Many years ago, I was hired to perform a safety audit for a laboratory. As I walked through one department, an employee asked what I was doing. When I remarked that I was looking for safety issues to keep her safe, she asked, “What are you keeping me safe from?” It was the right question. This...
Short of terminating a physician’s employment, appraising a physician’s performance is often the responsibility that administrative and medical staff leaders hate most. For many physicians, the phrase “performance appraisals” stirs up an unsavory image of managers sitting behind large desks...
One way or another, CMS is promising states that it will enforce its recent interim final rule requiring hospital and other healthcare staff caring for COVID-19 patients to be fully vaccinated. CMS published a warning to states February 9 that if they are contracted with the federal agency to...
One of the hardest parts of being a compliance officer can be keeping track of policies, procedures, logs, maintenance, equipment checks, and other documents that can mean the difference between a successful survey and a difficult plan of correction.
Understand who is supposed to be vaccinated and when, and establish a way to securely track and update your list of vaccinated staff as you anticipate surveyors from the...
The Joint Commission (TJC) surveyors have been true to their promise to begin surveying to the new COVID-19 vaccine requirement as soon as it became effective, and hospitals are already being scored for...
Is it time to move toward a centralized verification organization (CVO)? Many organizations are doing so to streamline the credentialing process, reduce administrative redundancies, and lower costs, according to Jodie Chant,MPA/HCA,...
CMS has officially put out guidance to its own state survey agencies that all its on-site surveyors should be fully vaccinated, and it expects the same of accrediting organizations (AO). However, according to Quality, Safety & Oversight Group memo QSO-22-10-ALL, AOs are expected to enforce...
Expect hospital accrediting organizations to continue to update their standards, especially to align more with the language in CMS Conditions of Participation.
Depending on what state your hospital or healthcare system is in and when you face your regularly scheduled survey, you might have weeks or only days to come into compliance with CMS’ interim final rule...
