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
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 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 more
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?read more
The Joint Commission has updated their sentinel event data, releasing data from the fourth quarter of 2017 and aggregating data from 2005-2017. 10 Most Reported Sentinel Events for Q4 2017 In 2017, 805 sentinel events were reported, with 87% of these events classified...read more
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.read more
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.