Sessions

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.

Learning objectives

• 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.