Regulatory Survey Activity Is Coming: Will You Be Playing Offense or Defense?

5 minutes

Hospitals have faced a considerable number of challenges during the pandemic, from managing shrinking margins to adapting to “surge standards of care.” Responding to regulatory and accrediting agency activities has not been one of these concerns, but as surveying activities resume, quality and safety scrutiny will be higher than ever in the days and months ahead. While hospitals cannot afford the cost of fending off severe regulatory findings, they also cannot afford to waste precious resources addressing minor, often inconsequential, issues. It is now more important than ever for hospital leaders to play offense and, not only ready themselves for survey activity, but also identify and solve the issues that truly impact safety.

As surveying resumes, hospital leaders need to understand the root causes of persistent vulnerabilities and take deliberate steps to mitigate risks once and for all, providing their organizations and patients with a true sense of safety. A practical approach to survey readiness — focused on efficient processes and high-impact, sustainable improvements — can help build a culture of compliance and ensure your organization is on the path to high-reliability care.

Preparing Your Organization for Heightened Scrutiny

As the COVID-19 pandemic initially took hold of the nation, survey agencies shifted from enforcement to a supportive approach. Accreditation surveyors were taken out of the field; state survey agencies were busy approving new testing sites; complaint investigations and follow-up surveys were conducted virtually or deferred; and waivers were plentiful. Survey agencies have now begun to slowly re-engage with hospitals and other healthcare organizations. While agencies will continue to support expansion of care delivery, their primary responsibility will be to ensure healthcare organizations are ready for potential future waves of novel infections and strictly complying with safety and clinical quality standards.

Organizations must prepare themselves for what’s to come — heightened agency scrutiny, expanded areas of focus and reduced tolerance for non-compliance with regulations and standards. As policies, minutes and data are more thoroughly reviewed through the new off-site, virtual pre-survey document review, there will be more significant findings related to burdensome policy expectations and lack of effective follow-through. Avoiding adverse actions will require identification and remediation of high-focus vulnerabilities and Joint Commission “hot spots:”

Pre-Pandemic Areas of Focus

  • Procedural-based infection prevention (i.e., high-level disinfection and sterilization)
  • Suicide prevention
  • Leadership
  • Environment of care/Life safety


New Post-Surge Areas of Focus

  • Respiratory and COVID-related infection prevention
  • Emergency preparedness/planning
  • Employee assistance
  • Behavioral health

From Surveys to Continuous Compliance

The Joint Commission and other accrediting organizations are now, more than ever, focused on sustained compliance with regulations and standards. Since 2016, the frequency of “significant” Joint Commission findings triggering follow-up surveys has increased substantially — the percentage of hospitals receiving at least one condition-level deficiency (CLD) jumped from 34 percent in 2016 to nearly 57 percent in 20191. The SAFER prioritization scheme and more consistent identification of CLDs during accreditation surveys is leading to greater focus on repeat, high-importance findings, triggering adverse actions for a growing number of organizations. The recurrence of significant findings now results in an escalation of adverse actions up to and including loss of accreditation. It is critical that hospitals take the long view of compliance and ensure that credible processes are in place to identify, remediate and monitor significant compliance concerns.

1 The Joint Commission Fact Sheets.

Our 3-step Approach to Survey Readiness and Response

The typical Joint Commission survey report has about 40 findings, and the number is growing day-by-day. CMS and State Agency reports can run in excess of 100 pages, and the hospital only has a few weeks to address them all. Yet accreditors and regulators have dwindling patience for repeated, unresolved significant issues. We know what works and what doesn’t:

What Doesn’t Work

  • Trying to craft permanent fixes to 100 pages or more of findings within a few weeks.

What Works

  • Our 3-step approach to survey readiness and response.


  • Resolve with the minor and inaccurate issues simply and with minimum overhead.
  • Identify the 5-25% of findings that are truly significant and must be fixed once of for all.
  • While crafting a response that will pass the follow-up survey or suffice as evidence of standards compliance, don’t kid yourself that the significant, systems defects have really been fixed.


  • Identify the underlying causes of the truly significant issues.
  • Establish oversight for systems improvement: assign accountability, establish time frames, provide support, and track success.


  • Permanently fix broken systems once and for all by clearing away the mountains of policy requirements and endless demands for documentation: make the right thing to do the easy thing to do.
  • Provide point-of-care education, monitoring and feedback.
  • Take all the time you need … as long as the underlying problem is truly and completely fixed long before your next survey.

Putting Your Game Plan Together

As hospital leaders regain their footing and prepare for the restart of survey activity, they must ask: “Have we created a true sense of safety? Is our organization prepared for when regulators come to the door?” A survey readiness assessment or mock survey can help your organization target resources, time and focus on issues that are most impactful before they become a safety concern or finding.

Our clients consistently report that they perform very well on CMS, state and accreditation surveys; have fewer adverse events; and are better able to focus on and resolve the truly important issues once and for all. Organizations that have taken a proactive stance have found a far more cost-efficient approach than responding to findings in “crisis mode.” As a recent Greeley client shared, “We have saved a lot of money by looking ahead and making corrections in a timely and efficient manner, using sound financial management, rather than trying to fix problems during accreditation crunch time. A mock survey is not just about addressing deficiencies and preparing for accreditation, but about establishing good practices and sustained compliance.”

Through intentional, forward-looking assessment and preparation, your organization can be ready for the heightened scrutiny from accreditors that is sure to come and well-positioned to deliver a safer future for your patients and community.

© 2023 Chartis Clinical Quality Solutions. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors. It does not constitute legal advice.

Related Insights

Contact Us

Get in Touch

Let's work together to tackle your most complex challenges.

Contact Our Team
Chartis High Reliability Care Solutions