Healthcare News & Insights

Four crucial practices to ensure survey readiness amidst regulatory changes

Regulatory requirements have undergone considerable changes in the past year, adding urgency and pressure for healthcare leaders to upgrade their compliance efforts. In this guest post, Larry LaCombe, VP of program management and facilities compliance at a company specializing in facilities management, safety, environment of care, emergency management and compliance, details four crucial practices healthcare facility must implement to achieve 24/7 survey readiness.


The introduction of The Joint Commission’s SAFER™ matrix, exclusion of Plan for Improvement (PFIs), expanded Life Safety Code and a shrunken timeline for correcting deficiencies all mean one thing: Waiting to address regulatory deficiencies in the months before a survey, as was common in the past, is now a recipe for disaster. Rather, healthcare organizations must pursue 24/7 survey readiness, staying vigilant to prevent, spot and correct problems on a daily basis – long before a surveyor spots them.

It’s easy to feel overwhelmed under the weight of such a lofty goal, but know that it’s well within your reach. To achieve 24/7 survey readiness, it’s helpful to cultivate four simple but crucial practices:

Be your own watchdog

Perform a self-assessment now to review potential deficiencies that could fall on the new SAFER evaluation matrix spectrum that’s used by The Joint Commission. Then repeat it periodically.

When evaluating the likelihood that a deficiency could cause harm to a patient, staff or visitor, it’s important to be critical, channeling the most demanding surveyor you can fathom. The SAFER matrix recognizes low, moderate, and high ratings. The low rating only applies to risks where harm would be extremely rare, while those with potential for occasional harm are ranked as moderate and the high rating is reserved for areas where harm could happen at any time.

In terms of scope, the SAFER matrix recognizes limited, pattern and widespread deficiencies. Note that the limited rating is designated for isolated incidents. Even two occurrences of the same deficiency, whether they’re rated low, moderate or high, can escalate it to a pattern.

For all deficiencies cited within the matrix, remediation must be completed and Evidence of Standards Compliance (ESC) documentation submitted to The Joint Commission within 60 days. High-risk deficiencies (limited, pattern and widespread) and moderate-risk deficiencies (pattern & widespread) within the matrix do require additional documentation of sustained correction efforts in the ESC, including leadership involvement and preventive analysis. Note that for those deficiencies, future surveyors will have access to those deficiency records for re-evaluation in subsequent surveys.

Be mindful that self-identification of issues no longer secures a greater timeline for correction, nor does it mean those deficiencies won’t be cited in the survey. But it’s still a good practice to track self-identified deficiencies in the time between surveys. This will allow you to address large-scale problems, like compliance with new Life Safety Code standards, well in advance of the survey so your facility has adequate time to budget for and implement corrections that might otherwise be impossible to achieve in the 60-day ESC window.

Don’t just pay attention to your own organization. Identifying industry survey trends – common deficiencies The Joint Commission is focusing on – is a relatively simple way to avoid the same hits at your facility. If hospitals are getting “dinged” on door latching, air exchange and pressure relationships, it would be wise to look at those same areas in your own facility.

One last note on self-assessments: Ensure you have a basic understanding of The Joint Commission’s annual ORYX performance measure requirements. This is a quality initiative that embeds performance and outcomes into The Joint Commission’s accreditation and certification process. Even if your survey isn’t due for a year or more, you’re still required to report yearly for an evaluation of performance.

To this end, your organization can provide chart abstractions, electronic Clinical Quality Measures (which are also required by the Centers for Medicare & Medicaid Services (CMS)), or a combination of both. While collecting and submitting this performance report may not be the explicit duty of hospital executives, they should at least understand the requirements and be confident the information submitted represents the facility’s compliance with The Joint Commission standards.

Stay organized

When a surveyor steps into your facility and sees staff scrambling to find compliance documentation, it raises red flags to that surveyor, increases his/her level of scrutiny and turns up the stress level for everyone. Clearly, you can’t prove to a surveyor that compliance goals have been achieved, if your records aren’t neatly organized.

You can avoid this by enforcing clear policies and procedures that ensure your documentation is easily accessible, up-to-date and consistent.

Whatever method you adopt, creating and enforcing policies that guarantee organized documentation is one of your chief responsibilities as a hospital leader.

Communicate the what & why clearly

Your staff can’t incorporate compliance standards into daily practices if they don’t understand them.

How will self-identified deficiencies be addressed? When will improvements begin and end, and who’s responsible for what? And why must they do certain things a certain way? Clear communications can be as simple as a visual timeline for testing all fire alarms or setting a date when all staff will complete a required training.

Staff shouldn’t know just what is required of them, but why. How does the requirement impact safety, patient care or the work environment? What’s at risk if the requirement isn’t observed? Understanding the why will go a long way to motivate staff to carry out their tasks in a compliant way and help them articulate a compelling justification to patients when challenged.

Don’t go it alone

No one expects you to know all the answers, and no hospital can do it alone. Astute leaders know their limits and don’t waste time trying to reinvent the wheel.

Whether it’s hiring a contractor to inspect and repair fire systems or training new hires about documentation requirements, the most successful hospitals are those that find trusted allies to advance their compliance on a daily basis. In any case, get in front of compliance concerns by developing your own, internal compliance training or partnering with a reputable expert.

As you strengthen your regulatory compliance efforts, not everything will go according to plan. Setbacks will happen. But your organization can bounce back quickly if good processes are in place.

By breaking compliance into smaller, actionable tasks and finding a trusted advisor to share those responsibilities, you can turn a massive undertaking into a matter of daily routine.

Larry LaCombe is the VP of program management and facilities compliance at Medxcel Facilities Management, specializing in facilities management, safety, environment of care, emergency management and compliance.

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