Accreditation & Compliance Journal
Subscribe to receive the latest hospital accreditation & compliance news and updates from our team.
You have Successfully Subscribed!
The Joint Commission has released sentinel event data from the second quarter of 2017. 10 Most Reported Sentinel Events for Q2 2017 So far in 2017, 400 sentinel events have been reported. The following are the 10 most reported sentinel events from the second quarter...read more
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 organizatioread more
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.read more
High and Low-risk Devices are all the Same to TJC Surveyors? New Maintenance Standards Could Prove Costly for Hospitals
Kevin Kiely, CHSP, CHFM, CPSO, HEM, senior consultant for Compass Clinical Consulting, is the featured in the August 1, 2017, edition of the Briefings on Accreditation and Quality Journal article, "High- and low-risk devices are all the same to surveyors; New...read more
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
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.