Spotlight: Sustainability framework improves compliance

In 2015, administrators at a 300-bed tertiary healthcare facility brought in consultants from The Greeley Company to assist the facility in remediating the process elements causing repeated failures to clear a specific Condition of Participation. Once on site, Greeley consultants found a number of areas causing the facility's noncompliance with the specific condition.

They discovered that the client lacked strong systems for managing events and tracking failures. Additionally, the facility suffered from garden-variety oversight issues and overspent on collecting data that provided few insights.

"We went in not just to help them with moving to compliance with the one condition out," one Greeley consultant summarized. "We soon realized that their whole quality and safety processes needed a strong framework for sustaining compliance."

Consultants counseled the client on its compliance methodology, explaining that to stay in compliance staff must effectively track and analyze actionable data and use those insights to tangibly improve care. Simply collecting data wasn't enough.

"Consultants encouraged the facility to adopt the Greeley framework for sustained compliance."

To remedy this issue, our consultants encouraged the facility to adopt the Greeley framework for sustained compliance. This methodology dictates that the fabric of health care – the sum total of clinical spaces within a given facility –  must include four essential characteristics: a strong, accountability-driven oversight system, effective communication practices, process implementation and process monitoring.

With this in mind, our consultants went to work crafting a sustainable compliance framework. 

First, we established an event-management system with which administrative and clinical personnel could track significant events throughout the day. This enabled the client to keep top-level administrators informed. Greeley consultants then tackled the facility's data collection and processing procedures, pointing clinical staff toward more consequential data points and encouraging them to monitor truly impactful processes addressed in CMS compliance regulations.

"Process monitoring allows you to identify trends and patterns," one of the consultants explained. "We did a lot of work with them because they were expending so much energy monitoring things with were not beneficial to them." 

Ultimately, this pivot toward more actionable data produced useful insights and led to measurable improvements in care. By the end of the project, the client had the tools it needed to achieve and maintain compliance.

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