Accreditation & Compliance Journal
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The Joint Commission (TJC) revamped their final accreditation survey report format for all accreditation surveys and certification reviews conducted after January 1, 2018. Working with customers, and field and central office staff, TJC addressed clients’ requests to...read more
What is Immediate Jeopardy? What are the primary goals of Immediate Jeopardy Guidelines? Who do the Immediate Jeopardy Guidelines apply to? Does Harm have to occur before considering Immediate Jeopardy? What are ‘triggers” for Immediate Jeopardy situations? What are components of an Immediate Jeopardy situation? What are questions to ask to determine if an Immediate Jeopardy situation exists?read more
Kate Fenner, RN, PhD, Managing Director, Compass, will present at Precision Medicine for Hospital CEOs: What You Need to Know about Genetic Testing, Precision Medicine, and Population Health Management, an intensive one-day summit for CEOs and administrators of health systems and hospitals on February 21, 2018.read more
The media has been chock full of news about sexual harassment and related issues creating a hostile work environment. Do not think that this news escapes either CMS (state) or TJC surveyors’ attention. We know from experience that issues in the news influence surveyors’ sensitivity and alertness to related Conditions of Participation and standards enforcement.read more
The Joint Commission has updated its hand hygiene standard for all accreditation programs. Effective January 1, 2018 surveyors will cite the failure of individuals to perform hand hygiene in the process of providing direct patient care as a deficiency resulting in a...read more
The purpose of the National Patient Safety Goals is to improve patient safety. The Joint Commission established its National Patient Safety Goals (NPSGs) in order to help accredited organizations address specific areas of concern in regard to...read more
Clinical Consulting experts take pride in diligently sharing objective analysis, news, insights, strategies, and tactics in media publications for healthcare professionals. In 2017, seven Compass Experts contributed 23 articles in media publications such as Trustee...read more
Four Reasons Psychiatric Care and Behavioral Health Hospitals are Vulnerable to Noncompliance with the CMS CoPs
What makes psychiatric care and behavioral health so vulnerable to noncompliance with the CoPs? We know that’s a complex question, but here are four possible answersread more
A patient handoff (also known as transitioning) is both the act of passing a patient between caregivers and the information exchanged between the sender (the provider giving away the patient) and the receiver (the provider taking the patient).These transfers can be as dramatic as airlifting a patient to a specialty hospital and telling the EMTs that the patient thinks she can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicinread more
The Joint Commission announces updates to its emergency management requirements, effective November 15, 2017. These updates align with Centers for Medicare and Medicaid Services (CMS)’s final rule on emergency preparedness to ensure healthcare professionals and...read more
This week is Healthcare Quality Week. Compass recognizes that healthcare quality professionals serve important roles in improving efficiencies and maximizing an organization's output, all while maintaining a culture that establishes safe, quality care. While their...read more
Each state has a designated agency, usually the state department of health, contracted with CMS for supervision and evaluation of all participating hospitals. Most hospitals encounter a state survey following a complaint, but CMS also requires that states conduct a validation (follow-up to accrediting agency survey to assure comprehensiveness) of 5% of accreditation surveys.read more
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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.