainable improvements in complex quality, cultural, policy, and procedural deficiencies.
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How to Deal with the Influx of Mental Health Patients in the Emergency Department?
An increasing number of psychiatric patients are being admitted to Emergency Department’s (ED) in nearly every hospital in the U. S. It’s an ongoing surge, and is heavily taxing ED’s and community hospital resources. How to deal with this growing influx of psych patients in the ED when you have limited resources?
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Common Problems in the ED: Insights from Emergency Department Consulting
Hospitals need to examine negative occurrences such as: extended Length of Stay (LOS), lengthy door-to-doc time, and high rates of left without being seen (LWBS). Anything that prevents the hospital from meeting the goal of decreasing these issues must be assessed. For example, the work-up time (the time patients arrive to when they leave) can oftentimes be decreased. One way to address this issue would be to closely examine turnaround times for all diagnostic tests
read moreAccreditation Options: Understanding the Joint Commission
Compass Clinical Consulting healthcare quality leader, Darlene Evans, MSN, RN, CPHQ, has been published in Becker’s Hospital Review with an article in an eight-part series on accreditation options about one of the biggest names in hospital accreditation, titled...
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Understanding the Healthcare Facilities Accreditation Program (HFAP)
HFAP is the accreditation process that has grown out of the former hospital approval process of the American Osteopathic Association. Founded in 1945, this accreditation program has experienced growth well beyond its traditional base of osteopathic hospitals to encompass over 200 acute-care hospitals, plus 200 other accredited entities.
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Accreditation: A Hospital CEO’s Strategic Choice
Compass Clinical Consulting Managing Director Kate Fenner, PhD, RN, has been published in Becker’s Hospital Review with the first article in an eight-part series on accreditation options, titled “Accreditation Options: A Hospital CEO’s Strategic Choice.” The clear...
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Profile in Healthcare Leadership: Cincinnati Children’s Hospital Medical Center
James M. Anderson retired in 2009 as president and CEO of Cincinnati Children’s Hospital Medical Center, a position he had held since 1996. He was instrumental in shaping the extraordinary growth at the medical center.
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Anesthesia Department Performance Improvement
An urban medical center in the Midwest was experiencing turmoil in its Anesthesia department. The organization was employing too many anesthesiologists, and as a result, individual productivity among this group of physicians was low. In addition, strained relationships between anesthesiologists and certified registered nurse anesthetists (CRNAs) were making it difficult for the medical center to recruit needed additional CRNAs…
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CMS Publishes Survey Memo on the Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems
By Marge McFarlane, PhD, CJCP, CHSP, CHFM, HEM The Centers for Medicare & Medicaid Services (CMS) posted a Survey and Certification letter (S&C 17-30 memo) on June 6, 2017, indicating that Medicare-certified healthcare facilities are expected to have water management...
read moreRegaining Conditions of Participation Compliance (CoPs) after Immediate Jeopardy & CMS Termination
Operational and leadership issues at one 274-bed inpatient psychiatric hospital in the Southeast had been emerging slowly over several years. Eventually> critical patient incidents culminated in regulatory scrutiny, and the hospital experienced a full survey by the Centers for Medicare and Medicaid Services (CMS). Findings of dysfunctional organizational culture, leadership, and management system inadequacies and suboptimal patient care outcomes resulted in Immediate Jeopardy and the hospital’s subsequent termination from Medicare. The state Department of Health and Human Services (DHHS) retained Compass Clinical Consulting to help the hospital regain certification.
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