Document everything, and often. For instance, inventory, classify and validate your assets, especially all PMs and other procedures associated with those assets. Store and update all records such as field inspection reports, internal and external test reports. Electronic records and filled-out forms should be reviewed to ensure that they demonstrate full compliance with the pertinent codes, standards, Joint Commission elements of performance (Eps) and other relevant guides. Plans, policies, procedures and forms should be reviewed regularly and used in staff education, along with the codes, standards and specific requirements that drive them.

Correcting deficiencies in a timely manner might be one of the best, but not the only means of mitigating compliance risk. CFS-FMI works directly with internal teams responsible for regulatory compliance to create a manageable approach to the creation of work orders in the CMMS system. Rather than creating in large batches of work orders as a result of an audit, work orders can be created/generated monthly, per shop by asset type and building.

Keep in mind, codes, standards and accrediting agencies have many required calendar intervals for ongoing inspections and testing. A health care organization needs an effective process to ensure that required inspection and testing intervals are satisfied.

Continuous compliance success factors include: leadership buy-in and involvement; structures that facilitate continuous process review and improvement; experienced and involved front-line staff; regular mock surveys; and periodic drills/compliance reminders.