The Greeley Company was delighted to share its insights about how to best prepare for and cope with changes in the survey process as State Agencies and Accreditation Organizations resume CMS survey activities. The following is our response to questions posed during the September 30 webinar.

Hospitals have faced a considerable number of challenges during the pandemic, from managing shrinking margins to adapting to “surge standards of care.” Responding to regulatory and accrediting agency activities has not been one of these concerns, but as surveying activities resume, quality and safety scrutiny will be higher than ever in the days and months ahead. While hospitals cannot afford the cost […]

As healthcare becomes more and more integrated through consolidation, acquisitions, and mergers, one of the most difficult challenges for a system or network to achieve is a highly effective system-wide criteria based privileging methodology. Greeley experts Sally Pelletier, Chief Credentialing Officer and Frances Ponsioen, Advisory Consultant identify strategies for optimizing privileging performance across an integrated delivery system below. Step 1: […]

Click here to visit our COVID-19 Resource Center May 29, 2020 On May 27, 2020, The Joint Commission (TJC) announced that it will begin returning to survey activities in the month of June (visit The Joint Commission’s website to view the official announcement). But, what will that mean? What will surveys look like? Which surveys will come first? How, specifically, […]

Visit our COVID-19 Resource Center  April 23, 2020  The COVID-19 pandemic has caused many challenges for healthcare organizations across the country.  Many organizations have been forced to activate their Emergency Operations / Emergency Response Plans (hereafter EOP) as they face a growing number of patients with COVID-19. What does the activation of an EOP mean for the Medical Staff Services […]

Visit our COVID-19 Resource Center  April 16, 2020  We are experiencing significant changes in healthcare as a result of COVID-19 and it’s not just been about patient care but also administrative changes, specifically changes to regulatory requirements. On April 15, 2020, the National Practitioner Data Bank (NPDB) announced through their NPDBD Insights that they are waiving all query fees beginning […]

Click here to visit our COVID-19 Resource Center April 13, 2020 In the event of an incident causing a large influx of inpatients into a healthcare organization, contingency actions outlining alternatives to usual staffing plans should be developed. The primary focus when implementing alternative staffing actions is patient safety. Alternatives to regular staffing plans will differ dependent upon the specific […]

Click here to visit our COVID-19 Resource Center April 7, 2020 During national or local “disasters” hospitals may face overwhelming inpatient volumes for which usual emergency management plan activities may be stressed. The following are considerations for guidelines of various activities necessary to expand capacity in order to effectively cope with incident-related surge inpatient volume. In many cases these considerations […]

Visit our COVID-19 Resource Center  April 6, 2020  On March 18, 2020, The Joint Commission published in their Standards FAQ’s the allowance of an automatic extension of medical staff reappointment and re-privileging beyond the 2-year period under certain conditions, specifically a national emergency that has been officially declared. It is incredibly rare for The Joint Commission to allow for an […]

Click here to visit our COVID-19 Resource Center April 6, 2020 The following is a brief summary of the process for obtaining pandemic-related waivers of federal requirements. Follow the links at the end of this post for additional details. What is an 1135 Waiver? There are many different ways to gain relief from a regulatory requirement. The 1135 Waiver is […]

Click here to visit our COVID-19 Resource Center March 27, 2020 The following recommendations are culled from CDC and other expert resources as healthcare organizations struggle to cope with shortages of personal protective equipment (PPE). These recommendations will vary over time and will be based on the health of the supply chain. The following measures are aimed at ensuring the […]

Click here to visit our COVID-19 Resource Center March 25, 2020 All healthcare personnel understand the risk of COVID-19 and the need to use PPE.  But Stanford has found that there may be a population of healthcare providers that are under additional risk for COVID-19; these individuals are proceduralists and the OR staff involved in endoscopic endonasal surgeries.  Please see […]

Visit our COVID-19 Resource Center  March 25, 2020  As healthcare organizations continue to evolve their workplace environment to accommodate COVID-19 demands, so must the way in which medical services professionals communicate with others regarding the credentialing and privileging process. New remote work models require us to look at how we communicate to multiple customers in multiple locations in an effective […]

Click here to visit our COVID-19 Resource Center March 24, 2020 As part of our COVID-19 blog series, on March 17, 2020 we covered a host of regulatory and accreditation issues that arose as survey agencies reacted to COVID-19. In this post we will dig a little deeper into implications for EMTALA during the pandemic. EMTALA and COVID-19  A CMS […]

