REGULATORY PREPARATION

A major relocation puts a JCAHO accredited facility under new scrutiny. We work with clients to identify all licensing and regulatory issues that must be addressed to ensure you successfully maintain your compliance post-move. Below are examples of our experience:

• Create Survey Preparation Models for use in each phase of preparation.
• Design customized Preparation Timeline of Activities and Action Plans based on the organization's survey timeframe.
• Create, design and implement materials with interdisciplinary team members, such as "Interdisciplinary Plan of Care" documents, tools and concurrent chart audit forms.
• Plan, organize and facilitate team meetings, including a Leadership Quality Action Team with participants from senior and medical staff leadership.
• Design management-training documents for administration and staff use.

• Develop an organization-wide Quality Management System for detailed reporting and the use of appropriate statistical interpretation tools.
• Establish a physician collaborative approach to quality that includes the medical staff in all aspects of quality improvement.
• Create the structure of the Quality Management department, using team-building tools to develop roles and responsibilities for organizational functions, that include but are not limited to:
    –  Peer reviews
    –  Performance improvement reports
    –  Intensive analysis
    –  Outcome analysis reports
    –  Data collection and management techniques
    –  Facilitation techniques
• Design an interface for statistical analysis and interpretation.
• Design and implement education plans using organizational PI models, featuring examples familiar to the organization's practice.
• Direct all quality and performance improvement activities.

• Collaborate on design and facilitate JCAHO educational preparation programs for all hospital employees, including Medical Staff and Board of Governors.
• Develop customized educational books and materials specific to each organization's assessed needs.
• Prepare customized education calendars for hospital-wide distribution.
• Design and teach formal education classes (including development of individual packets, flip charts, flow charts and posters) for JCAHO preparation.