Accreditation Compliance

Is your medical staff ready for your upcoming survey? Make sure by taking advantage of the following services:

Review of medical staff bylaws for compliance with standards relating to the medical staff

Kathy can perform a complete review of medical staff bylaws and documents and map them to all elements of performance in accreditation standards. This mapping document can be used to document compliance with standards and identify areas of noncompliance. Kathy can also draft bylaws language and recommended process changes needed to meet standards.

Credentials file audit for compliance with Joint Commission, AOA-HFAP, DNV-NIAHO, CMS Regs, or NCQA credentialing standards

In the busy credentialing office, it is very easy for things to “fall through the cracks”. Will your provider credentialing files stand up under rigorous surveyor examination? Have you had turnovers in your credentialing office since your last survey? If so, you may benefit from an independent audit of medical staff credentialing files. With over 20 years experience in credentialing, Kathy can provide a comprehensive review of credentials files to determine compliance with primary source verification requirements of accreditation standards, state law, and medical staff bylaws. Don’t be surprised on your next survey!

Education/training/coaching of medical and support staff regarding  survey process and interviews

Medical staff’s preparedness can make or break your survey. Make sure your medical staff knows what to expect during the credentialing interview and survey. Due to decreasing reimbursement, many employers are forced to cut back or stop paying for continuing education for their employees and medical staff officers.  See Educational Programs for a list of programs offered, or a program can be developed to meet your needs.

Development and implementation of pre- and post-survey compliance plans

Kathy can help with development, implementation and follow-up of compliance plans to meet medical staff standards including development of procedures and drafting of bylaws changes.

Staff Support and Training

Kathy will work with you and your staff to provide ongoing support for your medical staff office and training of hospital staff, medical staff leaders, and governing body in all aspects of medical staff services.  Let Kathy customize a plan to fit your specific needs.