Cedar Grove, New Jersey

• Ongoing review of the Hospital’s clinical and operational performance relative to Joint Commission standards
• Provided ongoing feedback to staff (“in the moment”) and leadership (via meetings and reports) of progress/status for active corrective action plans from the previous Joint Commission survey and current aspects of survey readiness
• Performed a pre-accreditation visit “mock survey” using Joint Commission parameters and format.
• Assisted with the review of accreditation survey findings and development of a corrective action plan
• Continued monthly visits to provide an independent audit of performance on approved corrective actions and continuing survey readiness
• Provided a structured Periodic Performance Review as per Joint Commission requirements.