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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Whitepaper: Accreditation Options for Hospitals & Health Systems

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.

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Why Become a Regulatory and Accreditation Interim Executive?

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.

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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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