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

A: Some organizations have found success in implementing a compliance oversight group. This group reviews the work of the ongoing compliance readiness team, the findings, action plan development, and progress toward meeting improvement goals. The oversight group should involve key leadership and PI management. This group is also charged to provide direction to the ongoing readiness teams and remove any roadblocks the teams encounter. The compliance oversight group provides an outlet for issues to be raised, discussed, and hopefully, resolved. If an issue can’t be resolved due to concerns such as budget constraints, at least the teams are provided direction as to how to proceed. Rather than create a new group or committee, these responsibilities could also be absorbed by a standing quality committee.

Ongoing compliance should not be considered its own silo in the organization. If a stand-alone oversight model is chosen, the oversight group should have a reporting mechanism through the organization’s quality leadership structure as well. Any issued raised should be integrated into the hospital’s quality process as appropriate.