Accreditation & Compliance Journal
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In the July 2017 Perspectives, The Joint Commission (TJC) announced the implementation of new and revised pain assessment and management standards, effective January 1, 2018, for its accredited hospitals. According to the announcement, these revisions come following...read more
The Systems Improvement Agreement between the hospital/healthcare organization and CMS binds the organization to engage in a series of improvement activities to address multiple deficiencies in compliance with the CoPs with the assistance of a third-party monitor/consultant approved in advance by the CMS Regional Office. The agreement grants the organization additional time to make sustainable improvements in complex quality, cultural, policy, and procedural deficiencies.read more
Compass Clinical Consulting healthcare quality leader, Darlene Evans, MSN, RN, CPHQ, has been published in Becker’s Hospital Review with an article in an eight-part series on accreditation options about one of the biggest names in hospital accreditation, titled...read more
HFAP is the accreditation process that has grown out of the former hospital approval process of the American Osteopathic Association. Founded in 1945, this accreditation program has experienced growth well beyond its traditional base of osteopathic hospitals to encompass over 200 acute-care hospitals, plus 200 other accredited entities.read more
Compass Clinical Consulting Managing Director Kate Fenner, PhD, RN, has been published in Becker’s Hospital Review with the first article in an eight-part series on accreditation options, titled “Accreditation Options: A Hospital CEO’s Strategic Choice.” The clear...read more
CMS Publishes Survey Memo on the Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems
By Marge McFarlane, PhD, CJCP, CHSP, CHFM, HEM The Centers for Medicare & Medicaid Services (CMS) posted a Survey and Certification letter (S&C 17-30 memo) on June 6, 2017, indicating that Medicare-certified healthcare facilities are expected to have water management...read more
Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing
It's common to think, "Immediate Jeopardy can't happen here" ... until it does. No hospital leader wants to think that Medicare termination could happen at his or her hospital. Indeed, Medicare termination is rare, but it has significant and real consequences for the...read more
TJC has published an addendum to Sentinel Event Alert 47: Radiation risks of diagnostic imaging. Originally published in September 2011, SEA 47 focuses on mitigating the risks associated with the use of ionizing radiation in diagnostic imaging, including cancer, burns, and other injuries.read more
Hospital Near-Death Experience: How Medicare Termination Can Push Your Organization to the Brink of Closing
No hospital leader wants to think that Medicare termination could happen at his or her hospital. Indeed, Medicare termination is rare, but it has significant and real consequences for the hospitals that experience it. “Hospital Near-Death Experience: How Medicare...read more
The Joint Commission (TJC) recently released the top standards compliance data for 2016. TJC aggregates standards compliance data regularly to pinpoint the areas that present the greatest challenges to accredited organizations and certified programs.read more
In January of this year, the Joint Commission implemented the SAFER Matrix for all accreditation and certification programs. The TJC SAFER matrix is intended to better identify and communicate risk levels associated with deficiencies cited during surveys. The SAFER...read more
The Joint Commission recently completed the third phase of its EP Review Project (a component of Project REFRESH), resulting in the deletion of many Elements of Performance (EPs) from the accreditation programs for ambulatory care, behavioral health care, critical...read more
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