Operationalizing Survey Readiness: A Framework for Daily Excellence

Maintaining continuous survey readiness is vital for rural and community healthcare organizations—but it’s also one of the toughest challenges amid staffing shortages and patient care demands.

This session explores how rural leaders can move beyond reactive checklists to build a proactive, organization-wide culture of compliance and quality.

Learn how to identify system-level vulnerabilities, use process improvement methodologies to address root causes, and create a sustainable readiness strategy that improves outcomes before the survey team arrives.

At the end of this session, you’ll learn how to:

  1. Identify the foundational components of an effective survey readiness program and explain their impact on clinical quality and compliance.
  2. Apply process improvement tools to analyze and address root causes of non-compliance within their organization.
  3. Develop a sustainable, cross-departmental action plan to ensure continuous readiness and improve patient safety in advance of accreditation surveys.
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Q&A

How do you assess clinical documentation compliance and alignment with CoPs or accreditation standards?

We would recommend developing a template of specific CoPs and other regulatory requirements as a starting point. After you audit for 3-6 months, you will likely see themes that can then be addressed by creating a Proactive Plan of Correction (PPoC)

What is your approach to testing staff knowledge of regulations like EMTALA or Swing Bed CoPs?

We recommend that staff first receive orientation and annual education on EMTALA and the applicable CoPs relevant to their scope of work. At huddles and staff meetings, “quiz” staff regarding these regulations. Make it fun and provide small prizes. We have also seen organizations create games such as” word find” or others within newsletters. This practice can encourage the staff to read the newsletter while providing an opportunity for competition and fun.

How are these dashboards accessed?

The 2567 Dashboard is located here.

Do you provide staff education or survey readiness training sessions?

Yes. We can tailor learning opportunities to meet your organization’s specific needs.

How often do hospitals need to do this? What is your recommendation?

We recommend staying survey-ready by developing a proactive plan for identifying areas of concern. It can be beneficial to have an outside evaluation to assist the organization in developing key areas of focus, including daily, weekly, monthly, and quarterly objectives.

How far in advance would you recommend we prepare for a survey?

As stated above, you should maintain survey readiness, including annual mock surveys, either completed in-house or through external assistance.

Is there a required frequency for policies to be reviewed example Q1 or Q3 years?

Policies and procedures must be reviewed/revised every 2 years unless otherwise outlined in the CoPs or through specific state regulations.

How often should we have an outside party come in to review our processes to make sure we are in compliance?

We recommend annual mock surveys, either completed in-house or through external assistance. The benefit to external assistance is having “fresh eyes” to see something you may not see.

How often by percent of surveys completed by an accrediting agency or a state agency does CMS do a validation survey? OR - any triggers that alert CMS to visit the rural hospital?

We have found no data indicating the percentage of validation surveys; however, CMS can complete both direct observation and look-back surveys, creating a two-pronged validation process.

Are there checklists available that would be great for CAH?

There are checklists for purchase through AOs and other suppliers, and if you utilize an external resource to complete a mock survey and/or other education, they usually provide the organization with checklists.

Do you anticipate additional audits with recent anticipated increases triggered by the new administration?

It is difficult to know how the typical survey processes may be adapted due to the changes at CMS. We may see no impact, more surveys, or fewer due to potential staff shortages.