Compliance | Certification | Readiness | Project Management | Training & Education

We’ve worked hard to develop compliance, training, and readiness programs and healthcare management products that meet the needs of our clients as well as provide the highest level of safety for every patient that may enter their facility.


 
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Intensive Preparation for Accreditation by The Joint Commission / Centers for Medicare & Medicaid Services

The NHC survey team provides hands-on guidance and instruction to prepare your team members and facility for the intense process of Accreditation by the Joint Commission and Joint Commission International, as well as CMS Regulatory Compliance. Our expertise is derived from years of surveyor experience for The Joint Commission and the Centers for Medicare and Medicaid Services and our TJC / CMS Preparation product includes:

  • Full scope survey preparation based on the needs and size of your organization as well as scope of services.

  • Team training and development to ensure employees comply with performance standards.

  • Development of and assistance with execution of plans of correction and management plans.

 

 
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Quality and Risk Assessment

The NHC survey team assesses all organizational programs and processes delivering complete risk assessments, root cause analysis reporting as well as hazard vulnerability assessments in the following areas:

  • Information Management

  • Life Safety

  • Environment of Care

  • Emergency Management

 

 
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High-level Disinfection and Sterilization

The NHC survey team tailors to and assesses each facility’s sterile processing practices assessing and providing a thorough evaluation of all aspects of sterilization processes including:

  • All-department infection risk and contamination assessments,

  • Review and application of the most frequent and difficult standards against department policies to ensure compliance.

 

 
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Education and Webinar Services

Our experts deliver advice supported by decades of experience for The Joint Commission accreditation and compliance and the Centers for Medicare and Medicaid Services. Our consultants provide webinar education tailored to the organization on topics such as:

  • Compliance with the CMS Conditions of Participation for Acute Care Hospitals, Critical Access Hospitals and Swing Bed, Long Term Care, and the Environment of Care and Life Safety

  • Sterile Processing for all services including Dental facilities

  • Sterile Processing for DNV accredited facilities for ISO 9000

  • Association for the Advancement of Medical Instrumentation (AAMI) ST-79 and ST-91 education

  • Compliance with standards and elements of performance for Joint Commission accredited organizations

  • Home Care and Hospice education

  • Pharmacy, Compounding and Medication Management

  • Infection Control for all programs (hospital, critical access hospitals, ambulatory care, dental clinics.)

  • Human Resources Management and related standards for survey preparation.

  • Primary Care Medical Home and Health Equity

 

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Medical Staff Safety Compliance

  • Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation

  • Credentialing and Privileging

  • Bylaws, Rules & Regulations 

  • Medical staff leadership in performance improvement, infection control and oversight of quality of care

  • Medical staff participation in patient safety initiatives

  • Medical staff participation in emergency management, disaster drills, disaster privileging, etc.

  • Expectations for continuing medical education

  • Expectations of the Medical Staff and organizational leadership


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Pharmacy Consultation

  • USP 800 and 795 Audit from gap analysis to compliance,

  • Medication Management Chapter Audit including a written report with areas of non-compliance and best practices identified.

  • Antimicrobial stewardship audit including a written report with areas of non-compliance and best practices identified.

  • Opioid stewardship program development including a gap analysis and support in the development/implementation of the program.

  • Anticoagulation therapy program development including a gap analysis and support in the development/implementation of the program.

  • Diversion Audit including a report identifying strategies to mitigate risk points.

  • Pain Management program development and consultation

  • Training and education webinars

  • Technology and use of bar-code verification

  • Proactive risk assessments

  • Root cause analysis and evaluation of system failures

  • Evaluation of collected data and evaluation of outcomes

  • Multidisciplinary approach to system problem solving

  • Evaluation of the specific Conditions of Participation related to medication management

  • Evaluation of all Standards in the Medication Management Chapter in preparation for Joint Commission survey.