Accreditation & Compliance Journal
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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
It is a frequent assumption that sterilization and high-level disinfection (HLD) are limited to the main OR and sterile processing departments (SPD). However, accrediting agencies are beginning to place a greater focus on hospital-based clinics and satellite practices...read more
This decision to maintain accredited status with one particular source is rarely questioned, much less examined from a strategic perspective. But perhaps it is time for hospital leaders to evaluate the decision to pursue accreditation and view it as a key element of their hospitals’ strategies. This whitepaper explores some of the accreditation options available to hospitals— including TJC, HFAP, DNV GL, and CIHQ—paying close attention to the philosophies of different accrediting bodies, as well as the implications, costs, and benefits associated with them.read more
We are pleased to welcome Lena Browning MHA, BSN, RNC-NIC, CSHA, to Compass Clinical Consulting. As part of the accreditation and regulatory compliance mock survey team, she will focus on helping client organizations prepare for survey by the Joint Commission or the...read more
Many hospitals find complying with regulatory and accreditation standards to be a challenge—knowing how to address deficiencies and ensure that the entire organization is prepared to do so is not something one learns in school. As a result, even an excellent hospital can find its well-being in jeopardy following a surprise survey that results in citations. Often, these organizations look to experts to assist in responding to the findings.read more
Kate Fenner, PhD, RN has been published in Becker’s Hospital Review in our eight-part series on accreditation options for healthcare organizations. The article, "Accreditation Options Update: Going Bare -- The State Option as an Alternative to Accreditation"...read more
The Joint Commission (TJC) announced in the August 2017 Perspectives that it has edited Medication Management (MM) standards for the ambulatory care, behavioral health care, critical access hospital, home care, hospital, nursing care center, and office-based surgery...read more
Victoria M. Fennel, PhD, RN-BC, CPHQ, has been published in Becker’s Hospital Review with the fifth article in our eight-part series on accreditation options for healthcare organizations. The article, "Understanding the center for improvement in healthcare quality"...read more
This whitepaper explores some of the accreditation options available to hospitals— including TJC, HFAP, DNV GL, and CIHQ—paying close attention to the philosophies of different accrediting bodies, as well as the implications, costs, and benefits associated with them.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.