Virginia Reigle, Director of Provider Services & Regulatory Compliance, Clinical Colleagues, Inc.
Most hospitals across the U.S. put ever-changing compliance and quality improvement standards toward the top of their list of organizational priorities. This is important for not only providing a safe environment for the delivery of patient care, but also for assuring that operations are aligned with standards set forth by the Joint Commission on Accreditation of Healthcare Organizations (TJC) and the Centers for Medicare & Medicaid Services (CMS).
Keeping your organization compliant and abreast of continuously evolving standards, regulations and requirements can be a cumbersome task, requiring a full-time commitment from one or more members of your team, depending on the size of your organization and scope of clinical services offered. Ongoing monitoring and the identification of opportunities for improvement will help you prepare for an upcoming site visit by surveyors from TJC, CMS or both. No department, unit or staff member is “exempt” from this process, so it is important that everyone working for your organization is up-to-date on quality standards and protocols, at all times.
There are a few things you can do proactively, to assure your team is prepared:
- Educate your staff about the national patient safety goals, and take steps toward putting the right processes in place to achieve them. You may find that significant changes must be made, or it may be that a few simple modifications to your existing procedures can make a big difference. Either way, is important to assess where your organization is achieving national patient safety goals, and where there are opportunities to improve, and then put a plan in place to implement change as needed.
- Assure your staff has a working knowledge of TJC and CMS standards and requirements.
Offer town hall meetings to allow members of your team to come in, learn and ask questions. Or include a column in each issue of your employee and physician newsletters or email blasts, offering a new educational tip or bit of information that will help people optimize compliance standards. Take a look at where you have opportunities to provide information, and then use them.
- Teach your staff how to interact with TJC and CMS representatives, when they do show up. Make sure they know how to answer a variety of questions related to internal quality and compliance processes and protocols. Preparing your staff for upcoming surveys is a valuable and worthwhile investment, and will go a long way in assuring optimal outcomes.
- Analyze your documentation procedures. Conduct an internal audit of patient charts to confirm that documentation is complete, accurate and free of abbreviations that appear on TJC’s “do not use” list. Review your established processes for medication and equipment labeling to assure that your team is following all of the correct steps. Lastly, assess your existing policies to confirm that everything is covered and that each department has written guidelines as needed.
- Schedule and complete Ongoing Provider Performance Evaluations (OPPE). Make sure each individual provider on staff is evaluated, as required, and that results are documented and filed.
It is important to remember that standards for compliance are established for a reason – it all boils down to delivering patient care in an environment that is safe. By making this a priority and investing time and effort to put the right protocols in place, you will be doing a good thing for your patients, and also assuring your hospital remains TJC and CMS compliant.
About Virginia Reigle and Clinical Colleagues, Inc.
Virginia Reigle is the director of provider services and regulatory compliance for Clinical Colleagues, Inc., responsible for assisting with credentialing and licensing coordination, quality assurance and monitoring, and other tasks related to improving compliance standards within hospitals. She works in collaboration with a team of physicians and healthcare business professionals at Clinical Colleagues, Inc. to provide cost-effective anesthesia management and consulting services at community hospitals nationwide. To learn more about Virginia Reigle and Clinical Colleagues visit www.ClinicalColleagues.com.