Understanding and Identifying Immediate Jeopardy Situations

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?

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Heads Up on Sexual Harassment in Healthcare Settings

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.

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Patient Handoffs: Where Mistakes are Made

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 medicin

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Happy Healthcare Quality Week!

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...

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Accreditation Options Update: Going Bare — The State Option as an Alternative to Accreditation

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.

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Increased Focus on Ligature Risks

More than 70 hospitals may currently be in or have received an accreditation decision of Preliminary Denial of Accreditation (PDA) so far this year, and it would appear that lack of compliance with the suicide prevention standards is one of the main reasons for this accreditation decision. Other areas that seem to be in the top citations are high-level disinfection and sterilization, and staff competencies.

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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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