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.

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Workplace Violence: Sentinel Event Alert 59

About 75% of workplace assaults occur in the healthcare and social service sector each year, and healthcare workers are four times more likely than others to take time off because of violence-related injuries. The Joint Commission is the latest healthcare heavy-hitter to call for better protections, announcing the creation of Sentinel Event Alert (SEA) 59, which addresses violence—physical and verbal—against healthcare workers.

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Preliminary Denial of Accreditation: How to successfully resolve

You’ve been notified by The Joint Commission that your healthcare organization’s survey resulted in Preliminary Denial of Accreditation. This was not an outcome anybody anticipated, as previous accreditation and CMS surveys were uneventful. What does this mean? How is this determined? And what steps need to be taken for successful and expedient resolution?

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Sexual Harassment: Taking on the Imbalance of Power in the Healthcare Setting

When you have a perceived and very real imbalance of power in the hospital setting, how can you make sure that this is addressed in your organization that people feel that they do have the right to speak out and that someone will take whatever action is necessary?

How do you build the culture and will to take on the imbalance of power within your organization?

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Sexual Harassment in Healthcare – How to Prevent?

As staff joins an organization they need to have as part of their required orientation, a zero-tolerance policy introduction and education about their rights and responsibilities. Every right usually has an attendant responsibility. The prevention part is making sure that managers and medical staff leaders are all aware and have a similar zero-tolerance policy.

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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.  


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