Continuous Compliance - Maintaining a constant state of regulatory readiness

Continuous compliance - Maintaining a constant state of regulatory readiness

This article first appeared in the May 2011 issue of HFM Magazine.

By David L. Stymiest, P.E., CHFM, FASHE

Continuous compliance also has been called continuous survey readiness. It involves proactively maintaining a safe health care environment conducive to high-quality patient care. It essentially means having staff at all levels doing the right things for the right reasons because they understand those reasons.


Just about all accrediting agencies conduct unannounced surveys or inspections. Even when organizations think they know approximately when the next unannounced survey is due, there is the potential for random unannounced surveys or a for-cause survey. Thus, continuous survey readiness is crucial. Ongoing training and thorough staff involvement in compliance activities are essential because key managers might be unavailable when the surveyors arrive.


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Compliance News: Accreditation Survey Findings Report Includes TJC and CMS Findings

By Dean Samet, CHSP 


In July of 2009 The Joint Commission modified its Accreditation Survey Findings Report to include both TJC and Medicare requirements which were identified as being less than fully compliant at the time of survey. This is primarily for organizations that use The Joint Commission accreditation for deemed status purposes. TJC has developed crosswalks of their requirements to Medicare Conditions of Participation (CoPs) as reflected in a new report format.