CMS Surveys: Preparing With Confidence - On-Demand

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CMS Surveys: Preparing With Confidence - On-Demand

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CMS Surveys: Preparing With Confidence - On-Demand

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Available ON-DEMAND

Presented on:
Monday, December 05, 2016

Original Broadcast:
Wednesday, February 24, 2016

Presented by:
Victoria Fennel, PhD, RN-BC, CPHQ
Julie Campbell, MHA, BSN, NE-BC, HACP

Are you ready for a CMS survey?

CMS has increased the frequency of its hospital surveys, and many healthcare facilities are finding themselves unprepared for the bump in federal scrutiny.

Join expert speakers Victoria Fennel, PhD, RN-BC, CPHQ, and Julie Campbell, MHA, BSN, NE-BC, HACP, for this impactful program. In addition to arming attendees with preparatory steps and strategies, Fennel and Campbell will examine a real-life case study to provide specific examples of survey citations and responses.

At the end of the program, you will be able to:

  • Utilize a compliance plan to develop an organization-specific, comprehensive approach to accreditation and compliance readiness
  • Identify at least three sources of information to review changes in the Conditions of Participation/survey process
  • Implement a gap analysis of your organization’s compliance readiness

Who Should Listen?

  • Accreditation Professionals
  • Survey Coordinators
  • Risk Managers
  • Directors of Nursing
  • Performance Improvement Managers/Directors
  • Quality Improvement Managers/Directors
  • Patient Safety Directors
  • Leadership/C-Level Management


I.  What happens during a CMS survey

  1. Increased CMS hospital scrutiny: More validation and complaint surveys
  2. What to expect on survey day: Survey protocol
  3. 2567 (Statement of Deficiencies)
  4. Responding to survey findings: The Plan of Correction
  5. Severe consequences: Condition-level findings, immediate jeopardy, termination of services
  6. Differences in the CMS and Joint Commission survey processes

II. The importance of being prepared for CMS surveys

  1. Compliance process plan
  2. Gap analysis

III. Case study

  1. Baylor Medical Center’s recent survey
  2. What the surveyor found
  3. How Baylor responded
  4. Lessons learned and sustainability


Meet the Speakers

Victoria Fennel, PhD, RN-BC, CPHQ, has more than 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety, and patient-centered care. Her clinical expertise and communication skills enable her to effect change and collaborate at all levels of a hospital, from nursing staff to management. As director of accreditation and clinical compliance for Compass Clinical Consulting, Fennel manages the quality of accreditation and compliance engagements and directs client education and advisement. 

Julie Campbell, MHA, BSN, NE-BC, HACP, has more than 25 years of nursing leadership experience. She has spent the majority of her career in various nursing management roles of a midsized hospital within Baylor Scott & White Health (BSWH). During the past six years, she has provided accreditation oversight of the North Texas BSWH hospitals, encompassing 12 hospitals of varying sizes. As North Texas Division vice president, Campbell assists in survey preparation, development of corporate policies and procedures, communications on revisions to regulations/standards, and recommendations of regulatory changes to various system councils to maintain continuous readiness.

Webinar system requirements and program materials:
To fully benefit from the webinar experience, please note you will need a computer equipped with the following:

Browser: Microsoft Internet Explorer 6 or later, Firefox, Chrome, or Safari, with JavaScript enabled
Internet: 56K or faster Internet connection (high-speed connection recommended) 
Streaming: for audio/video streaming, Adobe Flash plug-in or Safari browser on iOS devices

Prior to the webinar, you will receive an email with detailed system requirements, your login information, presentation slides, and other materials that you can print and distribute to all attendees at your location.

No problem. The On-Demand version is also available. Use it as a training tool at your convenience—whenever your new or existing staff need a refresher or need to understand a new concept. Play it once or dozens of times. A $199 value! 

Please note 
Participation in this webinar is just $199 per site. All materials must be retrieved from the Internet. 

Call your customer service representative toll-free 800-650-6787 or email if you have questions.