Q&A: Ongoing compliance success: Obtain leadership commitment

Q: What are some key steps to consider in maintaining ongoing survey readiness?

A: As the survey coordinator, do you know at any given time what the compliance issues are in your organization? Knowing the organization inside and out is the goal so that when the actual survey occurs, there are no surprises. Integrating ongoing compliance readiness into daily operations allows you to identify deficiencies and build action plans that lead to compliance on a day-to-day basis rather than once every three years prior to survey.

To begin, you must secure the commitment of senior leadership regarding the resources and support that will be needed during the ongoing readiness process. You will find at the senior level leadership level various degrees of interest in the accreditation process. If leadership is not involved and does not openly support the process, you may be faced with barriers when it comes to addressing and resolving issues that are identified. Having said all this, your first step is to determine who the leadership champion or executive sponsor will be for the ongoing process. Who takes the lead of accreditation issues in your organization? Typically, this is the CEO, chief nursing officer (CNO), chief medical officer (CMO), and the chief quality officer (CQO) or senior vice president, depending on your organization’s size and complexity.