Meet the Experts: Compliance Support Team

(11/7/2024)

Over the past three years, the Medxcel compliance support team has helped client facilities successfully complete 108 accreditation surveys in partnership with Medxcel’s regulatory compliance experts. Between 2022 and 2023, the team also helped facilities reduce ligature findings by 100% and high-risk findings by 84% on accreditation surveys. One Midwest hospital eliminated moderate and high-risk deficiencies entirely (100%) from 2021-2024.

Keeping healthcare facilities survey-ready demands constant vigilance, meticulous attention to detail, and collaboration with a diverse team of experts. Much like air traffic controllers, the compliance support team organizes signals and activities from regulatory compliance and life safety experts and accreditation agencies to ensure that healthcare facilities entrusted to us are well prepared for their next survey.
 
We invite you to get familiar with the team’s contributions, and their impact on the success of facilities like yours. 

Critical Role of the Compliance Support Team: What They Do and Why it Matters    

Compliance support functions like a traffic control tower, centralizing support and coordinating the timing and actions for various Medxcel teams tasked with regulatory accreditation, assessments, and compliance visits. 

We view those partnering teams as “spokes on a wheel” into compliance support: The regulatory compliance team conducts mock surveys at client facilities to gauge each facility’s survey readiness and give specialized support when requested. Support managers visit facilities at regular intervals throughout the year, ensuring their regulatory documentation — our Facilities Management Operations System (FMOS®) — is in order. They provide FMOS® training to new team members, as well as ongoing training year-round. Our life safety assessment teams walk every floor and open every door to conduct deep-dive assessments of each building. The life safety drawing team manages CAD drawings, updating where and how many doors, rooms, and other physical components exist in the building. Facilities also undergo formal accreditation assessments by The Joint Commission and other accrediting bodies and the results of those surveys are shared with the compliance support team.

Each of these teams and activities produce its own set of findings and metrics, and all of it comes into the compliance support hub to be disseminated throughout the organization. Medxcel benefits from its compliance support team being centrally located and ready to capture this information, enabling strategic compliance decisions in support of our clients nationwide. “We determine who needs to receive those reports, whether it’s the facility, field directors, or high-level leadership. Everyone at Medxcel’s corporate office has client counterparts that we collaborate with as well,” shares Sunny Khammoung, Manager, Compliance Support Services. In addition to providing facilities with any findings to be resolved prior to a regulatory survey, these metrics enable Medxcel leaders to launch action plans unique to each client. This process ranges from on-site visits by subject matter experts to weekly update meetings to check progress. Each facility is met where they are to ensure compliant operations.
 
Aside from data compilation, analysis and reporting, the team also manages the scheduling and coordination of visits to client facilities, following a sequence to discern where our teams should go next based on the date of each facility’s last accreditation assessment.
 
The compliance support team also helps facilities during active regulatory surveys. “If surveyors are on site, so are our experts, who lean on compliance support for assistance in compiling reports and disseminating final survey results,” Khammoung explains.

Helping Facilities Keep Up with Shifting Regulatory Requirements    

Successful regulatory surveys require 24/7 readiness, which in turn demands consistent collaboration to maintain documentation, drills, education, and the physical environment. “Surveys aren’t necessarily a pass/fail outcome, so sometimes people ask us, ‘How well did we do?’ They may have had some findings but, overall, the assessment grants the preliminary green light or denial of accreditation,” Khammoung explains. Compliance support tracks both facility-specific and trending regulatory findings, constantly refining our compliance efforts, helping facilities correct irregularities and prepare for the next survey.
 
That “always-on” oversight has paid off: Over the past year, the compliance support team has helped client facilities reduce survey findings of “moderate” or “high-risk” deficiencies by 30% through collaboration with our on-site compliance experts — a notable win considering how quickly regulatory requirements, surveyor focus, and conditions change in any given facility. On average, facilities that partner with Medxcel see a 16% increase in compliance scoresafter installing FMOS®.

Expertise Meets Results   

Over the past three years, the Medxcel compliance support team has helped client facilities successfully complete 108 accreditation surveys in partnership with Medxcel’s regulatory compliance experts. Between 2022 and 2023, the team also helped facilities reduce ligature findings by 100% and high-risk findings by 84% on accreditation surveys. One Midwest hospital eliminated moderate and high-risk deficiencies entirely (100%) from 2021-2024.