Q&A: Issuing the findings report

Q: What is the best way to present the findings report to my organization?

A: Once you have identified your findings and have categorized them, it is important to share them with leadership so that you have the appropriate resources assigned to address and resolve any issues identified. It is always helpful to classify the risk to the organization on the report. For example, which findings are direct impact, affect situational decision rules, or are priority focus areas? Make sure that leadership understands the impact of these findings. Be clear about communicating the link to the CMS CoP and the various accreditation decisions.

Present the summary by standards chapters and by standards. Organizations that do this have listed the outcomes data by chapters, indicating the total number of standards, those scored compliant, and those scored noncompliant; then, after the noncompliant section, they list a breakdown by category. Using a stoplight (red, yellow, green) approach for the findings report gives a good visual and delineates which categories are in compliance (green), which are partial or approaching compliance )yellow), and which are noncompliant (red).

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