Resource Library-Continuous Compliance and Survey Readiness

Video Transcription

Video Summary

Megan Turby explains how continuous compliance supports ongoing survey readiness and enables stronger quality improvement. She frames continuous compliance as a repeating cycle—define, measure, improve, and control—similar to the Plan-Do-Study-Act model. “Define” starts with building policies, procedures, and daily practices around non-negotiable requirements: state and federal regulations, billing rules, and applicable laws (e.g., HIPAA, OSHA, life safety, Stark, anti-kickback). Accrediting body standards (e.g., Joint Commission, ACHC) and other guidelines (CDC, WHO, specialty organizations) should also be incorporated.<br /><br />She emphasizes assessing policies with an “auditor’s eye,” tying each policy to specific regulations, and delivering practical education using the “5 Ws” (who, what, where, when, why) to improve staff understanding and buy-in. For “measure,” agencies should leverage existing activities (chart reviews, ride-alongs, spot checks) and standardize how data is collected and shared regularly to avoid last-minute scrambling.<br /><br />Improvement efforts should first confirm baseline compliance, then pursue higher quality goals while considering end-to-end process impacts. She recommends a survey readiness structure with a compliance-led core team (education, mock surveys, oversight) and a broader comprehensive team to support ongoing monitoring and survey logistics. Continuous reporting, mock surveys, and accountability reduce anxiety and sustain readiness.

Asset Caption

Speakers: Megan Turby, M.S.Ed, CHC, CPHQ

In this session you will explore how to ensure you have a robust continuous compliance program that encompasses survey readiness and quality initiatives. You will learn to develop processes with a compliant foundation and build upon them to ensure the highest quality of care. You also will learn how to assess your current resources to determine where and how you can gather more real time data to keep your finger on the pulse of compliance in your organization.

Meta Tag

Competency Tag RA2

Competency Tag Description Facilitate continuous survey readiness activities

Domain Tag Regulatory and Accreditation

Keywords

continuous compliance

survey readiness

Plan-Do-Study-Act (PDSA) cycle

healthcare regulations (HIPAA, OSHA, Stark, anti-kickback)

accreditation standards (Joint Commission, ACHC)

policy and procedure auditing

mock surveys and compliance monitoring