1. Survey Readiness

Our survey team specializes in hands-on guidance and instruction, preparing your team members and facility for rigorous Accreditation processes by the Joint Commission, DNV, Joint Commission International, and CMS Regulatory Compliance. Drawing from extensive surveyor experience with The Joint Commission, DNV, our TJC / CMS Preparation package can help your organization.

Survey Readiness is paramount in the constantly evolving landscape of healthcare organizations. Even well-prepared entities can face unexpected interpretations and requirements. To address this, our approach focuses on survey readiness built upon six key steps, integrating compliance seamlessly into your daily operations:

• Mock Surveys - The continual compliance review and mock survey offer continuous evaluation, ongoing readiness, updated industry insights, and a strategic approach for achieving a successful survey outcome. Crafted to maintain your preparedness, our mock survey procedure proactively addresses potential issues, ensuring a smoother process
• Sustained Accreditation Assistance (SAA) - This program offers continual evaluation, preparation, updated industry insights, and a lasting strategy to achieve successful survey outcomes.
• AHJ Survey Follow-Up - Following a Joint Commission, DNV or CMS survey, organizations frequently require assistance in interpreting findings and devising corrective actions. We offer support in crafting highly effective and efficient action plans that yield lasting solutions.
• Response and Remediation After Adverse Decisions - In the face of a 10-day correction plan issued by an accreditor or CMS, prompt response with immediate solutions is crucial. Leveraging our extensive experience working closely with both the Joint Commission and healthcare providers, Compass Consulting Group guarantees swift and effective resolution to adverse decisions. Moreover, beyond addressing challenges arising from adverse decisions, we adeptly navigate organizations through the CMS Systems Improvement Agreement (SIA) process.
• Compliance Education & Training - Standards and regulations consistently undergo updates and shifts in focus areas, creating a continuous evolution in compliance requirements. Keeping abreast of these changes can be challenging. However, we offer proactive preparation through educational updates, such as:
  • Our Newsletter: Our frequently published newsletter comprehensively covers new standards and regulations.
  • Tailored educational sessions: We craft sessions for staff groups, addressing critical issues, including commonly scored and challenging standards. During our preparatory survey, our final report transcends mere references to standards and observations of noncompliance. On the last day of the mock survey, we engage with your staff, providing educational insights into identified issues and strategies to prevent or redesign problems.

Our educational resources are available both onsite and through webinars, allowing your staff to participate collectively or individually as needed.

• Environment of Care (EOC) & Life Safety (LS) TJC Assessment  / Physical Environment DNV Assessment - Joint Commission's EC and LS chapters, DNV's PE chapters or CMS's K tags frequently present the most challenging aspects of survey outcomes. Due to the complexity and scattered nature of the requirements across various manuals and reference materials, we collaborate with Life Safety Code consultants to ensure comprehensive clinical and environment of care preparation. These experts possess the intricate details necessary for achieving full compliance, bridging the gap between regulations and implementation.

2. TJC/DNV Survey Preparation

We offer comprehensive Joint Commission survey preparation, encompassing onsite mock surveys and customized education and training programs. Specifically tailored to match the distinctive services and scale of your organization, these onsite preparation services are structured to replicate the expected Joint Commission / DNV agenda and survey format. Throughout the preparation phase, we offer the following services::

• Evaluates your adherence to Joint Commission/ DNV standards and elements of performance through the "tracer" methodology
• Produces a comprehensive written report utilizing a color-coded safety risk matrix, aiding in the identification and prioritization of non-compliant findings
• Offers guidance and illustrative examples for implementing essential changes to align with current compliance standards
• Educates your staff and delivers immediate feedback on effectively demonstrating compliance to the Joint Commission DNV survey team

Daily Agenda, Closing Conference, Action Plan/Report

Before our onsite presence, Compass Consulting Group collaborates with your team to outline a daily agenda for mock survey activities, structured upon the Joint Commission or DNV template. As a culmination, on the concluding day, our consultants convene a closing conference with your organization's leadership to summarize their findings. This includes:

• Assessing notable gaps, risk areas, and associated risk levels in your organization's survey readiness
• Outlining critical priorities and establishing necessary milestones for addressing observed deficiencies
• Delivering a comprehensive recommendation report and furnishing action plans for Joint Commission or DNV survey preparation within one week after the onsite visit

We deliver the final report in an Excel format, designed as a work plan featuring a color-coded safety risk matrix. This tool assists in attaining and sustaining compliance. Notably, many of our clients utilize this report to allocate corrective actions to staff and to monitor completion, ensuring ongoing compliance tracking.

