page contents

Joint Commission & CMS Survey Preparation

Onsite Hospital Survey Preparation Services

Successfully preparing our nation’s healthcare organizations for Joint Commission and CMS surveys for the past three (3) decades has blessed us with many learned lessons. Of course, the initial needs of our client facility leadership team are often expressed simply as “Help Us Pass This Survey”. A mission we have never failed to accomplish.

One such lesson, is that we are often humbled by client leadership feedback that speaks to their new-found strategies and confidence to better reduce Hospital Acquired Conditions (HAC) such as infections and injuries. I ask your trust. There are just too many organizational improvements that you can derive by engaging our hospital survey readiness program to list here. As you read on, you will learn that our mock survey assessment, training and implementation services are not targeted solely to meet Joint Commission and CMS compliance requirements.

Do You Just Want to Get an ‘A’? Or Become One?

As Joint Commission consultants, our approach exceeds the target of just getting an ‘A’ on the survey. We are driven to also help you examine and strengthen procedures and practices to add genuine patient outcome value and reduce risk. One of many examples might be that, for you, this value will translate into better training and competency measurement processes to drive increased inter-departmental integration. Did you know that 80% of healthcare errors and injuries are caused by miscommunication between healthcare staff? [Source: TJC Center for Transforming Healthcare]

Your organization can become an ‘A’. We can help. In addition to better patient care outcomes, increased integration of clinical team performance and risk avoidance – let’s not overlook the reality that ‘A’ organizations don’t lose money.

Reduce Hospital Acquired Condition$

Hospital Quality and CostAll Hospital Acquired Conditions (HAC) can cause your organization to forfeit reimbursement. That’s money that could have been used for new technology, equipment, additional staff…I think you get it. This may be a good time to refresh yourself on the key realities associated with HAC penalties that went into effect back in 2009.

The Facts

• A Hospital Acquired Condition (HAC) is defined as one that could reasonably have been prevented through the application of evidence-based guidelines.

• Medicare will financially penalize 751 hospitals in fiscal 2018 for their lagging performance on measures designed to prevent hospital-acquired conditions. That’s almost 25% of our nation’s hospitals.

• The Association of American Medical Colleges estimates hospitals will lose approximately $430 million in total as a result of the Medicare payment cuts — more than the previous year.

• HAC’s have a very broad echoing effect beyond reimbursement, impacting your patients, their families, communities and your staff on a personal level.

The Consequences of a Patient Fall with Injury (HAC)

The growing trend of hospital patient falls is staggering.

  • The Agency for Healthcare Research and Quality (AHRQ) states that between 700,000 and 1,000,000 people fall in the hospital each year (AHRQ).
  • Falls is the Number 1 Hospital Acquired Condition.
  • 31% – 51% of all falls in a hospital result in an injury.
  • Fall-related injuries account for 15% rehospitalizations.

Learn more about how the unfortunate consequences of a patient fall extend far beyond the preventable injury itself. Patient Fall Consequences

Remote Survey Document Improvement Services

And as you know, some key hospital policies and programs are best evaluated annually. But ALL must be reviewed and approved at least on a triannual schedule. And let’s not forget having your Quality and PI Program Annual Appraisals completed and ready to present. Not just for the sake of a surveyor. But to assure that they are updated with the most recent evidence-based best practices. Once updated, these mission critical documents need to be applied to updating your staff orientation / training / education programs, as well as you program performance goals (patient safety, environment of care, nursing, human resources, information management, performance improvement, infection prevention, etc.) Updated policies lead to updated staff performance – the surest way to assure a great survey outcome.

You can learn more about our time and money saving healthcare document improvement services. Hospital Document Pre-Screening Services

You can also learn more about the best strategy to document an Annual Appraisal of your Medication Management Program. Medication Management Appraisal

Hospital Survey Expertise

As you should expect, we have the commanding experience required to guide your organization to comply with all Joint Commission accreditation and CMS Conditions of Participation performance expectations. And achieve high reliability.  Reduce risk. Improve regulatory compliance. Improve clinical outcomes. Improve reimbursement.

This infographic will offer you an abbreviated summary of our areas of survey preparation expertise.

Hospital Survey Specialties

 

We are standing ready for your call or email.

 

The Survey Preparation Process

We are experienced project management specialists. So naturally, we have process-mapped the flow of all client interactions from your first phone call inquiry all the way through until you receive your final written Action Plan Report.

This infographic will offer you some insight into our hospital survey preparation methodology. While always polite and professional, we have never been regarded as rigid. We pride ourselves on agility and flexibility to meet the unique challenges and circumstances of each of our client organizations. Weekend consultation is also available to help our clients meet tight deadlines.

CMS Survey Preparation

 

Hospital Survey Preparation Video Series

Referencing Patient Safety as an example, you are invited to sit back and take a few moments to learn about the most common performance improvement documentation barriers that might be challenging your healthcare organization. We can help.

You can also learn about the many challenges that new facilities and departments often face as they set out to design and implement a regulatory foundation to achieve their mission to deliver safe and effective healthcare.

 

ODAM…How to Overcome the Your Patient Safety Improvement Documentation Barriers

An overview of Mr. Walsh’s survey preparation observations on the reasons why your Patient Safety program may be failing to live up to its maximum value potential. And how to improve.

 

Leadership Training and Regulatory Compliance Implementation for NEW and Existing Facilities

An overview of the survey preparation services we offer you to overcome the unique management and regulatory challenges that face all new start-up healthcare organizations.

 

HTSI and HospitalSurveyExperts.com is not affiliated in any way with The Joint Commission which owns the Joint Commission, TJC and JCAHO trademarks. HTSI and HospitalSurveyExperts.com is also not affiliated in any way with CMS, which owns The Centers for Medicare & Medicaid Services and CMS trademarks.
Call Now Button