Visit our COVID-19 Resource Center  March 24, 2020  Faced with a global pandemic, hospitals across the country have activated their Emergency Operations Plan.  Healthcare’s responsibility to patient safety has never been more important as we face a significant crisis, one that requires everyone to be vigilant and responsible. Last week, the President passed the Coronavirus Preparedness and Response Supplemental Appropriations […]

Click here to visit our COVID-19 Resource Center Amid ongoing concerns regarding the containment of the COVID-19 virus and a continued focus on hand hygiene, the Food & Drug Administration (FDA) has enacted provisions for temporary compounding of hand sanitizer by pharmacists in State-licensed pharmacies and Federal facilities. However, the compounding of hand sanitizer must be in strict accordance with […]

The Boy Scout motto of “be prepared” resonates strongly for healthcare organizations at the time of a disaster.  Hospitals need to have a well-defined procedure for when non-privileged practitioners need authorization to provide patient care when the hospital has activated its Emergency Operations Plan. Recognizing that an organization’s routine credentialing and privileging process is not a practical manner to expeditiously […]

CMS and The Joint Commission recently issued a string of notifications to the healthcare industry in response to the novel COVID-19 Coronavirus outbreak. This blog post will cover the highlights of their updates, however we recommend that you visit the CMS and Joint Commission website for the full communication. The Joint Commission In its March 9, 2020 communication, the Joint […]

The following is an excerpt from the Q&A following our Insights webinar, “Meeting The Joint Commission’s New Perinatal Safety Standards” hosted by Bud Pate and Lisa Eddy, Senior Consultants with The Greeley Company. To watch the free on-demand recording of the webinar, please click here. Q: Does the criteria for cases to be reviewed need to be spelled out in […]

Avoiding patient harm has been healthcare’s goal from the days of Hippocrates. Yet achieving this goal remains elusive. Despite years of attention to the Universal Protocol, patient identification, escalation of clinical concerns, medication reconciliation and other thoughtful approaches to patient safety, there is little evidence that the incidence of harm has diminished. Greeley will describe the organizational capabilities necessary to […]

The Greeley Company was delighted to share its insights about how to best prepare for and deal with CMS and accreditation findings in hospitals in the coming year. The following is our response to questions posed during the November 6 webinar presented by the National Association for Healthcare Quality. Watch the On-Demand Webinar >  Q: Can you offer some concrete […]

This post is an insightful Q&A with Greeley’s Senior Advisory Consultant, Kim Wilson, MS, BSN, RN. Q: Do you think electronic health records (EHRs) are clinically useful?  A: There’s a lot of factors that contribute to the usefulness of an Electronic Health Record (EHR).  Overall, we’ve come a long way from the old paper charts that often hid out among […]

In the last decade alone, Greeley has educated over 11,000 physicians and hospital leaders through our  Physician and Hospital Leadership Education national seminars. In anticipation of our upcoming events in Phoenix, AZ and Boca Raton, FL we have expanded our educational offerings to include four new programs. These programs cover critical issues in today’s evolving healthcare environment, such as moving […]

Do you need assistance in creating an effective credentialing policy for returning practitioners? Contact us: 888.749.3054 Is your facility open to working with clinicians who seek to return to practice after an extended voluntary absence from patient care?  Do you have consistent policies for addressing requests from practitioners to expand/change their scope of practice and refresh skillsets they have not […]

What are the Odds of a Medicare Deficiency after a Joint Commission Survey? Your hospital has a 50-50 chance of being in serious trouble when the survey team walks out of your door at the end of your next full Joint Commission survey. That means half of accredited hospitals will also need to prepare for a Medicare Deficiency Follow-up Survey […]

On May 23, 2019 The Greeley Company held a national online webcast covering the Physician Burnout Epidemic. (View this free webinar.) This post is an insightful Q&A with Greeley’s Chief Medical Officer, Dr. Rick Sheff, on his approach to addressing physician burnout. Physician burnout is an epidemic, and like most epidemics, there isn’t one simple solution. However, the Greeley Company […]

The Greeley Company held a national online seminar covering the top 20 Joint Commission and the top 22 CMS citations in recent years. This post covers the questions posed by the webinar audience, along with Greeley’s response.

Question: Surveyors have cited us for standards, such as contracted services, and are inconsistent with content of this webinar…. Is this where negotiation with surveyor is necessary?

Question: Should screening for suicidality be documented for all patients or only if certain criteria are met?

Question: Can you go into more detail about what the regulations require for medication storage. In our facility, pharmacy insists that any and all medications be locked unless under 24/7 observation.

Question: Does food storage include staff refrigerators or only refrigerators with patient items?

Question: You said that orders for non-violent restraints no longer need to be renewed every 24 hours?

