All Entries in the "Survey Readiness" Category
Verbal Orders in Outpatient Settings
As more care is provided in outpatient settings, where on-site physician presence may be sporadic, the need to obtain verbal or telephone orders is on the rise.
Multi-Dose Vials: Multiple Compliance Targets
The Joint Commission (TJC) recently released answers to many common questions about the correct storage, use, and disposal of multi-dose vials in clinical settings. While this information will settle several uncertainties, achieving compliance may still be a challenge.
New CMS Anesthesia Regulations: Pre- and Post-anesthesia Evaluation
This article discusses pre- and post-anesthesia evaluations and is the fourth installment in a series outlining compliance challenges associated with the new CMS Anesthesia Services CoPs.
New CMS Anesthesia Regulations: Responsibilities of the Anesthesia Services Department
This article discusses responsibilities of the Anesthesia Services Department as part of a four-part series outlining compliance challenges associated with CMS’s new Anesthesia CoPs.
New CMS Anesthesia Regulations: Anesthesia Administration and Privileging Practitioners
This second post in a four-part series discusses who can administer anesthesia and how they should be privileged in order to comply with new CMS Anesthesia Services CoPs.
New CMS Anesthesia Regulations: Defining Anesthesia Services
CMS has issued changes to its Anesthesia Services CoPs. This first post in a four-part series clearly defines both anesthesia and sedation to help hospitals assess vulnerabilities in these areas.
Security for Syringes and Sharps: The Regulatory Expectations
While regulatory standards govern the appropriate use of syringes and sharps, no specific regulations require that syringes be totally absent in any location. The lack of regulations about the location of sharps does not, however, remove the hospital’s responsibility for safeguarding sharps and syringes.
TJC and CMS Survey Expertise Coming to A City Near You
Compass Clinical Consulting’s Practice Leader for Accreditation and Regulatory Compliance, Ruth Elzer, RN, MS, will be speaking at seminars across the country this summer. Check out the following events for the most recent information regarding compliance with the standards of The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS).
Journal of Healthcare Management Features “Guide to CMS Compliance” by Compass Clinical Consulting Accreditation Expert Ruth Elzer
The Journal of Healthcare Management recently featured a column by Compass Clinical Consulting Practice Leader for Accreditation and Regulatory Compliance, Ruth Elzer, RN, MS. The column, which is included in the March/April edition of the journal, offers insight and practical advice and expert analysis on how to comply with regulations from the Centers for Medicare and Medicaid Services (CMS) in 2010.
Joint Commission Medical Staff Changes: A Few Surprises
Since The Joint Commission’s MS.1.20 Implementation Task Force was convened in December 2007, the group has been working to define which aspects of the management of the Medical Staff need to be written specifically into the bylaws, and which items can be adopted through rules, regulations and related documents. The recently announced changes to the MS.01.01.01 standard include a few modifications that will come as a surprise to some hospitals and require action before the March 31, 2011, effective date.
Choosing the Right Tool for Hospital Risk Assessment: Failure Mode and Effects Analysis
Parts I and II of this series outlined two tools for risk assessment and how each can assist in evaluating the impact of potential risks within a hospital. This installment will focus on Failure Mode and Effects Analysis (FMEA). This tool can be used to examine an event and its component parts to discover weaknesses and decrease the likelihood that they will occur.
Choosing the Right Tool for Hospital Risk Assessment: Focused Risk Vulnerability Analysis
by Amanda Brown, RN, MSM, CIC Part I of this series outlined the power of simple risk assessment to identify, mitigate, and eliminate hazards in the day-to-day operations of a hospital. Parts II and III will present approaches to risk assessment that are more complex and require more attention from multidisciplinary teams. In this installment, [...]
Choosing the Right Tool for Hospital Risk Assessment: Simple Risk Assessment
How can hospitals ensure that patients, employees, and visitors are safe in an environment rife with its own unique risks? The solution begins with risk assessment. This installment of our three-part series on risk assessment will describe the approach and tools that accompany simple risk assessment.
In 2010, Hospitals Must Take Patient Complaints Seriously
Both The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) require hospitals to arm patients and families with specific instructions about how to register complaints. These expectations have likely increased the volume of complaints processed over the last year. But, even more importantly, subtle changes in the content of complaints may pose a challenge for hospitals in 2010, particularly if the impact of these complaints is underestimated.
Joint Commission Surveys: Unannounced – and in 2010 – Unplanned
So you heard that the survey process was unchanged for 2010. Not so fast. As it turns out, The Joint Commission’s (TJC) 2010 Survey Guide subtlety outlines a survey process that holds some surprises for the new year. The latest surprise includes a new challenge for hospitals, the requirement to develop an agenda with surveyors minutes before the survey begins.