Going Beyond CMS & TJC Minimum Safety Standards: The Patient Safety Assessment

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High risk Medical Device

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 maintenance standards could prove costly for hospitals.”  EXCERPT:  Many were shocked by The…(Read More)

Healthcare Facilities Accreditation Program Compass Clinical Consulting

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 has encountered common problems in each Emergency Department (ED) through expert interim and consultant engagements in a variety of healthcare organizations. Our Emergency Department expert and clinical consultant, Alisa Slimick, MBA, BSN, RN, provides insight into this area from her own experience working in a range of healthcare settings. What “Red Flags…(Read More)

The Joint Commission (TJC) is, by far, one of the biggest names in hospital accreditation. Formerly known for years as the Joint Commission on the Accreditation Healthcare Organizations, TJC’s mission still rings true today: “To continuously improve healthcare for the public in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to…(Read More)

Compass Clinical Consulting’s Director Kate Fenner, PhD, RN, is featured in a series about Hospital Accreditation Options for Hospitals and Health Systems in Becker’s Hospital Review Magazine. Excerpt: The clear majority of hospitals seek voluntary accreditation, most through The Joint Commission (TJC) and now, several hundred through the Healthcare Facilities Accreditation Program (HFAP…(Read More)

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…(Read More)

What is a CMS Systems Improvement Agreement: FAQ'S

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…(Read More)

Isaac Abraham, MSN, RN, has worked with us at Compass Clinical Consulting for many years. He’s one of the most truly authentic, compassionate, skilled, gifted and exceptional leaders (and teachers) in healthcare consulting. Isaac specializes in the treatment of Mental Health Patients in the Emergency Department (ED). A tireless advocate for psychiatric patients, Isaac…(Read More)

Patient Safety Assessment

What is a Patient Safety Assessment? It analyzes your current patient safety practices and processes to determine how effectively they prevent human errors and detect and correct system vulnerabilities and weaknesses that can lead to events of harm and adverse outcomes…(Read More)