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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.

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Upcoming Surveys

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  1. 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

  2. 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.

  3. 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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