How do you inspire, create and build an ongoing culture of readiness for the Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) Surveys for your hospital or health system?

As clinical consultants since 1979, we know the following strategies and tactics work.

Internal Resources: Prepare, build and strengthen your internal resources. Because TJC and CMS surveys are unannounced, preparation and ongoing readiness are critical. Test and survey (examples below) your organization on a consistent and but unannounced, schedule.

Related: CMS & TJC On-site Education and Preparation Classes

Tracer Methodology Mock Surveys:  This allows staff to respond to mock survey conditions while identifying opportunities for targeted improvement.

CMS & TJC Survey Preparation: Prepares your organization for an unannounced validation survey through the intense scrutiny of state surveyors in a safe setting. Survey and test your departments on a regular, but un-announced, schedule. If your staff doesn’t have the time or resources to do this, or you need a fresh set of eyes, hire a skilled consultant team (like Compass Clinical) who specialize in Accreditation and Regulatory Compliance.

Related: What’s the Difference Between CMS and TJC Survey Preparation?

CMS Conditions of Participation (CoPs) surveys: This applies to acute care hospitals, critical access hospitals, psychiatric hospitals, home health, hospice, and ambulatory surgery centers.

Related: How to Prepare for A CMS CoPs Survey – Strategies for Success

The Joint Commission (TJC) survey:  This applies to acute care hospitals, critical access hospitals, psychiatric hospitals, physician practices, home health, hospice, ambulatory surgery centers, laboratory and  Disease Management Certification.

Related: TJC Documents Five Most Challenging Requirements: Home Health and Hospitals

Tracer Methodology Mock Surveys:  This allows staff to respond to mock survey conditions while identifying opportunities for targeted improvement.

EMTALA surveys focus on areas such as Emergency department, obstetrics, and behavioral services.

Related: Four Common Emtala Vulnerabilities Hospitals Should Know … But Probably Don’t

Focused Standards Assessment:  Assessments include cleaning and high-level disinfection; sterilization processes; behavioral health patients in the ED assessments; and Environment of Care areas.

Related: Increase Your Focus on Infection Control in Ambulatory Surgery Centers

Life Safety Code and NFPA Survey:  This applies to acute care hospitals, critical access hospitals, and ambulatory surgery centers.

Related: Focused TJC and CMS Mock Surveys: Environment of Care and Life Safety

College of American Pathology (CAP) survey includes laboratory services and waived testing.

OSHA Survey: Focuses on compliance to safety and health legislation.

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For more information on creating and maintaining a culture of CMS & TJC Survey readiness, contact us at 800-241-0142 or use our contact form.

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