by Twila Loudder
Accreditation Advisor

There are no secrets to success. It is the result of preparation. — Colin Powell

Maintaining and sustaining continuous accreditation compliance is a challenging endeavor during “normal” times for the accreditation professional. What is going on currently should just be viewed as part of the job, right? No, there is nothing routine about the job today.  Today’s environment requires an accreditation plan that reflects leadership commitment to compliance and empowers accreditation professionals to monitor regulatory changes and strategically meeting the requirements while dealing with the ripples of the COVID-19 pandemic.

The current public health emergency created by the novel coronavirus disease 2019 (COVID-19) has changed the focus of a “normal” day in the life of many health care professionals, including accreditation professionals. They may have been asked to pivot from compliance activities, including accreditation survey activities, data management and quality improvement to engaging and implementing pandemic response activities. However, when the pandemic subsides, accreditation professionals must pivot back to primarily focus on regulatory and accreditation compliance. 

Here are five key strategies to help refocus your team during this pandemic and resume proactive, continuous accreditation compliance to help ensure your organization is always “survey ready.”

  1. Engage leadership early and often for support. Leaders are crucial in influencing and advocating for change. How an organization engages in accreditation activities begins and ends with leadership. This includes senior leaders, department managers, medical staff and the governing body. Engage them proactively in post-pandemic planning and keep them engaged by meeting frequently. Leaders want and need to know where there are regulatory compliance gaps.  Leader engagement breaks down barriers and facilitates the necessary changes through allocation of resources, including financial and human resources.
  2. Conduct regular assessments of regulatory compliance. To fully understand the impact of pandemic-related activities, organizations must assess for policy and process modifications that intentionally or unintentionally occurred. Your organization will need to determine if those changes can be maintained post-pandemic or if they were put in place based on temporary regulatory allowances, e.g., reusing personal protective equipment. Assess conditions using online tools to make it easy to get staff feedback.  Discussion with staff and leaders during staff and committee meetings, and short one-on-one meetings can also provide valuable insights. As pandemic conditions diminish, when talking with employees, it will be important to be sensitive to their frame of mind. Chances are, everyone including leaders, physicians and staff may be mentally, physically, and emotionally exhausted as they recover from the emergent processes implemented to care for COVID-19 patients.
  3. Review the organization’s response to COVID-19. Identify and understand what gaps may have evolved or were discovered. Perhaps protocols around emergency provider privileging blocked available clinicians from being able to assist in the pandemic response, or contingency strategies for providing personal protective equipment (PPE) weren’t immediately accessible to staff who needed it. Maybe there were gaps in the organization’s infection control plan for management of an unprecedented influx of infectious patients. Whatever the gaps, only after a thorough assessment has been performed will the organization be able to plan and take actions for the future.
  4. Plan for recovery. Based on assessments and re-evaluations, create a recovery plan for your organizational accreditation program. The recovery plan should include goals and objectives and focus on areas of vulnerability. Think patient and staff safety first and foremost. One goal might be to update your plan for the influx of infectious patients. Be sure to review and include current clinical and epidemiological information from local, state, and federal resources. Another goal might be to update your emergency provider privileging process. Be sure to include members of the internal medicine, cardiology, infectious disease, pulmonology, neurology and surgical departments. Another goal may relate to your PPE contingency strategies. Using information from the gap assessment you can develop specific strategies for each department or unit. Set a deadline and communicate with all stakeholders once the plans and policies have been updated. By remaining focused on everyone’s safety and achieving quality patient outcomes, planning and prioritization requirements will appear obvious and allow you to spend precious time, effort, and resources where most beneficial.
  5. Educate employees on new or improved strategies. Assessment, evaluation, and planning are only pieces to getting your accreditation program back on track. Educating employees on new policies, processes, and priorities will be crucial to the success of maintaining and sustaining the organization’s regulatory compliance plan. Be flexible in the delivery of the education. Consider the audience and the time and effort it will take to complete the education. Consider using an online learning management system (LMS). Education delivered via an LMS can provide swift, consistent, and organization-wide training in easy to manage sessions. When using written material or classroom-taught education, be sure to use sign-in sheets to document “attendance” of your employees. Lastly, don’t forget to add the “why” to the education. Adult learners must understand the “why” that drives change to fully embrace and implement it.  

In summary, engage leadership early and often, assess how the pandemic affected your organization, and determine where you actually were in your accreditation compliance plan before COVID-19 and where you are as the crisis subsides at your organization. Meet with leaders in short bursts to limit their time away from their other duties. Once the recovery plan is created, education of everyone involved will be key to achieving success. Finally, do not forget to document all your recovery activities. Take credit for your improvement activities and leverage them when surveys resume. Learn more about Vizient’s Continuous Accreditation Compliance program and how we can help.

About the author.  As Accreditation Advisor, Loudder is responsible for delivering Accreditation and Regulatory Services to members encompassing hospital, ambulatory and critical access organizations. She provides content expertise on CMS conditions of participation and The Joint Commission (TJC) accreditation standards. She conducts compliance assessments, on-site or virtual coaching during TJC surveys, and provides educational presentations on accreditation and CMS compliance requirements.

Published: August 10, 2020