by Diana Scott
MHA, RN, CPHQ, Senior Director, Accreditation Advisory Services


“Game over.” It’s the angst clinicians feel as they realize it’s only a matter of time before they see the accreditation surveyors coming through the door. Adding to the angst is the fact that The Centers for Medicare & Medicaid (CMS), as the consumer advocate, is pushing for a more straightforward review by the accreditation organizations, such as CMS’ “see it-cite it” methodology. Instead of accepting 90% as an acceptable opportunity for improvement, 100 percent compliance is expected.

But what if we changed the approach from game over to game on? What if the focus was on being continuously compliant with regulations and accreditation requirements instead of just when we felt a survey was imminent? That’s the level of care and safety that we expect for our family members and ourselves, right? We certainly don’t want to wonder which physicians and nurses are working in the ED when our family member rolls through the door!

Here are a few ways your organization can migrate to a game-on approach and begin to use time and energy proactively to be continuously compliant and ensure you are providing safe, quality care.

Conduct an internal assessment to identify the areas that are proving to be the most challenging when providing evidence of compliance. Have individuals in the role of regulatory and compliance – who are experienced and knowledgeable in the standards – conduct the assessment using the patient tracer methodology, a key part of The Joint Commission’s survey process.

When assessing internal compliance, it’s not about how many units or departments your compliance assessment team can get to. It’s about drilling down to find what the real compliance challenges are. Using the patient tracer methodology, assess care of the patient from door to discharge, whether it’s an inpatient or outpatient service. It’s an excellent strategy to evaluate the whole process. 

A great way for individuals to see firsthand what is actually occurring and become personally more knowledgeable about the requirements is to engage staff and managers in the assessment process. To aid in this approach, those with knowledge and experience can create user-friendly audit tools in a yes/no format that make it quick and easy to evaluate compliance and tally the results. This allows the organization to prioritize any areas of deficiencies and to dedicate resources – human or financial – to achieve compliance.

Senior leaders have overall accountability for the organization’s performance and want to be informed where the organization stands on the fundamental requirements of quality and safety. Report the outcomes of your internal assessment and the status of compliance on problem areas to the senior leadership team so they can provide support and the necessary resources to resolve issues.

These strategies move your organization from game over to game on. Your leadership team can have confidence that CMS and accrediting organization requirements are being continuously met, every day by every staff member. Organizations with a “game on” mentality strive to be continuously compliant. They refuse to suffer the angst that comes with playing survey roulette. Instead, they use that time and energy for actions that help them to be compliant at all times.

To read more about continuous readiness, click here.

About the author. An accomplished nurse and consultant, Scott leads accreditation advisory services for Vizient. In this role, she provides direction and support for member organizations’ compliance with The Joint Commission (TJC) standards and CMS Conditions of Participation (CoPs). Her areas of focus include mock survey assessments, education programs on TJC standards and CMS CoPs, onsite coaching during surveys, and post-survey activities, including adverse decision response. Diana has participated in more than 250 TJC accreditation surveys over the past 17 years.

Published: July 13, 2017