• Improving Patient Safety Proven practices and proprietary processes that
    improve patient safety and clinical operations

  • Compliance & Accreditation CMS & TJC Compliance and Accreditation
    CMS Survey Prep, Training
    Immediate Jeopardy (IJ)
    Systems Improvement Agreement (SIA)

  • Sterilization and High-Level Disinfection Develop a safe and compliant SHLD program
    Assess for CMS readiness
    Assist with program implementation and validation


Performance Improvement

Clinical Operations Management Systems (COMS) that improve clinical performance and deliver the highest standard of care in full compliance with organizational policies and procedures with each patient encounter.

Organizational Change

Change principles and practices to improve the effectiveness of organizational leadership including; board development, physician relations and developing quality cultures of high reliability.

Compliance & Accreditation

CMS & TJC ongoing readiness and response services. Meet quality and safety requirements and avoid cost-debilitating impact of CMS decertification including, Immediate Jeopardy (IJ), Systems Improvement Agreements (SIA).

Interim Executives

We provide exceptional interim healthcare executives and clinical directors that create an immediate impact while you take the time to find the best possible permanent candidate to join your team full-time.


Productivity Improvement

Integrated healthcare delivery system saves $8 million through pay practice reform and staffing management plan.

Case Management

Hospital saved more than $10 million with Compass case management performance improvement process. Higher levels of reimbursements, shorter stays...

ED Redesign

ED volume grew from 17,000 visits per year to 26,000 while patient satisfaction scores, which were previously declining, have risen to an impressive 98%.

CMS Compliance

100% success rate in bringing hospitals back from CMS Immediate Jeopardy, Systems Improvement Agreements, and Medicare Termination.


Cary Gutbezahl, MD, CEO

Playing it Safe
with the CoPs

Featured in Trustee Magazine

CMS Conditions of Participations (CoPS) define specific duties for hospital boards. Boards may play a bigger role than they know in keeping a hospital's doors open.

Terri Marshall, MS, RN

Why Wait for Analytics
to Identify the High-Risk Population?

Featured in "Case in Point Magazine"

Healthcare providers do not have to wait for the analytics—case managers can be recruited to identify high-risk populations early in a patient’s enrollment...

Isaac Abraham, MS, RN

Treating, Not Boarding, Mental Health Patients in Emergency Departments
Featured in Becker's Hospital Review

ED crowding is exacerbated by the increase in the number of patients with mental disorders, substance abuse problems or both, who present with acute problems.

Victoria Fennel, PhD, RN-BC

How to Prepare for a
CMS CoPs Survey

Featured in Becker's Hospital Review

Surveys are unannounced; however, sometimes there are signals that a survey may be imminent. For example, a patient, member may express their dissatisfaction...

Kate Fenner, PhD, RN

CMS and the
Systems Improvement Agreement

Featured in H&HN Magazine

The Centers for Medicare and Medicaid Services use systems improvement agreements to give hospitals time to respond to an immediate jeopardy...

Fox Business News

Does Healthcare Reform Mean
Good News for Hospitals?

Featured by Dagen McDowell

Compass Clinical Consulting Managing Director Kate Fenner on the impact of the healthcare reform law on the nation’s hospitals.


Compliance Connections

Compliance Connections is a series of web-based educational sessions designed for healthcare leaders interested in staying up-to-date with the knowledge of industry standards needed to keep their organizations compliant while providing safe, quality patient care.

Knowledge Center

Stay informed about the latest issues and challenges facing hospitals nationwide. Our collection of case studies, white papers, interviews, feature stories, and "Profiles in Healthcare Leadership" offer multiple ways to stay current with information you need.

Compliance & Accreditation Journal

Ideas, information, and insights for ongoing Centers for Medicare and Medicaid Services, (CMS) and The Joint Commission (TJC) readiness, including CMS survey preparation, building the capabilities and culture for continuous readiness, addressing specific vulnerabilities or priority areas, and guidance in effectively responding to a low Joint Commission or CMS survey.


Contact us
Compass Clinical Consulting
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