Our programs and recommendations are designed to surpass TJC, CMS survey expectations.
The Joint Commission Survey Readiness – Gap Analysis
The Joint Commission is an independent non-profit organization that accredits and certifies healthcare organizations. Their goal is to improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. SMMA provides on-site assessment and a gap analysis of the medication management standards and the national patient safety goals that are relative to accreditation and regulatory compliance. Our goal is to ensure compliance with the medication management standards of The Joint Commission.
USP <797> addresses policies and practices for preparing, packaging, and storing compounded sterile products. The intent of USP <797> is to reduce the potential for contamination caused by an unclean environment, pharmacist error, lack of quality assurance, incorrect beyond-use dating, and other factors. SMMA provides an on-site assessment and gap analysis of the USP <797> standards. Our goal is to ensure compliance with the standards addressed by USP <797>.
State Department of Health
The Department of Health in most states now reviews and oversee the medication management process in hospitals and health-systems. SMMA will review State Department of Health requirements and provide a gap analysis of the medication management standards that are relative to state accreditation and regulatory compliance.
CMS (Centers for Medicare and Medicaid Services)
CMS grants “deeming” authority to organizations such as the Joint Commission to enforce standards for the federal Conditions of Participation. It is therefore critical that hospitals are aware of all current CMS standards. SMMA provides on-site assessment and a gap analysis of the medication management standards that are relative to accreditation and regulatory compliance. Our goal is to ensure compliance with the medication management standards addressed by CMS.
All findings and comments are documented. A final written report is presented to the client within 30 days after the on-site assessment. A gap analysis is provided that compares regulatory standards to issues that have been identified. Opportunities for performance improvement are suggested.