Understanding DNV GL – Healthcare’s NIAHO Program | Accreditation Options

DNV GL’s NIAHO® standards are directly related to the CMS Conditions of Participation and apply to hospitals of all sizes. To focus efforts on the fundamental aspects of the Conditions of Participations, the standards are less prescriptive than the Joint Commission’s and the survey process supports CMS’ quality initiatives with focus on continual improvement prioritized by the organizatio

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First Update of Surgical Site Infection (SSI) Guidelines by CDC in 18 years

In May 2017, the Centers for Disease Control ( CDC) released its new guideline “Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017,” for surgical site infection (SSI) prevention, the first such update since the turn of the century. Estimated costs of SSIs range from $10,443 to $25,546 per infection, although it can cost more than $90,000 to treat an SSI involving a prosthetic joint implant or an antimicrobial-resistant organism.

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FAQ: What is a CMS Systems Improvement Agreement?

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.

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Anesthesia Department Performance Improvement

An urban medical center in the Midwest was experiencing turmoil in its Anesthesia department. The organization was employing too many anesthesiologists, and as a result, individual productivity among this group of physicians was low. In addition, strained relationships between anesthesiologists and certified registered nurse anesthetists (CRNAs) were making it difficult for the medical center to recruit needed additional CRNAs…

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Regaining Conditions of Participation Compliance (CoPs) after Immediate Jeopardy & CMS Termination

Operational and leadership issues at one 274-bed inpatient psychiatric hospital in the Southeast had been emerging slowly over several years. Eventually> critical patient incidents culminated in regulatory scrutiny, and the hospital experienced a full survey by the Centers for Medicare and Medicaid Services (CMS). Findings of dysfunctional organizational culture, leadership, and management system inadequacies and suboptimal patient care outcomes resulted in Immediate Jeopardy and the hospital’s subsequent termination from Medicare. The state Department of Health and Human Services (DHHS) retained Compass Clinical Consulting to help the hospital regain certification.

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Contact Compass Clinical Consulting

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.