Regulatory Compliance

Regulatory compliance ensures that practices meet and exceed local, state, and federal requirements for proper testing, safety, infection control, and billing. On-site assessments address a variety of compliance issues and help practices prepare for regulatory site surveys. Each practice is required to meet or exceed the standards measured by each of the surveys relevant to their practice.

Ambulatory practices may receive site visits as part of one or more of the following surveys:

Joint Commission Survey

See the Joint Commission Readiness page.

The Joint Commission sets national patient safety goals with the National Quality Forum (NQF) and offers information about many hospital quality indicators. JC surveys are unannounced and take place 18 to 39 months after the previous survey.

The Joint Commission survey team reviews the environment of care, conducts on-site observations and interviews, and evaluates compliance with hospital standards related to:

• Emergency management
• Environment of care
• Infection prevention and control
• Leadership
• Medication management

Magnet Survey

The Magnet Recognition® program distinguishes health care organizations for quality patient care, nursing excellence, and innovations in professional nursing practice, and publicizes successful nursing practices and strategies across American health care organizations.

Appraisers visit practices to look for:

• Nurse participation in decision-making
• Outcomes (e.g., falls, pressure injuries, catheter-associated urinary tract infections, central-line-associated blood stream infections)
• Interdisciplinary patient- and family-centered care
• Continuity of care across the continuum
• Peer review and professional development
• Diversity
• Patient/family involvement in care plan
• Communication flow between nurses and leaders

Department of Public Health (DPH) surveys

Three types of Centers for Medicare & Medicaid Services (CMS) surveys are conducted:

• Certification/Recertification Surveys are conducted when an organization applies to become a CMS provider. Recertification ensures that the organization is maintaining standards that comply with CMS requirements.
• Complaint/Allegation Surveys are conducted in conjunction with a credible complaint. The surveys can be unannounced, and the scope of the survey may be limited to the nature of the complaint.
• Validation Surveys are conducted at random intervals to validate the accreditation process. A hospital that has been accredited by the JC and is deemed Medicare-compliant is open to a CMS validation survey.

Practices are required to participate in surveillance rounds sponsored by the Ambulatory Management department. These are conducted in several reviews to ensure minimal disruption to operations and patient care.

Surveillance rounds include:

• A Clinical Practice Assessment (CPA) by patient safety, quality, and risk nurses who observe clinic practices
• JC 101 to review the JC survey process
• Environment of Care (EOC) rounds focusing on the environment of care in ambulatory practices
• A mock JC survey conducted by the MGH/MGPO Ambulatory Management team
• Interdisciplinary Tracers (IDT) focused on compliance with the JC’s National Patient Safety Goals

CPA

Patient safety, quality and risk nurses in Ambulatory Management conduct interactive CPAs to assess compliance, promote standards and policies, and share best practices in these practice areas:

• Infection control
• Medication management
• National patient safety goals
• Phlebotomy and IV competencies
• Staff orientation/competencies
• Universal safety protocols

JC 101

MGH Ambulatory Management offers managers and support staff a one-hour educational session, Joint Commission 101, to review the JC survey process, including:

• Tracer methodology (tracing a patient at every touchpoint through the hospital)
• Survey Analysis for Evaluating Risk (SAFER) matrix scoring methodology

IDT

The IDT team, focused on compliance with the JC’s National Patient Safety Goals, visits approximately 20 high-risk ambulatory locations each year and completes clinical tracers for each inpatient care and procedural area. Results lead to process improvement in infection control, prevention and medication management, and safety.