Are you Ready? Regulatory Readiness in Healthcare

Preparing a healthcare organization for regulatory surveys (inspections) conducted by accrediting agencies is an ongoing, intensive, collaborative endeavor. These on-site survey visits, and an organization’s subsequent actions validate that safe, high-quality care is always provided in a clean and functional environment.  How often organizations are visited for their preparedness depends on the accrediting or regulatory/government agency involved. 

The healthcare industry is governed by a variety of agencies who do not just trust but verify and visit to observe the care provided to patients and directly witness safety practices applied by staff and providers. Regulatory bodies such as the California Department of Public Health (CDPH), The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), the Occupational Safety and Health Administration (OSHA), Accreditation Association for Ambulatory Health Care (AAAHC) and numerous others.   

Each of these regulatory bodies has established standards and regulations (or rules) which must be followed by organizations, many times in order to receive payment for services rendered. Surveyors spend a lot of time on the patient care units and in the support services departments interviewing individuals, therefore educating them, and helping them understand the “why” and “how” behind a regulation and its connection to the provision of safe, quality care and task performance is very important.  

Regulations and standards should be easily accessible to staff and leaders; however, this is not always the case. Additionally, the interpretation of these standards is not always clear when read and applied to practice. 

Should you utilize a consultant to assist in the readiness of your healthcare organization, make sure the consultant has direct experience with healthcare accreditation, is knowledgeable in the survey process, and has access to your last survey results.  Utilizing a consultant is a great way to “practice” what the real thing will be like next time.