"Our organization has been a member of Georgia’s Continuous Service Readiness Program since its inception in 1997. During any past three-year period our hospital has had 12 regular visits totaling 36 hours of on-site consultation. That consultation has consisted of:
reviewing documents and offering suggestions for improvement;
updating staff on new/revised standards
assistance with the SOC and environment of care documentation plus touring the building for Life Safety Code compliance;
educating and mentoring selected staff in performance measurement and improvement concepts including the "how-to" of Root Cause Analysis and Failure Mode Effects Analysis and Criticality;
consultation with our leadership as we have merged two hospitals and two medical staff into one organization and one medical staff;
evaluating all of our 20+ outpatient clinics for safety and compliance with standards;
cross-referencing our medical staff bylaws/rules and regulations with standards for compliance and spot checking our credential files;
evaluating our personnel files for compliance with standard requirements;
validating standard compliance in the open and closed medical records; andThere is at least weekly and sometimes-daily contact with our regional representative about our being in compliance with standards plus assisting us to strive for excellence in our goal of providing safe and quality patient care.” --CSR Georgia member organization