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.
read more
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...
read more
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.
read more
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.
read more
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
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?
read more
The Joint Commission on Workplace Violence: Q&A
The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers.
read more
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.
read more
The Joint Commission to Require Distinct ID Methods for Newborns
The Joint Commission (TJC) has approved a new requirement intended to reduce newborn identification errors. Starting January 1, 2019, hospitals and critical access hospitals that provide labor and delivery services will be subject to this new element of performance at National Patient Safety Goal NPSG.01.01.01, EP 3.
read more
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?
read more
Becker’s Healthcare: 2018 list of 100 great hospitals in America
Becker’s Healthcare released its 2018 edition of “100 great hospitals in America,” recognizing excellence in clinical care, patient outcomes, and staff and physician satisfaction.
read more
TJC Issues Sentinel Event Alert 59 on Physical and Verbal Violence Against Healthcare Workers
TJC has issued Sentinel Event Alert 59 to help organizations recognize and acknowledge physical and verbal violence directed against healthcare workers from patients and visitors, better prepare staff to handle violence, and more effectively address the aftermath.
read moreContact Compass Clinical Consulting
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 at (513) 241.0142, via email, or through the contact form below.