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Patient Safety Structural Measures (PSSM) Toolkit
As part of the FY2025 final rule, CMS is requiring hospitals to participate in the Hospital Inpatient Quality Reporti...
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Browse our extensive toolkit library for helpful tips, tools and resources designed to make your job easier!
Our toolkits are your one-stop-shop for information pertinent to improving processes, identifying best practices, reducing risks, obtaining education information, and much more.
Have an idea or a specific need for a toolkit you don’t see listed here? Please contact Vice President of Patient Safety & Risk Stacie Jenkins at staciejenkins@lhatrustfunds.com to share your suggestion.
Featured Toolkit
As part of the FY2025 final rule, CMS is requiring hospitals to participate in the Hospital Inpatient Quality Reporti...
Learn MoreDisruptive physician behavior negatively impacts patient safety, staff satisfaction and increases the likelihood of medical malpractice claims. Disruptive behavior poses a challenge for leaders in healthcare to address and it is important for leaders to have a plan in place to handle them when they arise. This article from MGMA addresses how to confront physicians with behavioral issues and how to develop an organizational plan of handling disruptive behavior that will promote a change in culture.
This 2019 Joint Commission resource provides a description of regulatory requirements as related to Medical Staff processes and compliance strategies, discusses new standards impacting the Medical Staff, describes common survey findings and provides a description of a successful OPPE/FPPE program.
Provided below is a downloadable PowerPoint presentation on the responsibilities and related processes of the credentialing committee. This is a useful tool in the orientation and onboarding of new committee members, offering an overview of the expectations placed on the committee with regards to patient safety.
The information within the presentation should be used as a guide and edited as necessary to reflect your facility’s specific process.
This presentation provides information about OPPE/FPPE as it relates to a healthcare organization and the Joint Commission. It will:
Healthcare providers and facility administrators can use this sample credentials file chart audit to ensure compliance with hospital standards and policy. The downloadable form provides a comprehensive checklist field including necessary elements of review to ensure credentialing documentation is in place for physicians on staff.
Through thorough assessment using this form, you can determine which physician files at your own facility are out of compliance with proper credentialing procedures, helping to safeguard against accidental oversights and room for liability.
The credentialing process is information-intensive, often requiring a multitude of components for completion. Staying organized and updated on what details you need is important in the successful implementation of the credentialing process.
To stay on target with your assessment process, use our Comprehensive Credentialing Checklist to ensure that all needed information has been verified prior to presenting for next level of approval or review.
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