System-wide End of Year Mock Survey Summary Report

A comprehensive report from all mock surveys for all system hospitals, detailing the most frequently cited accreditation standards or clinical regulations over the past year.

A benefit of working with Compass Clinical Consulting for system accreditation services is the option of receiving an annual system-wide summary report.

Using data from all mock surveys conducted at hospitals and facilities of your organization from the 1st to 4th quarter of the previous year, this report synthesizes every hospital or facility in the system and organizes and tallies the most frequently cited accreditation standards or clinical regulations over the past year.

Similar to Compass’ CMS and TJC mock survey format, the comprehensive report displays all Condition-level findings identified during the mock surveys with the potential of the hospitals being terminated from the Medicare program if not corrected. This aggregation of data from all hospitals reveals the frequency of the findings. When findings and individual hospital deficiencies from similar size organizations are aggregated and compared, trends and patterns, as well as underlying system vulnerabilities, can be noted.

Our Summary Report: An Overview

A comprehensive report for all surveyed entities, available only from a system level view.

  1. Summarizes frequently cited standards and CMS Conditions of Participation.
  2. Identifies common challenges, trends, and patterns across entities for system-level action.
  3. Provides a road map for accreditation and regulatory compliance improvement.
  4. Includes a system-wide heat map of vulnerabilities that acts as an accessible overview for multiple audiences.
  5. Eliminates surprises at the system level of accreditation and regulatory compliance.

The end-of-year summary report includes charts depicting the top most challenging CMS Conditions of Participation (CoPs) or TJC Elements of Performance (EPs) cited in reports and their percentages for different kinds of facilities such as:

  • Hospitals
  • Critical Access Hospitals
  • Home Care

Aggregated data of high frequency standards from all reports are depicted in a list of corresponding findings.

There is Excel sheet with findings included in the summary report, mirroring the setup of a single report deliverable.

Additionally, this aggregated report includes a heat map with the levels of risk assigned based on likelihood of harm (low, moderate, high) and the scope of the issue within the organization (limited, pattern, widespread) representation of the high-risk standards/CoPs, to better prioritize efforts.

How a Summary Report will Stimulate Lasting Improvements in Your Organization

Given the potential significance of the findings of the aggregated compliance assessment, changes will need to be implemented quickly and be sustainability monitored. Otherwise, serious reputation and financial consequences can follow an adverse survey. A sense of urgency is necessary to garner support for any change initiative and in preparing for successful CMS and TJC surveys. Diligence by hospital leaders, hospital colleagues, and the medical staff will be required to ensure compliance is achieved and continuously maintained.

The number and extent of areas of focus may seem daunting and difficult—however, our support doesn’t end with the report. Compass is equipped to provide on-site expertise and monitoring to better assure compliance and reduce organizational risk.

After initiating this process of discovering common citations, Compass can help with continual accreditation and clinical compliance support and retainer services.

Additionally, continuously receiving these summary reports from Compass in subsequent years will allow leadership to visualize the improvements being made at their healthcare organizations and the advancement of the mission of safe, quality care.

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.

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