In June 2021, CREF was given a 90-day preparation period to ready 5 newly acquired hospitals for reaccreditation survey – a program that typically takes 6-12 months. With 1 survey already overdue, and 2 imminent, the risk was high, and action was needed – quickly.
To further complicate the situation, these 5 new sites also had to transition their Computerized Maintenance Management System (CMMS) to another version amidst the acquisition.
With a compressed timeline, CREF immediately deployed a team prior to closing to ready on-site staff, review documentation, complete a full life safety and environmental audit of the buildings, and develop a plan to remediate any risks.
Throughout the survey process, CREF provided physical on-site support, weekly reports on open-and-closed items, and was instrumental in challenging, and ultimately correcting, one of their findings during the clarification process – a rare occurrence within The Joint Commission.
CREF mitigated 1,044 findings identified during the initial life safety and environmental audit, across the 3 hospital locations, and wrote a corrective action plan within the 90-day timeline.
At the Triennial Reaccreditation Survey, the Joint Commission found only 7 low-limited level findings at 2 of the sites, in total, while the other site had 12 moderate-to-low limited findings: an improvement from 2 serious condition level findings in their previous survey.
Through CREF’s regulatory program and iCREF’s proprietary software platform, the survey was a success. Our services eliminated the need for resurvey, resulted in a positive reputation for our client - cited publicly, allowed for less serious deficiencies - meaning less business interruption, allowed for zero unforeseen costs, reduced premium labor costs, and improved patient safety, experience & quality of care.