Four steps healthcare organizations can take to meet the scoring revisions

If hospital survey results during the past year are any indication, 2019 should be a very busy and challenging year for hospitals across the country.

Joint Commission representatives have begun emphasizing the need for an additional “NFPA Time Out” for some surgical cases.

Hospitals seem to have a season for everything. There are preparations and protocols and promotions for the onset of tourist- and flu-seasons.

Among the topics slated for “enhanced” attention during Joint Commission surveys are high-level disinfection and sterilization, which continue to be problematic for hospitals across the country.

If you are looking to make a change at your hospital to define or revise the way you do or should be doing things, be sure you understand whether the change should be made in policy, procedure, or guideline, or to what extent in each.

There are two types of recommendations that can come out of a mock survey: good recommendations and unhelpful recommendations.

If your hospital is accredited by The Joint Commission (TJC), your CEO recently received a letter.

No more Mr. Niceguy. It started as “better guidance” for prescribers as concerns mounted that the over-prescription of opioid pain…

As more states legalize marijuana, more physicians have begun recommending cannabis to their patients for the management of pain, nausea, anxiety, and loss of appetite.

If you are still using “laundry list” privileging as opposed to core privileging, you are likely struggling to perform meaningful OPPE and FPPE. If a laundry list for a typical specialist includes 60-80 privileges, how do you determine current competence for each?

Hospitals and medical staffs all too often experience predictable areas ….

If you are still using “laundry list” privileging as opposed to core privileging, you are likely struggling to perform meaningful OPPE and FPPE.

Is your organization struggling with physician engagement — getting physicians on the organized medical staff on board with scheduling imperatives, quality and cost initiatives, and management expectations?

Every organization has struggled at one point or another to fill this key and complex role. It takes time to find a great Chief Medical Officer.

In recent weeks (months?!), there’s been a lot of discussion relative to the identification and mitigation of risks in the environment relating to the management of behavioral health patients.

Have you made any New Year’s Resolutions for your medical staff services team for 2018? Here are some resolutions Greeley helped clients make and achieve for 2017.

Co-Author: Sally Pelletier, CPMSM, CPCS Are your patients and practitioners protected in the ambulatory environment?

The most recent data shows unemployment among salaried employees at hospitals is flat-lining at 1.4 percent and turnover in healthcare

Can you connect these dots to suboptimal financial performance in your organization?

Cultural Challenges Integrating Physicians with Hospitals and Systems More than half of physicians practicing in the United States

Cultural Challenges Integrating Physicians with Hospitals and Systems More than half of physicians practicing in the United States

ATTENTION In-House Counsel and MSPs: Do these negligent credentialing scenarios sound familiar?

Age catches up with all of us, but in medicine, it’s catching up with some more than others.

According to a 2016 survey, as many as 58 percent of physicians in the United States are employed by a hospital or physician group.

By now everyone should be well aware that two categories of standards rise to the top in the volume of regulatory findings. These are Environment of Care and Infection Prevention and Control. One standard in particular receives a lot of citations varying widely in range: Joint Commission Infection Prevention and Control standard IC.02.02.01. However, while a variety of findings roll […]

You may have heard in passing that the FDA banned the use of powdered gloves in January 2017 due to patient and employee safety. You may have moved on thinking the use of these antiquated gloves was not an issue for you. Think you are safe? Who uses or orders powdered gloves anymore? Think again. Powdered gloves still exist. One […]

Summary: The Greeley Company’s consulting model is intended to help hospitals and their affiliated Medical Staffs build and strengthen effective leadership and oversight processes. We teach and reinforce the Greeley Medical Staff Leadership Model and the Framework for Sustained Compliance to help hospitals attain and maintain lasting and value-driven improvements to safety, experience and efficiency. We also recognize The Joint […]

How to clarify Don’t get hung up on the clarification format. Sometimes explanations don’t fit well into the Joint Commission’s “who, when, what, how, and why” outline and your explanation won’t be clear.

Rumor has it that the Joint Commission removed the option to clarify survey findings. This rumor is not true.

The Joint Commission has proposed some changes to it’s national patient safety goal for suicide prevention.

As you might know, The Greeley Company assists organizations of all sizes and types with their important external peer review needs.

Over time, The Joint Commission (TJC) has intermittently circled back to the processes organizations use to manage Life Safety Code (LSC) issues during construction

A key way to propel our hospital data to the next level of usefulness is to consider where our “red lines” are.

I always look forward to the mail on Friday because it usually includes the latest issue of People Magazine.

The song remains the same – only the tempo has changed! As we head toward the promise of a very different 2017 regulatory landscape under a new President

The Greeley Company is well known for our national physician and hospital leadership seminars.

