一个800 +床医院南正在经历significant leadership changes, including the transition of an interim Chief Executive Officer, Chief Nursing Officer, and many director- and manager-level interims. The hospital contracted with Compass Clinical Consulting to engage an Interim Regulatory Specialist in the Quality Department to provide leadership amid these transitions, while guiding the department toward its accreditation and compliance goals and providing support in the face of staffing vacancies and other challenges.

The Situation

具体而言,质量部门在两个不同的个人中受到两年的临时领导,包括指南针的另一种质量和认证领导者。该署在此期间也失去了许多工作人员,包括以前的指南针临时,担任主任,曾管理过DNV GL认证过程。

在这种领导变革期间,临时监管专家维持了该部门的职能,通过投诉回答领导了组织,并建立了为未来认证调查做准备的行动计划。她另外使用她的联合委员会(TJC)专业知识,帮助医院了解从DNV GL转移到TJC认证的过程,以及最终实现这一目标所需的资源和承诺。

Accreditation and Compliance Goals

At the onset of the engagement, the organization expressed the goals of supporting compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs), maintaining DNV GL accreditation readiness, and working with department and executive leaders to move the organization down the path toward TJC accreditation readiness.

该组织和临时监管专家共同调查了CMS CM CMS要求和DNVGL GL期望的所有临床领域,并为该地区的管理人员以及执行领导者提供了报告。金博宝官网测量师团队包括临时,该地区的质量协调员,设施安全的代表以及正在调查的手术区域的主任。结果总结并报告给素质委员会。这一阶梯确保该组织有一个基线,以衡量其对其认证和合规目标的进展。


Within weeks of arrival, two employees of the department left the organization, and the other Compass interim director was replaced by someone who was retiring within 30 days. Upon the director’s retirement, the leadership role of the department remained vacant for several months. Additionally, one of three remaining employees was out of the department for three months.

The department would have floundered without adequate staffing and necessary leadership, so the Interim was asked to support the medical staff quality committee and keep the department running until a new director was identified.


  • 隐私违规潜力
  • 在手术/程序领域的重要IC问题潜力
  • Medication management and security
  • Individualization of care plans

这些问题领域需要注意 - 并迅速 - 确保组织能够提供安全,优质的护理。

Solution: Relationship Building, Process Changes, and a Focus on Compliance


通过既定的领导力存在,临时能够通过其认证和合规性挑战有效和有效地指导组织,包括DNV GL投诉回复和QIO投诉回应。她还制定了一个行动计划,为中风协调员和行政领导者以及计划的行政领导者进行准备和响应DNV调查;为实验室的美国病理学学院提供了领导力;并支持移植协调员在准备TJC重新认证移植程序时。她与其他人和其他人合作,为调查准备了本组织。

该部门内的发展和组织变革导致设施中更有效的方案开发。临时对患者信息的管理进行了变化,并协助开发内部审计计划。她通过重新设计角色和责任,澄清角色预期和更新来解决组织变革的流程来更新了DNV GL调查响应计划。然后,临时会见了关键人,以审查计划的变更并确保他们的理解。

Additionally, the Interim prepared all documents related to the organization’s state license renewal and worked with the facilities department to ensure that the updated licenses were posted in all required locations when received.




Additionally, as a result of the engagement, the organization has put processes in place to prioritize accountability and sustained compliance. Weekly mock surveys have been implemented, rotating through each of the operative areas. The Senior VP and the survey team meet regularly to review progress and identify additional resources and actions that may be required to address problem areas. Environment of Care staff also embraced the addition of a quality representative on the team surveys.

If you would like to find out more about the successes our interims have had in the ED or other areas and how your hospital can maintain safe, quality patient care, contact us atinfo@compass-clinical.com或(513)241.0142。

Photo credit:Thinkstock / iStock