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Services Provided
TJC Compliance
Patient Safety Approaches that enhance prevention and reduction of medical errors using risk assessment and failure mode and effects analysis.
Sentinel Event Response assistance for analysis and review of systems and processes, latent system faults and corrective actions.
Medication Management addresses the critical phases in the medication process to eliminate risk points, reduce potential failures, and enhance patient safety.
Environment of Care Audit for development, implementation and evaluation of safety management plans for Safety, Security, Hazardous Materials, Emergency Management, Life Safety, Medical Equipment and Utilities; Life Safety Code Compliance / Statement of Conditions; Statement of Conditions, Hazard Vulnerability Analysis, and Environment of Care documents.
Restraint Use Reduction for innovative strategies to assist staff and physicians with patient management approaches and alternatives to restraint.
Moderate Sedation and the anesthesia continuum to address practice, education and privileging challenges with organizations.
Staffing Effectiveness evaluation and facilitation strategies to enhance awareness and integration of staffing concepts and variables to enhance patient outcomes.
Surveillance, Prevention, Control of Infection program assessment from development through implementation and evaluation, using risk assessment and analysis techniques.
back to top>>>TJC Accreditation – Regulatory Prep
On-site Assessment assists healthcare leaders identify strengths and opportunities for performance improvement within their organizations.
Rehearsal / Mock Surveys prepare all levels of organizational staff for TJC’s interactive survey process as Associates assess the organization's readiness for accreditation.
Document Examination assists organizations in maintaining standards compliance
compliance while instituting changes to respond to a dynamic healthcare environment.
Educational Preparation designed to familiarize organizations with accreditation standards and the new survey approach to accreditation.
Facilitated Implementation to assist organizations with challenging areas in health care, risk assessment, risk reduction for high risk processes, using techniques such as the Failure Mode and Criticality Effects Analysis.
back to top>>>Risk Management
On site system evaluations, including:
Risk Assessments
Vulnerability Assessments
Evaluation of emergency management preparedness
Review of critiques related to individual organizations as well as community readiness structures.
Evaluation and measurement of organizational compliance programs, as it relates to the US Sentencing Commission Guidelines and OIG guidelines.
Evaluation and development of organizational HIPAA compliance programs, as it relates to Privacy, Security, Transactions and Code Sets, and National Provider Identifiers.
Workers Compensation
Litigation Preparedness
Environment of Care
Document Review
Review of and assistance in preparation of the Statement of Conditions™
Proactive Risk Assessments
Management Plans
Life Safety Code
Life Safety Code Education
Building Tour
Document Review
Building Maintenance Program
Enhancing Organizational Synergy
Leadership Strategies to enable organizational leaders to identify opportunities, prioritize performance initiatives and manage organizational outcomes.
Integration Strategies: Off-site/On-site to foster inclusion, uniform care processes and the development of standards for performance throughout the organizational system.
Medical Staff Affairs Appraisal of credentialing procedures, bylaws, rules and regulations; competency and design of medical staff organizations.
Interdisciplinary Integration for team building, collaboration, cooperation and organization wide continuous performance improvement activities.
back to top>>>Accelerating PI Initiatives
Improving Organizational Performance through continuous performance improvement
and risk reduction strategies for multidisciplinary decision making to enhance outcome management.
Prioritizing Performance Improvement initiatives through strategic alignment of mission, vision, values, business plans, and performance and outcome management.
Proactive Risk Assessment, such as Failure Mode and Effects Analysis, is used to assist organizations to identify risk points in care processes and facilitate risk reduction activities.
Root Cause Analysis enables organizations to identify underlying systems issues that contribute to potential failures in patient and organizational processes.
Responding to ORYX-Core Measures using statistical process analysis and evaluation, as well as appropriate process improvement strategies.
Organizational and Patient Outcome Management based on the alignment of strategic goals, financial and performance objectives, risk assessment and targeted improvement.
back to top>>>Laboratory Services
TJC (formerly JCAHO), CAP and COLA accreditation readiness
Assessment of current lab functioning and proficiency testing
Lab Integration for complex organizations
Interim Direction
Education & Training
Leadership Strategies
Strategic Planning enhances the organizations financial viability and service to patient populations.
Assessment of Current State to provide a realistic assessment of current strengths and challenges to focus organizational resources in appropriate directions for positive performance and financial outcomes.
Team Effectiveness strategies to enhance team concepts for patient safety and collaborative thinking.
Development of Strategies for new and challenging situations facing organizations.
Outcome Management based on the alignment of strategic goals, financial and performance objectives, risk assessment and targeted improvement.
back to top>>>Medical Staff Affairs
Bylaws, Rules and Regulations evaluation for compliance with regulatory and accreditation requirements, including graduate medical education programs.
Allied Health professionals challenges in credentialing and the assurance of ongoing competence in patient care and management.
Credentialing for Medical Staff, licensed independent practitioners and allied health professionals to assure competence in patient care and management.
Appointment – Reappointment processes to assure qualified health care providers, ongoing competence and regulatory compliance.
Criteria for Privileging to promote uniform requirements for privileged staff that enhance Medical Staff performance and patient outcomes.
Data to Support Reappointment for individual providers, group, and external comparisons, to use aggregate data for analysis of competence and performance.
Performance Improvement processes to assist Medical Staff and licensed independent staff to improve patient outcomes through risk reduction and outcome management strategies.
Peer Review process development and implementation to foster performance improvement, support reappointment, and promote competence in patient care management.
back to top>>>Integration Strategies
Organizational Integration evaluation and strategies to address criteria for accreditation and public representation.
Functional Integration evaluation and strategies to address functional criteria for accreditation and organizational integration.
Inclusion – Exclusion of Services bases on the organization’s use of organizational and functional criteria for accreditation.
Multiple Sites-Services may present challenges for regulatory and accreditation purposes and can be addressed through organizational and functional inclusion / exclusion strategies.
Multiple Components of Care may be surveyed as one system or multiple entities or not at all, using inclusion / exclusion strategies.
Complex Corporate Structures may be confusing when determining survey processes and accreditation awards as single or complex entities.
back to top>>>Emergency Preparedness
On site assessments
Emergency Management Tracers
Hazard vulnerability assessments
Evaluation of emergency management preparation
Review of critiques related to individual organizations as well as community readiness structures
Establishment of incident command center
Integrated Emergency Management training
Pandemic Readiness assessment
back to top>>>
Interim Support
Support for new survey coordinators, quality managers and regulatory compliance staff.
Assistance during turnover to keep on track.
Pharmacy
Interim Pharmacy Direction & Support
Identification of Best Practices Related to Pharmacy Automation
Custom Services
Custom Requests to facilitate organizational priorities for patient safety and performance improvement.
back to top>>>
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