Sessions
All sessions will be held 1 - 2:30 p.m.
Session 1 | April 2
Survey readiness 101: Overview and getting started
Speakers:
Matthew Sandoval, MHA, CPHQ, CJCP, HACP, FACHE, Principal (Costa Mesa, CA), Health Management Associates
Trisha Bielski, RN, BSN, MSN, CCRN, CEN, ACCNS-AG, Senior Consultant (Austin, TX), Health Management Associates
Robert Ross, MHSA, FACHE, Managing Director, Delivery Systems, Health Management Associates
This module provides an essential foundation for healthcare organizations seeking to prepare for DOH, CMS, TJC and DNV regulatory and accreditation surveys. Participants will gain a comprehensive understanding of the fundamental principles of survey readiness, with an emphasis on developing a continuous readiness culture. We’ll explore national and statewide survey trends, common challenges and best practices for addressing them. Special attention will be given to interpreting and applying standards, maintaining ongoing compliance and fostering team collaboration to achieve survey success.
Participants will learn how to approach accreditation as a dynamic, organization-wide process rather than a one-time event. The session will highlight strategies for self-assessment, performance improvement and documentation to prepare effectively for any survey. By the end of the module, attendees will feel confident taking the initial steps toward creating a robust framework for survey readiness and sustained compliance.
- understand the foundational elements of survey readiness and differences between DOH, CMS, TJC and DNV survey processes;
- identify national and statewide trends in accreditation and their implications for hospital operations and compliance;
- recognize common challenges healthcare organizations face in survey readiness and learn practical strategies to address them;
- develop a framework for fostering a culture of continuous survey readiness and sustained compliance;
- learn effective approaches for conducting organizational self-assessments and identifying performance improvement opportunities;
- understand the importance of documentation and evidence-based practices in maintaining survey readiness; and
- gain actionable steps for engaging multidisciplinary teams in the accreditation preparation process.
Session 2 | April 9
Preparation: How to mitigate risk and prepare for upcoming surveys
Speakers:
Matthew Sandoval, MHA, CPHQ, CJCP, HACP, FACHE, Principal (Costa Mesa, CA), Health Management Associates
Michele Bosworth, MD, FAAFP, LSSGB, Physician Principal (Austin, TX), Health Management Associates
Robert Ross, MHSA, FACHE, Managing Director, Delivery Systems, Health Management Associates
This module details the essential activities for organizations to prepare for unannounced surveys from DOH, CMS, TJC and DNV. We’ll explore national and statewide survey trends, common challenges and best practices for responding to them. Special attention will be given to interpreting and applying standards, maintaining ongoing compliance and fostering team collaboration to achieve survey success.
Participants will learn how to approach survey preparation as a dynamic, organization-wide process rather than a one-time event. The session will highlight strategies for self-assessment, performance improvement and documentation to prepare effectively for any survey. By the end of the module, attendees will feel confident in taking the initial steps toward creating a robust framework for survey readiness.
- understand key elements in developing a survey readiness plan;
- learn how to integrate a survey readiness plan into existing hospital activities;
- identify in advance key roles/personnel needed for a successful survey outcome;
- incorporate survey readiness activities into daily operations (i.e., patient and staff rounding) to assess and maintain readiness;
- use practical pre-survey assessment tools to identify and correct improvement areas prior to surveyors arriving; and
- incorporate resources available from HANYS and other sources into your survey readiness program.
Session 3 | April 16
They’re here: Establishing a survey response and management protocol
Speakers:
Trisha Bielski, RN, BSN, MSN, CCRN, CEN, ACCNS-AG, Senior Consultant (Austin, TX), Health Management Associates
Matthew Sandoval, MHA, CPHQ, CJCP, HACP, FACHE, Principal (Costa Mesa, CA), Health Management Associates
Robert Ross, MHSA, FACHE, Managing Director, Delivery Systems, Health Management Associates
Effectively managing DOH, CMS, TJC and DNV surveys requires a proactive and well-coordinated approach. This module will equip healthcare leaders and teams with tools and strategies to manage survey readiness and response protocols effectively. Participants will explore national and statewide accreditation trends, identify common compliance gaps and understand best practices for conducting surveys.
