02 — Capability · BC-1850.50
Accreditation Readiness
Stay ready at all times for accreditation and regulatory surveys, many of them unannounced for hospitals, and for health plan accreditation reviews and program audits, by tracking every applicable standard, running mock surveys, hosting surveyors and closing findings on time. The wider obligations register is compliance.
- Survey Readiness
- Accreditation Management
- Continuous Survey Readiness
In scope
- Standards and conditions of participation mapped to owners and evidence
- Tracers and mock surveys
- Survey hosting and surveyor document requests
- Plans of correction and evidence of compliance
Out of scope
- The organization-wide regulatory obligations register (see BC-140.10)
- Quality system certification for manufacturing sites (see BC-550.10)
- Internal audit of controls (see BC-160.20)
Decomposes into · 4
- BC-1850.50.10Accreditation Standards TrackingKeep each applicable accreditation standard and condition of participation mapped to an owner, policy and evidence, and update the map when standards change.
- BC-1850.50.20Mock Surveys & TracersFollow patients and processes through the organization as surveyors would, find gaps before a real survey does, and track the fixes.
- BC-1850.50.30Survey Visit CoordinationHost on-site and virtual surveys, produce the documents and staff surveyors ask for quickly, and record every observation they make.
- BC-1850.50.40Survey Finding CorrectionWrite plans of correction for survey findings, carry out the fixes, and submit evidence that the standard is met by the deadline.