Leadership Accountability for Survey Readiness

Surveys by accrediting organizations are a means to determine if a healthcare organization’s performance is aligned with their established standards for quality and safety.  More than ever before, these agencies are holding leadership accountable when the facility fails to meet established accreditation and/or regulatory requirements.

In any healthcare organization, leadership’s first priority must be  to ensure the safety of patients, employees, and visitors. This includes the delivery of safe healthcare services and ensuring a safe environment in which to deliver and obtain these services.  To accomplish this, leaders must ensure they are creating the culture and establishing processes that embrace safety, provides sufficient oversight of services and assesses the organization’s compliance with regulatory requirements.

Leadership Engagement

Although successful organizations utilize checks and balances each day to ensure they are aligned with established safety regulations, it must still submit to periodic review by regulatory bodies.  Leaders must ensure they are familiar with their regulatory agency’s survey process and expectations of compliance.  Most important is that leaders have a team who are competent in the details of the regulatory requirements, maintain vigilance in requirement changes and are trusted to provide a clear analysis of the organization’s current compliance status based on internal reviews.

Leaders must ensure that their organization and staff are in a state of constant survey readiness.  This requires active engagement with their team members, holding them accountable to regulatory standards and supporting and celebrating their efforts in achieving compliance.  Participating in mock survey activities, conversing with process owners about safety concerns and challenging/mentoring middle management members to know their people and their processes are other strategies that leaders can employ to engage with their team.

Many organizations include within their committee structures a dedicated committee to Accreditation & Regulatory Compliance and Readiness. Key leaders from within the organization serve as members to support the organization in the management of barriers to compliance and to reinforce the importance of compliance to the organization.  To support the committee's work, some organizations utilize dashboards or Performance Improvement Teams to both share data on compliance and to facilitate organizational changes when non-compliance is identified. Committee members are selected in a manner to ensure representation of services lines provided by both internal resources and external resources to the organization’s patients.

Leaders must be involved in reviewing both the data and data analysis from monitoring activities and ensure that they are using this data to drive organizational change.  They must ensure they are part of the reporting process for data from major safety concern areas such as infection control, medication management, patient safety and workplace violence.  Areas of concern that are identified must be addressed and communicated throughout the organization to ensure transparency and commitment to improvement.

During actual survey events, leaders play a central role by representing the organization to the survey team and setting the tone of the survey.  They must ensure their team responds quickly, in an organized fashion, in addressing any safety concerns expressed by the survey team.  This will ensure they convey their dedication to patient safety and support of the regulatory process.


Leaders play a critical part of their organization in supporting safety for both patients and their staff.  As a result, they are now being held to higher degree of accountability for this responsibility.  Their guidance in establishing a robust culture of safety and engagement in preparing their organizations for survey will be important actions in eliminating patient harm.

To learn more about how we can help with Leadership training and programs contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.

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