Upcoming Surveys CMS Transplant Survey Patient Safety Licensing Survey TJC Hospital Licensing Survey All surveys in open window for a visit No announced dates File review session will be part of all surveys May 2012

Lessons Learned from Recent Surveys ALWAYS keep Health System HR in the loop. Health System HR should be the first area contacted when a file is requested, BUT if any Department is called directly for a file, follow-up with HSHR ASAP. All Med Ctr and DGSOM personnel files go through Health System HR for final review prior to any survey interview. Be clear about reason for file request when speaking with HR personnel so both parties can work together for fast and accurate outcome.

Going Forward… Complete diligent review of personnel files. Continue to track HR Competency Reports. Inform staff/mgrs what requirements are coming due or overdue. Be extra mindful of credential expiration dates. Must have current online verification printed prior to expiration date and placed in file. --Staff cannot work with an expired license, not even with a cancelled check and copy of renewal paperwork