Accreditation & Regulatory

Accreditation & Regulatory Support

Welcome to organizational readiness
At Adept Health, we support continuous readiness by building collaborative relationships within your organization. Our goal is to help you deliver safe, high quality healthcare by maintaining organizational readiness and identifying vulnerabilities.
Our accreditation & clinical regulatory department carries out its mission in five fundamental ways:
  • Oversight– prevent and detect noncompliance
  • Insight– make policies and procedures more efficient and effective
  • Foresight– identify emerging issues
  • Adjudication– resolve interpretation conflicts and provide expert opinions
  • Hindsight– use past experiences from the organization to improve the accreditation and regulatory program.
We are here for you with the following support:
  • Assess organizational readiness and vulnerabilities for evaluation by external regulatory bodies (rounds, mock surveys, parity studies, etc.)
  • Educate organizational staff on standards and regulations applicable to their organization
  • Manage survey process for client facilities
  • Coordinate The Joint Commission disease-specific certification and other related surveys
  • Establish and maintain Regulatory Oversight Committees (ROCs) and continuous readiness processes
  • Identify applicable accreditation standards and regulations, and simplify the link between the standard and the organization’s practice
  • Collaborate with leadership in establishing accountability for organizational compliance with standards and regulations
  • Serve as a resource for multidisciplinary teams established to assure compliance with The Joint Commission and other regulations and standards
  • Coordinate the development of client’s policy and procedure processes in conjunction with leaders
  • Assign champions and coordinate responses to complaints, regulatory risk events and sentinel event alerts, and National Patient Safety goals in conjunction with the facility leaders and patient safety teams
  • Manage The Joint Commission and regulatory processes (Evidence of Standards Compliance (ESCs), action plans, policies, Focused Standards Assessments (FSAs), documentation compliance efforts, etc.)
Pre-survey support
  • Mock surveys — Our specialists can give your team a realistic, constructive mock surveys to help prepare for visits from The Joint Commission, DNV, disease-specific certifications, OSHA and many more
  • Command center structure, processing and training
  • Survey notification system and unit check list
  • Board of trustees member of The Joint Commission/regulatory survey orientation materials
  • New senior leader accreditation and regulatory overview and training session
  • Leader education module on Immediate Jeopardy and continuous readiness
  • Accreditation and clinical regulatory consulting services, as requested
During survey
  • On-site or remote survey support upon request
  • Post-survey response and support
  • Clarification/appeal template and support
  • ESC (evidence of standards compliance) template and support
  • MOS (measure of success) template and support
  • Complaint response template and support
  • Immediate Jeopardy response template and support
  • Pre-Joint Commission (PJC) regulatory review of comprehensive systematic analysis (CSAs), either independent or in preparation for The Joint Commission submission, if required
  • Orientation and training pathway for facility accreditation and regulatory-appointed person
Wisdom when you need it
  • Weekly networking phone calls with Accreditation & Clinical Regulatory department to review The Joint Commission, CMS state agency regulatory updates
  • Survey observations and experiences
  • Participation in The Joint Commission Focused Standards Assessment (FSA) synchronized process from January to April each year
  • Corporate opening with opportunities to network and meet surveyors, including The Joint Commission lead surveyor
  • Annual continuous readiness workshop with accreditation and regulatory team
  • Annual ambulatory workshop focusing on The Joint Commission regulations
  • NH EC-APET — Accreditation practice exchange for EC, LS and EM. Review of The Joint Commission findings and updates
  • Policy management software and services and strategies
Additional resources
  • Continuous readiness roadmap
  • Regulatory Oversight Committee structure
  • Accreditation & Clinical Regulatory Focus newsletter