Onsite Training and Education

Our consultants offer spontaneous education during tracer activities, integral to our Joint Commission or DNV mock surveys. This educational component emphasizes practical implementation suggestions and actionable insights derived from our on-site visits.

Furthermore, we offer structured classroom training sessions for client staff. Organizations often benefit from an educational program held on the engagement's last day, where their staff gain insights into frequently scored standards, new standards, and effective implementation strategies. This setup allows your team to engage directly with our consultants, addressing their specific concerns and benefiting from their wide-ranging experience across different organizations.

3. Patient Safety System Support

One of the most recent and comprehensive studies on diagnostic errors found that medical misdiagnoses— overlooking a disease or diagnosing it erroneously or late—lead to an estimated 371,000 deaths and 424,000 permanent disabilities every year in U.S. Does your patient safety program adequately tackle this concern? That's precisely the aim of the Compass Consulting Group Patient System Support initiative. It offers an onsite or virtual focused assessment targeting key components crucial for attaining top-tier patient safety outcomes. Our consultations, spearheaded by seasoned patient safety officers with decades of experience, specialize in preventing, managing, and implementing solutions for major adverse patient events.

Are you experiencing recurrent adverse events (either identical or similar) even after conducting a root cause analysis?

Are your improvement initiatives not sustaining or becoming ingrained as intended?

You might not have experienced any adverse events previously. However, if you have encountered such incidents, are you worried about your team's ability to respond effectively? If an adverse event occurred, do you believe that the involved staff members aren't adequately supported afterward? If you've answered "Yes" to any of these, it's worth considering a thorough evaluation of your patient safety program. A Patient Safety System Analysis typically includes:

Examination of:

• • Vital organizational documents and data
  • Root cause analyses and reviews of near-miss incidents
  • Incident reporting system assessment
  • Review of safety culture surveys and associated action plans
  • Evaluation of improvement methodologies and processes
  • Interviews with staff, management, medical professionals, senior leaders, and board members
  • Environmental surveillance overview

Following this comprehensive assessment, a confidential written report will be furnished, outlining strengths and areas requiring improvement.

Additional services provided encompass:

• • Aid in action plan formulation and execution
  • Situation management response team support
  • Performance tracking and monitoring
  • Team STEPPS Train-the-Trainer program
  • Training sessions for governing bodies, leadership, medical staff, and personnel

4. Joint Commission International

For global healthcare entities, Joint Commission International accreditation stands as a powerful method to showcase top-notch patient care, particularly to American medical travelers. However, the accreditation process is intricate and far from straightforward. Should your aim be JCI accreditation, Compass Consulting Group is well-equipped to assist you in accomplishing a successful outcome. We support your comprehension of crucial and quantifiable aspects within the standards, aiding in overcoming language barrier challenges along the way.

Preparing your staff for the Joint Commission International (JCI) accreditation process marks the initial phase of this journey. We initiate the path to accreditation through a sequence of webinars dedicated to the JCI standards.

Our program involves several days  three-hour training sessions conducted before any onsite engagements. This approach offers substantial benefits to hospital managers and team members involved in the accreditation process:

• Provides a comprehensive understanding of crucial requirements
• Enables clarification of ambiguous standards for your team

Upon completion of this webinar series, we furnish preparatory surveys, empowering your staff to facilitate a streamlined and successful JCI survey.

Onsite Readiness Assessment for Joint Commission International (JCI)

After the training concludes, our team of consultant surveyors conducts an onsite assessment to evaluate readiness. We generate a written report detailing noncompliance findings and offer guidance as necessary. Furthermore, we offer the option for a follow-up survey to gauge compliance with previously identified issues and corrective actions. Additionally, we assess compliance by conducting patient tracers and engaging in interview sessions with staff.

5. Remote Survey Preparation

Compass Consulting Group utilizes technology to enhance healthcare operations seamlessly. Our remote and virtual technology service offers convenient access to our team for accreditation and compliance needs. Our virtual services (phone, email, and video) deliver extensive knowledge and expertise akin to an in-person engagement. Our professional experts are available to conduct virtual assessments across platforms at any stage of your accreditation cycle, ensuring timely and comprehensive support.

Remote & Virtual Survey Technology Solutions

• Mock Surveys
• Sustained Accreditation Assistance (SAA)
• AHJ Survey Follow-Up
• Response and Remediation After Adverse Decisions
• Compliance Education & Training
• Environment of Care (EOC) & Life Safety (LS) TJC Assessment / Physical Environment DNV Assessment