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


An alphabet soup of regulations, guidelines and standards, all competing for resources, some financial and almost all involving human capital to implement and execute, are coming at clinicians and hospital administrators faster than the F-18s that fly over my neighborhood in Virginia Beach. The speed and pace of change in our industry have managers’ and staffs’ heads spinning. The first challenge is staying on top of the information that is coming fast and furious while also verifying the source of truth. The second challenge is effectively communicating information about the change to the organization.

Many of our partners in the health care industry – AHA, CMS, CDC, to name a few – do a great job of summarizing changes through subscription email services, journals and websites, but how do you sort through the ‘must dos’, the ‘should dos’ and the ‘think about its,’ then prioritize the initiatives and the resources to maintain regulatory and accreditation compliance?

Three strategies for staying on top of the information
While each hospital is unique, the following strategies can help manage the flow of information. 

  1. Identify existing departments or functions in your organization to partner with that are most impacted by specific regulatory agencies. For example, most organizations have an environment of care or physical environment committee. Request that this group track regulatory changes pertinent to the NFPA 101: Life Safety Code®. Another typical committee in your organization is infection control and prevention. This is a great team to track changes coming from the CDC. Ask a representative from these committees to report in on a routine basis at your accreditation/regulatory council meetings to facilitate coordination of new information.
  2. Develop a standardized report template that makes it hassle-free for a department representative to share the essential information. The template should include fields for:
    • Source of truth, i.e. the regulatory or accreditation agency
    • What the change is
    • Effective date
    • Is it a mandated ‘must do,’ ‘should do’ or a ‘think about it?'
    • Anticipated resources needed to make the change
    • Who will be the change champion?
  3. Establish a multidisciplinary forum responsible for designing and executing compliance action plans with leadership representation to break down barriers and expedite implementation of new regulatory requirements. Assign a project leader who would be accountable for the timeline and completion of the action plan. Schedule periodic progress reports for the accreditation/regulatory council that include data to verify the change has been executed and sustained.

Vizient believes it’s important to model the best practices we advocate so our accreditation team compiles a monthly Continuous Patient Safety Readiness Plan which reflects all changes that have occurred in a succinct and actionable format. This document is a goldmine of information that makes it easy for accreditation and regulatory leaders to quickly see what the priority action items are for the upcoming months.

Staying abreast of regulatory changes is not for the faint of heart. But through teamwork, continuous communication, and leadership involvement, the challenge is manageable and can be done systematically to achieve regulatory and accreditation compliance, resulting in better patient care and patient and workplace safety.

For information about Vizient’s accreditation solutions, click here.

About the author. An accomplished nurse and consultant, Diana 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: October 26, 2016