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:
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?
3. Inadequate integration of Quality Assurance and Performance Improvement principles and practices with organizational operations.
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.
6. Minimal medical staff involvement in clinical operations system design and implementation.
7. Lack of feedback and action based on data.
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.
9. Failure by leadership to understand and operate according to the Conditions of Participation.
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
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.