Compliance
Full Service, On-Site Survey Preparation for Continuous Compliance

Cameron Bruce Associates helps healthcare facilities maintain continuous compliance with TJC Environment of Care and other regulatory requirements. Our fine-tuned project management process will guide you from your last survey all the way through your next survey. We bring critical issues to the forefront so your time and efforts are most effective. And unlike many consultants, Cameron Bruce Associates will stay with you every step of the way to help manage the myriad details of continuous EC compliance and provide the resources to get the tasks done.

  • Conduct Mock Surveys
  • Schedule Regular On-site Reviews
  • Monitor Compliance
  • Review Regularly Produced Documents (Minutes, Reports)
  • Review Performance Improvement Data
  • Assess Document Management Systems
  • Update and Revise Policy and Procedure Manuals
  • Develop Training Materials
  • Provide Training with Documentation
  • Review, Collect, and Organize Documentation
  • Develop Survey Documents (Management Plans, Quarterly Reports, Annual Evaluations, etc.)
  • Develop Presentation Materials
Compliance Tools

Our compliance products can help take the stress out of standards and code compliance. We offer proven tools that save you precious time and money! We will work with you to customize these items to your unique facility needs. You get excellent model documents plus the electronic files. In the future, just update the document yourself or give us a call for help.

  • Compliance Checklist
    We assess your compliance and then maintain your compliance checklist so you can monitor your readiness from year to year.

  • Mock Surveys
    We have created an exhaustive mock survey tool to conduct a detailed EC Assessment of your facility. Our mock surveys are usually 3 to 4 days and result in a summary scoring that becomes a project management tool to prepare your organization for a survey. Our EC Assessment includes TJC and DHS standards.
  • Annual Evaluations
    Annual Evaluations are key documents in TJC surveys. Let us customize your seven annual evaluations in a tested and proven format that surveyors commend.

  • Emergency Management Plans
    The Hospital Emergency Incident Command System (HEICS) format was developed in California in 1991. The incident command system protocol is required by the National Fire Protection Association (NFPA 1600) and The Joint Commission. Major new requirements from The Joint Commission took effect in 2001 and 2002, and for 2006 the focus has expanded dramatically. For more information, follow this link: Emergency Management.

  • Safety Orientation and Training Handbook
    Under the new accreditation process and tracer surveys, staff knowledge is more important than ever. Addresses all seven EC standards. Ideal for new employee orientation and annual training for your unique facility needs.

  • Manager's Training Guide
    Facilitates orientation and training of department-specific safety topics.

  • EC Management Plans
    Seven EC Management Plans in a concise, easy-to-use format. We continually revise these plans to reflect changes in the standards and surveyor expectations.

  • EC Documention Binders
    Binders, each with a Table of Contents and tabbed sections to help you organize your documentation for the Life Safety Code Specialist, EC Review session and the Emergency Management Review session.

  • Policy and Procedure Manuals
    Allow us to customize our proven manuals to your facility or update your own manuals. We offer tested models for house-wide applications and support services departments. For more information, follow this link:  Policy and Procedure Manuals.

Customized Policy & Procedure Manuals

Cameron Bruce Associates has developed or edited over 120 policy and procedure manuals for over 40 hospitals and has an extensive library of resources to customize manuals for any facility. We specialize in HICS-based Emergency Management Manuals. We can either deliver all manuals ready for distribution, or just the "Print Master" for your own printing and collating. You also get the manual on disk, and we archive a copy in our fireproof safe.

  • Manuals - Administrative, Safety, Security, Emergency Management, Engineering, Biomedical, Environmental Services, Telecommunications and Infection Control
  • Forms - develop new forms to reflect new processes
National Patient Safety Goals

Each summer TJC publishes National Patient Safety Goals which take effect the following January. These goals are developed from a review of TJC's database of sentinel events. Your facility must address every National Patient Safety Goal that is published. Examples include improving the:

  • Effectiveness of Communications Among Caregivers
  • Safety of Using High-Alert Medications
  • Safety of Using Infusion Pumps
  • Effectiveness of Clinical Alarm Systems

 
Sentinel Event Alert #37
 
The Joint Commission recently-issued Sentinel Event Alert #37 (SEA #37), addresses the need for healthcare facilities to improve the reliability of their of emergency power (EP) systems. SEA #37 goes beyond minimum code standards and recommends that organizations take steps in a number of areas to reduce patient risk from both internal and external power failures.

Cameron Bruce Associates can assist your facility in all six recommendations and strategies highlighted in SEA #37.

  • Conduct a gap analysis
  • Conduct a vulnerability analyses on EP systems based on organizations' emergency management plans
  • Complete an inventory for critical areas and systems

While The Joint Commission does not specify a timeframe for completing an SEA, facilities should begin to address an SEA within 60-90 days of publication.

 

 

 

 

 

 

 

 

 

 

 

1042 Country Club Drive, Suite 1C, Moraga, CA 94556
voice 925.376.9220 • fax 925.376.9223 • cba1@sbcglobal.net