Is your organization’s electronic health record process truly survey-ready? Proactive risk assessments can be conducted to mitigate safety hazards and known risks. We recommend addressing three common risk areas.read more
The Achilles Heel during Survey for Infection Prevention and Control: High-Level Disinfection and Sterilization
Many organizations struggle to properly disinfect or sterilize medical and surgical equipment or devices that are not single-use disposable. It may seem like a small or isolated problem, but like any Achilles heel, it can result in major failure.read more
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
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
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
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
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 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
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 (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
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
Contact 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.