Using Accreditation & Regulatory Survey Results to Drive Improvement
At the conclusion of this session, learner will be able to:
- Identify corrective action elements that are applicable to CMS and accrediting organization processes
- Identify the impact of repeat findings from previous surveys, including The Joint Commission’s process for a related accreditation decision of Preliminary Denial of Accreditation
- Apply learnings to the development of robust corrective actions for survey findings
The Centers for Medicare and Medicaid Services (CMS) requires a robust process for responding to deficiencies identified during survey activity – whether that be CMS surveys related to complaints or allegations, or surveys conducted by accrediting organizations with deemed status. Additionally, healthcare organizations across the continuum are challenged with implementing robust, sustainable change to identified deficiencies.
Additionally, The Joint Commission continues to enhance its processes for all aspects of the accreditation process. With the advent of TJC’s SAFER MatrixTM, there is the need for more robust analysis of higher risk areas of non-compliance. In addition, leadership involvement in sustainable change must be demonstrated. Strategies for development of meaningful corrective actions will be explored and sample Evidence of Standards Compliance will be shared. Also addressed will be TJC’s increased focus on organizations that have a decision of Preliminary Denial of Accreditation for repeat findings. Organizations challenged with trends in non-compliance that carry from one survey to the next will be challenged with a more intense timeline for addressing those findings – including a ten-day turnaround on corrective action planning, and ongoing communication between TJC leadership and that of the healthcare organization.
Join this session to learn more about navigating the post-survey process to create robust, sustainable improvement on identified findings and get access to tools and resources to assist in that journey. This session is appropriate for healthcare organizations across the continuum that receive CMS funding and are provided deemed status by an accrediting organization.
Presenter – Jill Ryan, CPHQ, HACP
Jill Ryan is Chief Executive Officer and a Senior Consultant at Courtemanche & Associates. In this role, Jill is responsible for the daily operations of the firm and assuring the provision of the mission of the company. She works with clients to enhance Courtemanche & Associates’ offerings through onsite and virtual consultation, web conferencing, and development of new services to meet clients’ needs.
Ms. Ryan has nearly three decades of healthcare administrative and regulatory experience. She has served as survey coordinator and patient safety officer, facilitating numerous successful Joint Commission surveys, Centers for Medicare and Medicaid Services (CMS) surveys and state surveys. Jill has worked in senior leadership for the majority of her career and has demonstrated skills in governance and medical staff relations, leadership and management development, facilitation of strategic initiatives and the creation of infrastructure to support operational growth and business goals.
Ms. Ryan has developed numerous unique regulatory compliance tools and resources to assist organizations in accreditation and regulatory success. Of note, she developed the concept of the “Mini Tracer” which is highlighted in Performance Tracing: A Primer on Tracer Methodology. No stranger to the educational needs of regulatory compliance, Ms. Ryan also developed TJC Boot Camp and TJC 101 to keep organizations on track with accreditation basics and changing regulatory requirements.
Ms. Ryan was also instrumental in developing and implementing the concept of Care Enhancement to operationalize culture change at the operational level of healthcare organizations enhancing compliance and patient care outcomes. This unique approach modifies organizational dynamics and creates the synergy needed between staff and leaders to attain positive organizational outcomes.
In addition, Ms. Ryan is a Certified Professional in Healthcare Quality and a Healthcare Accreditation Certified Professional.