The module highlights real-world strategies for addressing immediate jeopardy findings, condition-level deficiencies and performance improvement requirements. Participants will learn how to manage surveyor interactions, prepare documentation and implement action plans that meet DOH, CMS, TJC and DNV expectations. Additionally, the session will provide practical steps for engaging staff and maintaining compliance post-survey to avoid repeat findings.
- understand current national and statewide trends in healthcare accreditation, including key focus areas for DOH, CMS, TJC and DNV surveys;
- identify common compliance gaps and develop strategies to address them effectively;
- design a comprehensive survey response and management protocol including pre-survey preparation, onsite survey coordination and post-survey action planning;
- implement best practices to sustain accreditation readiness, including fostering a culture of continuous compliance and quality improvement;
- recognize the critical components of surveyor interactions and prepare staff to respond to inquiries confidently and accurately;
- analyze and address survey findings in real time, including condition-level deficiencies and immediate jeopardy, to demonstrate compliance with accreditation standards and regulatory requirements; and
- develop ongoing education and an engagement framework to ensure sustained readiness and compliance.
Session 4 | April 23
Responding to survey findings: How to develop a strong correction plan and knowing your options
Speakers:
Michele Bosworth, MD, FAAFP, LSSGB, Physician Principal (Austin, TX), Health Management Associates
Trisha Bielski, RN, BSN, MSN, CCRN, CEN, ACCNS-AG, Senior Consultant (Austin, TX), Health Management Associates
Robert Ross, MHSA, FACHE, Managing Director, Delivery Systems, Health Management Associates
This module focuses on effective strategies for responding to DOH, CMS, TJC and DNV survey findings. Participants will understand the critical elements of developing clear and achievable plans of correction that address survey findings while establishing sustainable and reliable improvements.
Through case studies, real-world examples and interactive discussions, this module highlights key trends impacting healthcare organizations at the state and national levels, such as evolving CMS Conditions of Participation, TJC’s focus on patient safety goals and DNV’s risk-based standards. Participants will leave with actionable insights to develop strong, compliant POCs, mitigate risks and maintain continuous readiness for future surveys.
- identify national and statewide trends in accreditation findings and their implications for healthcare organizations;
- compare and contrast DOH, TJC, CMS and DNV corrective action plan expectations;
- develop a comprehensive and actionable POC that addresses survey findings and meets compliance standards;
- evaluate the strength of actions in terms of their potential for long-term sustainability and reliability; and
- describe ways to strengthen weaker action to ensure approval and your organization’s ability to maintain compliance.
Session 5 | April 30
What’s next: Leveraging survey findings and strengthening organizational quality and compliance
Speakers:
Michele Bosworth, MD, FAAFP, LSSGB, Physician Principal (Austin, TX), Health Management Associates
Matthew Sandoval, MHA, CPHQ, CJCP, HACP, FACHE, Principal (Costa Mesa, CA), Health Management Associates
Robert Ross, MHSA, FACHE, Managing Director, Delivery Systems, Health Management Associates
This module focuses on effective strategies for leveraging DOH, CMS, TJC and DNV survey findings to strengthen continued organizational quality and compliance. Participants will explore how survey findings identify gaps or weaknesses in organizational quality and compliance strategies and how to address those gaps or weaknesses.
Through case studies, real-world examples and interactive discussions, this module highlights best practices for healthcare organizations’ quality and compliance structure and strategies.
- evaluate survey findings to determine themes for improvement;
- discuss best practices for quality and compliance, including data reporting;
- build a sustainable accreditation readiness culture that integrates proactive risk management and continuous quality improvement; and
- use case studies and real-world scenarios to refine organizational quality and compliance strategies.
Note: Samantha Lang, Senior Consultant (New York, NY), Health Management Associates, is providing project management and coordination for this joint webinar series.