The three-year mark is fast approaching since your last triennial survey. While keeping compliant with accreditation standards is a foundational goal for your organization, and ever-present in the back of your staff’s minds, the reality is that it’s near impossible to come away unmarked. The pressure of patient care often takes precedence over check-box activities. It’s a challenging balancing act, but one that offers real value with the right survey program in place—for you and for your organization’s patients.
Sustainable Solution Support
We know that the best way—perhaps the only way—to implement sustainable solutions to regulatory challenges is to focus on the big issues. We help healthcare organizations focus on underlying root causes so they can eliminate the most important survey vulnerabilities once and for all.
Chartis Clinical Quality Solutions' Partnership for Survey Success is a cyclical survey readiness program that minimizes risk and enhances patient safety. Compliance is never “done;” it requires continuous monitoring over your three-year accreditation cycle to ensure that you are managing the risks that matter most—those that will make you vulnerable to a survey citation or worse, and those that could impact patient safety. This is particularly important as accrediting organizations are intensifying their focus on high-risk processes and resolution of past deficiencies.
We Bring Process Expertise
At Chartis Clinical Quality Solutions, we recommend focusing only on true, underlying process issues. The approach to fixing these issues is to make the process easier to understand and implement. The easy thing to do should be the right thing to do.
Partnership for Survey Success Methodology
At the completion of each phase, we will provide a written report of findings with recommendations for improvements and corrective actions.
PHASE 1: Initial Assessment (immediately following survey)
- Conduct pre-survey document review to identify and sort prior survey high-risk/high-impact findings
- Collaborate on developing implementable corrective action plans for submission to accrediting organization
- Evaluate level of success in achieving sustainable improvements related to prior corrective actions
- Conduct exit conference with executive leadership and designees to present findings and recommendations for improvement
PHASE 2: Touch-Point (mid-point in triennial survey cycle)
- Evaluate level of completion of hospital’s corrective action plan
- Provide synopsis of areas of noncompliance or lack of progress along with recommendations for achieving intended goals
PHASE 3: Survey Rehearsal (in anticipation of survey)
- Review high-risk vulnerabilities commonly existing in the environment of care (EOC); identify areas requiring immediate action
- Consult with staff on how to demonstrate that prior deficiencies are corrected
- Conduct readiness survey rehearsal with staff to prepare for survey
- Evaluate current state of survey readiness, provide recommendations for enhancing staff survey response
Clinical compliance and survey preparation must evolve—just-in-time mock surveys may not provide the value healthcare organizations need. We partner with our clients over the course of their accreditation cycle to sort through survey findings, focus on resolving the high-risk underlying root causes, and simplify processes to enhance long-term success. We leverage our decades of experience, proven methodology, access to regulatory insights, and library of model documents to partner with our clients.
- There are approximately 30 requirements for improvement on the typical Joint Commission survey report.
- The Joint Commission classifies findings in two tiers of importance—findings assigned to the higher level of importance, about 25% of all findings on an average report, are key contributors to Condition-level findings.
- Findings related to the Environment of Care and Life Safety Code account for most citations on a typical report.
- Findings of higher significance are dominated by infection prevention and the identification and protection of potentially suicidal patients.
Meg Hartwell is Senior Vice President of Client Services with Chartis Clinical Quality Solutions. She brings more than 30 years of consulting and healthcare experience to the firm.
Lisa Eddy, MSN, MHA, RN, CPHQ
Lisa Eddy is the Vice President of Clinical Compliance and High Reliability with Chartis Clinical Quality Solutions. With more than 25 years of consulting experience specializing in CMS certification and accrediting agency regulatory compliance, Lisa supports her clients with a wealth of knowledge and firsthand experience.
Phillip Boaz, RN, MSN, CIC
Phillip Boaz is a Senior Consultant with Chartis Clinical Quality Solutions. He brings his clients more than 30 years of consulting and healthcare experience in the areas of critical care and trauma nursing, infection prevention, risk management, and regulatory compliance.
J'Neil Bogren, MSN, MHA, RN
J’Neil Bogren is a Senior Consultant with Chartis Clinical Quality Solutions. She brings more than 25 years of consulting healthcare experience and 10 years of experience as a Masters-Prepared Registered Nurse to the firm.
Catherine Garrison is a Compliance Consultant with Chartis Clinical Quality Solutions. She brings more than six years of consulting and healthcare experience to the firm.
Kim Wilson, MS, BSN, RN
Kim Wilson is a Senior Consultant for Chartis Clinical Quality Solutions with more than 20 years of experience in clinical nursing, leadership, regulatory compliance, and informatics. Kim’s proven approach to simplification and process redesign benefits her clients in a variety of areas.
Jeanne Wypyski, LCSW
Jeanne Wypyski is a Senior Consultant with Chartis Clinical Quality Solutions. She brings more than 32 years of healthcare experience specializing in behavioral health.
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