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Physician engagement strategies

Does your organization excel at developing, implementing and monitoring quality and safety processes across the facility or system? Does your leadership team support the efforts of assuring adherence to quality and safety requirements?

Our goal is to guide your delivery of safe, high-quality healthcare by developing and maintaining a quality and safety program and identifying gaps in care.

Our clinical improvement department carries out its mission in five fundamental ways:

  • Oversight – prevent and detecting noncompliance
  • Insight – make policies and procedures more efficient and effective
  • Foresight – identify emerging issues
  • Adjudication – resolve interpretation conflicts and provide expert opinions
  • Hindsight – use past experiences from inside and outside the organization to improve the accreditation and regulatory program.

 Working with you

How we work with you


  • Assess organizational quality assurance improvement program readiness and vulnerabilities for external evaluation by regulatory bodies
  • Educate organizational staff on quality standards and CMS payment/penalty programs applicable to their organization
  • Coordinate The Joint Commission disease-specific certification and other related surveys
  • Collaborate with leadership in establishing accountability for safety culture and high-reliability techniques to improve and maintain a safer healthcare delivery system
  • Serve as a resource to the multidisciplinary teams established to ensure QAPI compliance with The Joint Commission, Det Norske Veritas (DNV) and other regulatory entities
 Improvements

A clear path to improvement


  • QAPI assessment — review of current program and compliance with the CMS QAPI requirements
  • Advice and resources for multidisciplinary compliance teams to ensure QAPI compliance with The Joint Commission, Det Norske Veritas (DNV) and other regulatory entities
  • Evaluation of processes and performance for driving quality, length of stay, infection prevention, CMS and other reported measures
  • Enhanced data reporting and use of process control theory to drive quality
  • Disease-specific certifications application assistance
 Payments/penalities

Access to CMS payment/penalty programs


  • Value Based Purchasing (VBP) evaluation and strategies for improvement
  • Hospital Re-admission Reduction Program (HRRP) data and performance review
  • Bundle Care Payment Initiative
  • Medicare Access and CHIP Reauthorization Act (MACRA)
  •  Safety

    Safety program tailored to your facility


    • Safety culture assessment
    • Evaluation of current safety processes to prevent harm
    • Establish and support a safety culture and high-reliability techniques to improve and maintain a safer healthcare delivery system
    • Orientation and training pathway for promoting and maintaining a culture of safety
    • LeapFrog Safety Score gap analysis and action plan development to improve and maintain safety score
    Contact us today
    704-384-6370