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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The Joint Commission Updates Hand Hygiene Compliance
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...
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The Joint Commission’s Hospital National Patient Safety Goals for 2018
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...
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Compass in the Media – 2017 Contributions
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...
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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 answers
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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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The Joint Commission Updates Emergency Management Requirements
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...
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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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TJC Sentinel Event Alert 58 Focuses on Inadequate Hand-off Communication
Inadequate hand-off communication is a contributing factor to adverse events, including many types of sentinel events.
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Accreditation 101: Finding Success as an Accreditation Specialist
Nan Tomsky, MN, RN, CPHRM, Principal Consultant at Compass Clinical Consulting, and Richard Curtis, RN, MS, HACP, CEO of the Center for Improvement in Healthcare Quality and a nationally recognized expert on the CMS Conditions of Participation (CoPs) and certification...
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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.