When it comes to regulatory readiness every organization has the same goal: TO BE PREPARED. While there are several different paths a hospital or healthcare network can use as an organization to be prepared; many use tracers and/or rounds to track and ensure compliance for readiness. While this is the best path, there are some additional items that you can do to ensure your organization is prepared in the event of a regulatory audit.
- Compliance is Key. An organization needs to be educated with compliance requirements of not just the Conditions of Participation but also the Conditions of Coverage. Set compliance levels in your rounding application to track your performance against those levels making it very easy to identify areas in which you may have an opportunity for improvement. This best practice goes beyond ensuring compliance with Conditions of Participation and Coverage but also state standards, The Joint Commission and DNV, based on your accrediting body. Often a solution can link questions to standards for the best possible method of tracking compliance. A good practice is to create surveys based on the most common findings. Finally, as standards are updated make sure your rounding partner makes the necessary updates to your solution.
- A Culture of Safety: It may seem odd to even mention safety but often it still bears repeating. By always having patient safety at the forefront you are going to have an easier time with compliance. This means always focusing on some of the areas surveyors focus on such as fire safety, infection control, patient falls, surgical safety, ligature risks etc. When everyone works toward a common goal of a culture of safety items often get fixed before they even occur ensuring a higher level of regulatory readiness.
- Teamwork: Ensure you have the right team in place to help monitor regulatory compliance. If you don’t already have a team in place, create one. Select members to sit on this team from different disciplines and levels of the organization to get greater adoption across all levels. As a part of this team assign a top leader. This leader is responsible for compliance, tracks survey completion, reviews reports and issues and works with hospital leaders to set the direction. This is also the go-to point in charge of data when your organization has an audit. Having a subject matter expert ensures the most seamless audit.
- Repeat Offenders: Don’t just round to round. Make it productive by identifying issues/deficiencies and put a corrective action in place. Proactively fix issues quickly so they don’t negatively impact compliance scores. Make repeat offenders a focal point by creating rounds specific to ensuring the corrective process is working. In sum, always audit your current compliance and act quickly and swiftly.
- Analyze Your Data: As an organization, a continual review and analysis should be completed on your data. Understand the areas in which you are compliant and the processes that are successful in those areas, so they can easily be transferred to areas that require more focus and process improvement.
By constantly auditing your compliance efforts and making sure your hospital is prepared there is no longer the stress and worry about a surveyor appearing at any time. Your organization will be in a state of regulatory readiness.