TSIG Organization Assessments
TSIG Consulting, Inc. provides organizational assessments to determine standards compliance across all functional areas. We have vast experience in providing mock surveys utilizing a team consisting of a Physician, one or more nurses, and a Life Safety surveyor. Additional specialists can be added as warranted by the specific needs of the client. Accreditation surveys conducted by CMS, TJC, or other accreditation agencies are generally unannounced making it critically important that healthcare organizations are in a state of continuous compliance readiness. TSIG utilizes a variety of customized methods to meet the needs of the organization. Mock surveys by TSIG simulate CMS/TJC surveys by using similar evaluation tools and agendas. TSIG surveyors are former regulators and healthcare clinical, compliance, and Life Safety managers who have a deep understanding of each functional area and all facets of the actual survey process.
The survey process
Prior to conducting the mock survey, TSIG will undertake a significant planning protocol in order to allow us to tailor our survey to meet the needs of the hospital. Our process will identify the hospital’s specific needs and plan the survey accordingly.
During an organizational assessment and mock survey, TSIG will utilize the Tracer Methodology, wherein our consultants will trace patients from admission to discharge. In addition, high risk processes across the entire hospital are evaluated as required in the 2017 Joint Commission Activity Guide. TSIG will interview department leaders, staff, medical staff, patients and families to gain a deeper understanding of each functional area and assess how the hospital presents its program. A formal review of patient records, medical history, infection statistics, policies, procedures, committee meeting minutes, risk assessments, and testing data will occur to enhance our overall understanding of the organization and to attest to the organizations ability to present their program in a successful manner. A review of the Focused Standards Assessment (FSA) will be undertaken to assure the hospital has successfully implemented its plan of action and achieved its stated goal and Measures of Success. TSIG will consistently provide education and guidance to the staff related to survey expectations and strategies for optimal survey success.
Final Report and program development opportunities
At the conclusion of the onsite assessment, TSIG will begin formulating an in-depth Standards Compliance report that addresses the findings across all functional areas. This report will provide a summary letter that highlights specific areas of concern and successes. Each standard will be presented with any specific elements of performance that need to be addressed. A detailed record of the observation is presented followed up with an extensive recommendation plan for each program deficiency.
Post-survey, our program development specialists are at the ready to engage the organization for deeper review of specific areas, strategy development to enhance areas of concern, or more extensive onsite assistance to develop program areas that require a fresh perspective and new approaches.