Compliance Library

The provider described in its self-study report the generation of activities designed to change competence, performance, or patient outcomes as described in its mission statement. However, there was no evidence of the implementation of this process in the activities reviewed. The activities… More

The provider described its process of planning a yearly curriculum around the gaps identified for each specialty/care team. The curriculum builds – starting with a root cause analysis of the problem, identifying the educational need (knowledge, competence or performance), and determining the best… More

The provider described its process of planning a yearly curriculum around the gaps identified for each specialty/care team. The curriculum builds – starting with a root cause analysis of the problem, identifying the educational need (knowledge, competence or performance), and determining the best… More

The provider describes a planning process that uses practice data from its departments as the basis for the education. However, in the majority of activities that were selected for review, the provider was not able to demonstrate any gaps nor articulate the educational need for the activities. … More

The provider describes a planning process that uses practice data from its departments as the basis for the education. However, in the majority of activities that were selected for review, the provider was not able to demonstrate any gaps nor articulate the educational need for the activities. … More

The provider asks its learners what topics they want covered at the next annual meeting. As well, in planning its online modules, the provider uses its expert faculty recommendations for hot topics and developing areas of interest that should be included. Rationale: The provider did not describe or… More

The provider asks its learners what topics they want covered at the next annual meeting. As well, in planning its online modules, the provider uses its expert faculty recommendations for hot topics and developing areas of interest that should be included. Rationale: The provider did not describe or… More

The provider has a flexible application process for departments and affiliated hospitals that asks a series of short questions: 1) what’s the problem you are trying to address; 2) how do you know it’s a problem and what do you think is contributing to the problem; 3) are you seeking to change… More

The provider has a flexible application process for departments and affiliated hospitals that asks a series of short questions: 1) what’s the problem you are trying to address; 2) how do you know it’s a problem and what do you think is contributing to the problem; 3) are you seeking to change… More

The provider has developed a planning process, on an institutional basis, that asks planners to describe professional practice gaps and their underlying educational needs. In addition, the provider uses quality and safety data as the basis for its regularly scheduled series. The provider… More