在我们的m88.com网址临床咨询工作,我们有权作为寻求知情指导的医院和卫生系统为值得信赖的顾问认证和临床合规性m88.com网址问题。我们使用各种机构 - 无论大小和资源。我们的一部分努力侧重于经历近距离的医院CMS examination

Nine Common Traits of Organizations Experiencing CMS Scrutiny

A recent review of these clients suggests that there are nine common traits that may predispose a healthcare organization to CMS compliance challenges:

1.不成比例的重点关注数量的结果

他们的目标是“良好的数字”,董事会成员和高级领导专注于金融和管理控制系统,不太关注临床服务成果的核心业务。m88.com网址财务业绩往往优先于一阶业务,而临床质量可能不会被视为高优先级,因此,收到不太强调。m88.com网址这很少是一个预期的领导力结果,并且只是财政压力的结果,大多数医疗保健领袖经历。必须稳定地专注于提供安全保健的核心使命,同时持续专注于优先考虑金融活力。

有关:How to Involve the Board in Patient Safety

2. Lack of frontline manager knowledge of applicable Conditions of Participation.

前线管理人员必须了解如何翻译看似模糊的参与条件(警察into everyday operations. For example, the core infection control requirements may be seemingly well communicated, but does the manager of patient registration understand and implement these requirements? Does the manager of patient registration ensure that registration staff complies with requirements for handwashing and observing potential patient infection issues? Do the staff know who to notify for assistance should an issue arise?

有关:Creating a Culture of Continuous Readiness

3. Inadequate integration of Quality Assurance and Performance Improvement principles and practices with organizational operations.

质量保证和性能改进(QAPI)设定测量,改进和确保患者护理安全的目标和过程。当QAPI与医务人员领导,护理和其他临床领导人协调,或者在正在审查运营管理时被忽视时,可能会发生断开连接,允许关键数据和反馈循环无法识别和未答复。m88.com网址

有关:Timely Changes to CMS’ Conditions of Participation

4.未能使用哨兵事件和近距离脱靶as learning opportunities.

Sentinel Events (SEs) and near misses happen in all hospitals with some frequency, shaking organizations to their core as an affront to their common commitment to rendering safe and effective care. Institutions that learn from these occurrences experience fewer of the same in the future. There is tremendous information to be obtained—such as through a Root Cause Analysis—that can better shape and influence clinical care across the organization. Using SEs and near misses as a way to grow organizational capacity and resilience is a hallmark of an effective hospital.

有关:专注于TJC和CMS模拟调查结果:护理环境和生命安全

5.投资高等教育,员工发展,发现更好的实践

之前遇到并解决了大多数问题和机会,并且可以为组织改进的仿真进行建模。但不投资于持续学习,调查和查询的绝大组织经常无法实施最佳实践和预防计划。领导者应不断扫描外部环境以获得更好的实践,并考虑如何将这些实践纳入其组织。

有关:Compass offers customized on-site Accreditation & Compliance education classes

6. Minimal medical staff involvement in clinical operations system design and implementation.

作为护理的守门人,医生影响患者的安全和质量,并作为其他工作人员的榜样,以证明患者护理安全和疗效的承诺。当临床业务领导地位最小的可见性时,可能对警察最小值遵守,以惊人的合规风险离开组织。明升体育网址m88.com网址

有关:Compass Clinical Operations Management Systems

7. Lack of feedback and action based on data.

风险组织可能会从结果衡量到患者参与的吞吐量的所有内容。但是,它未知是收集一旦收集的数据。它用于改变流程,驱动决策和改变行为吗?或者是令人生意的整理,报道和遗忘?通过关键临床信息驾驶是成功组织的重m88.com网址要属性。收集了这一重要数据后,应开发行动计划。

有关:性能改进系统

8. A crisis-to-crisis existence.

An organization that consistently has all hands on deck to address the latest problem but fails to ever achieve smooth sailing commonly denotes a failure of established safe processes. Attention is focused on the issue of the day, rather than the systems, controls, and culture that reliably produce safe care. Crises occur in any dynamic environment, but an inordinate crises focus means the company never achieves “normal,” outlier incidents become prevalent and safe, reliable care cannot be consistently delivered.

有关:医院近死经验:Medicare终止如何推动您的医院到关闭的边缘

9. Failure by leadership to understand and operate according to the Conditions of Participation.

医疗保险和医疗补助服务的中心代表大多数医院最大的付款人。然而,很少有高级领导人熟悉自己的CMS参与条件,这简单地代表了医院与CMS进入CMS的合同。本组织同意秉承某些最小(警察)以换取合同所涵盖的患者护理的付款。在申诉或验证调查收益率的征集结果时,在申诉或验证调查结果中表明未能遵守警察经常表现出对预期的理解,仍然存在。不太可能对其他付款人来源的合同要求是类似的。

有关立即危险和CMS终止后恢复参与度量的条件

Summary

These are the characteristics we frequently note when assisting an organization inCMS jeopardy。它从来没有意图或设计的无能,导致医院或卫生系统的审查。相反,通常没有掌握合规性和康复策略的重要性,以维持日常行动中的合规性。明升体育网址

好医院有时会经历差的结果,但通过检查这九九常见的特征,医疗保健领导人将能够识别自己的组织内的漏洞领域。

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Kate Fenner, Managing Director of Compass Clinical Consulting, has more than 35 years of experience in senior healthcare leadership roles in university, regional, state and, national organizations. Throughout her career, she has worked with and presented to hospitals on a variety of regulatory topics including performance improvement, leadership standards, human resources management, root cause analysis, and board involvement in quality. In addition, she has led and participated in dozens of mock surveys to help healthcare organizations meet the standards and expectations of regulatory bodies such as the Joint Commission, the Centers for Medicare and Medicaid Services, and state departments of health. She is a regular keynote speaker throughout the country and has authored a leading college text on law and ethics in healthcare.

This article first appeared on Becker’s Hospital Review.

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