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The TJC & CMS Connection Strengthens

The TJC & CMS Connection Strengthens

Link between TJC Standards and CMS CoPsEvery year, CMS publishes an annual report which includes a report of disparities between surveys conducted by accrediting organizations and by CMS State Agency surveyors. The desirable disparity rate is less than 20 percent. However, disparity rates have remained higher than that, prompting, CMS to continue to influence how TJC and other accrediting bodies survey. As accrediting organization requirements have become more aligned with CMS Conditions of Participation, hospitals and other healthcare entities are encouraged to be on top of the CMS survey process. CMS currently provides three worksheets to assist in evaluating key functions and processes within organizations. Those worksheets exist for Discharge Planning, Infection Control and Quality Assurance and Performance Improvement (QAPI). In addition, there is a separate worksheet for Psychiatric Hospitals/units. The worksheets are very comprehensive and often challenging to incorporate into tracer activity.

Over the next several months, we will highlight each of the CMS worksheets, providing background, ways to incorporate into tracer activity and strategies for success. In addition, we will provide a link for the worksheet being highlighted. Be on the lookout for first article where you can learn about the CMS Infection Control worksheet. We recognize that some organizations may already be using these worksheets. If that is the case, we would love to hear from you your suggestions for obtaining compliance. Please email us with your ideas, questions and/or comments at info@courtemanche-assocs.com.

Visit our CMS page for a free CMS Survey Checklist!

Jill Ryan

Author Jill Ryan

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