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Upcoming Surveys. CMS Transplant Survey Patient Safety Licensing Survey TJC Hospital Licensing Survey All surveys in open window for a visit No announced dates File review session will be part of all surveys May 2012. Lessons Learned from Recent Surveys.

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Presentation Transcript
upcoming surveys
Upcoming Surveys
  • CMS Transplant Survey
  • Patient Safety Licensing Survey
  • TJC Hospital Licensing Survey
    • All surveys in open window for a visit
    • No announced dates
    • File review session will be part of all surveys

May 2012

lessons learned from recent surveys
Lessons Learned from Recent Surveys
  • ALWAYS keep Health System HR in the loop.
  • Health System HR should be the first area contacted when a file is requested, BUT if any Department is called directly for a file, follow-up with HSHR ASAP.
  • All Med Ctr and DGSOM personnel files go through Health System HR for final review prior to any survey interview.
  • Be clear about reason for file request when speaking with HR personnel so both parties can work together for fast and accurate outcome.
going forward
Going Forward…
  • Complete diligent review of personnel files.
  • Continue to track HR Competency Reports.
  • Inform staff/mgrs what requirements are coming due or overdue.
  • Be extra mindful of credential expiration dates.
  • Must have current online verification printed prior to expiration date and placed in file.

--Staff cannot work with an expired license, not even with a cancelled check and copy of renewal paperwork

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