Accreditation & Compliance Journal
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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
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.read more
Inadequate hand-off communication is a contributing factor to adverse events, including many types of sentinel events.read more
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...read more
Victoria Fennel, PhD, RN-BC, CPHQ, was published in Becker's Hospital Review in part seven of the eight-part “Accreditation Options” series. In the previous articles, we have analyzed the four main sources for external accreditation with deeming status. The article,...read more
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