January is a time when many of us reflect on the happenings of the previous year and will set new goals for 2017.

As hospitals form more expansive networks, small inefficiencies in individual credentialing processes compound and become increasingly disruptive at the system level.

External Peer Review (EPR) typically is thought of as the review of a medical record for individual cases in which concerns have been raised regarding the quality or appropriateness of care.

Medical staff services departments might need interim staffing assistance at any point for a variety of reasons.

Think you have your physician peer review covered? Before you answer “yes,” consider: Would you rate your peer review as highly efficient, fair, and effective?

Over 500 healthcare executives and industry leaders from across the country will gather November 7-9 at the Swissotel

As The Greeley Company continues our work with hospital and system administrators and physician leaders in this unprecedented time of change in healthcare

Dan Nielsen, former healthcare executive turned speaker and author, conducted several enlightening interviews at the 2016 Becker’s Hospital Review Annual Meeting in Chicago.

Another NAMSS conference has come and gone. This is an event that many of us look forward to every year—a chance to see old friends and meet new

The Greeley Company is looking forward to participating in the National Association Medical Staff Services (NAMSS) 40th Educational Conference and Exhibition,

Administrators at a 300-bed tertiary healthcare facility brought in consultants from The Greeley Company to help guide them through a compliance remediation program.

The Greeley Company is pleased to release the fourth and final part of our new guidebook, The Greeley Guide to External Peer Review.

in May and June, The Greeley Company released the first two parts of our four-part new guidebook,

For those of you who closely follow the ebb and flow of the physical environment regulatory compliance season, 2016 has been an unusually busy year

Last month, The Greeley Company released the first of our four-part new guidebook, The Greeley Guide to External Peer Review.

The increasing spotlight on quality and safety issues in healthcare has made peer review more important than ever.

The number of employed practitioners at your hospital is increasing. Provider enrollment with the managed care payers is time-consuming and long delays are being encountered. A significant loss of revenue has been incurred over the last year due to the inability to bill for patient care services while your practitioners waited to be credentialed by the payers.

If you were among the healthcare leaders who participated in the recent Becker’s Hospital Review Annual Meeting in Chicago

Today, Tuesday May 3, 2016, CMS announced the full adoption of the provisions of the 2012 edition of NFPA 101 Life Safety Code, effective July 5, 2016.

Over 1,500 healthcare executives and industry leaders from across the country will gather later this week, April 27-30, at the Hyatt Regency, Chicago,

The considerable length of time it can take to credential and enroll practitioners in health care networks

“Stop the line” is a very familiar term to me, through my years of experience in the hospital setting.

My colleagues from The Greeley Company and I hope that you’re enjoying this holiday season and feeling energized for the New Year!

A little over a week ago, I had the “NAMSS experience.” This year’s conference theme was about embracing change.

A regional hospital with 350+ beds and a physician group practice of approximately 20 physicians plus allied health practitioners had tried to collaborate multiple times for more than ten years.

How to Manage Temporary Privileges to Mitigate Risk and Protect Patients Thursday

The Chief Executive Officer/General Counsel and Credentials Chair of a 25-bed, physician-owned surgical hospital engaged The Greeley Company about conducting a gap analysis between their existing processes and leading practices, with the goal of making improvements based on Greeley methodologies.

Recent public statements by CMS representatives have raised questions about the mechanism a hospital should use to authorize/approve temporary privileges.

As my Greeley colleagues and I continue our work with hospital administrators and physician leaders nationwide in this unprecedented time of change in healthcare

During a July 2014 Joint Commission survey, one of CHRISTUS Santa Rosa Medical Center’s specialty hospitals experienced some specific compliance challenges related to their core privileging forms.

Historically, the medical staff services department has operated behind the scenes in healthcare organizations,

t should come as no surprise that nine out of the 10 most frequently cited standards during 2014 TJC surveys were directly applicable to the management of the physical environment.

After performing some random credentialing file reviews, a multi-entity health system of 200+ beds that is part of a larger academic

The Greeley Company is looking forward to participating this week in the Becker’s Hospital Review 6th Annual Meeting, May 7-9 at Swissotel, Chicago, IL.

We have all had beliefs we held to be true, only to find out at some point in the future that those beliefs were myths.

The Greeley Company’s Chief Credentialing Officer, Sally Pelletier, was recently interviewed for the following story on physician imposters in Becker’s Hospital Review:

The imperative in healthcare today is to rapidly and significantly improve quality and reduce costs.

A contractor is building several new homes in my community. I have been watching the excavation and grading of the property, the concrete basements being poured and the walls going up.