Accreditation & Compliance Journal
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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
We work with a wide range of institutions—both in size and in resources. A significant portion of our effort focuses on hospitals experiencing close CMS examination.
A review of these clients suggests that there are common traits that may predispose a healthcare organization to CMS compliance challenges:read more
During recent focused CMS assessments of Ambulatory Surgery Centers (ASCs), several facilities have been cited with noncompliance in the areas contracted services, emergency equipment, and a sanitary environment. Noncompliance with these CMS Q-tags could potentially be cited at the Condition level.read more
Based on the findings of a recent study published in JAMA Internal Medicine, mortality rates are lower for patients who are admitted during weeks when TJC surveyors show up unannounced than during other times of the year. What does this mean for hospitals?read more
Earlier this year, the Joint Commission's Leadership (LD) Standard LD.01.03.01 EP 12 for deemed-status home health agencies and hospices was expanded to apply to deemed-status hospitals, critical access hospitals, and ambulatory surgical centers. Read more: Leadership...read more
Your quality team has studied the new standard changes, updated policies, and conducted tracers to monitor compliance. What else can you do as an executive to help …read more
TJC Issues Sentinel Event Alert 57: The essential role of leadership in developing a culture of safety
TJC Sentinel Event Alert 57 calls upon healthcare leaders to prioritize patient safety and demonstrate a commitment to the organization’s safety culture through everyday actions.read more
Patient Safety Awareness Week, which is intended to increase awareness about patient safety among health professionals and the public, starts next week, Sunday March 12th - Saturday, March 18th. The National Patient Safety Foundation's goal is to bring together and...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.