By conducting a full audit the week before each survey

Through continuous monitoring via audits, dashboards, leadership rounding, and real-time reporting reviewed at Quality Council

By assigning one compliance officer to handle all regulatory tasks

By posting compliance reminders on bulletin boards throughout the facility

Wait for surveyors to identify risks during an on-site visit

Focus only on risks that have resulted in past citations

Name specific current risks (e.g., staffing sustainability, medication safety) and describe active mitigation strategies

Delegate all risk identification to the compliance department

By reviewing quality reports only during annual board meetings

Through structured QAPI meetings, performance dashboards, incident trend analysis, and direct frontline engagement

By hiring consultants to manage quality programs externally

Through monthly email updates from the quality department

Maintaining the same staffing ratios regardless of patient volume

Allowing charge nurses to make all staffing decisions without documentation

Basing staffing on patient acuity, census, skill mix, and regulatory requirements with documented decisions and escalation protocols

Relying on staff self-scheduling to fill all shifts

Document the event → file it → review it at the next quarterly meeting

Report the event → assess the patient → notify leadership → complete root cause analysis when indicated → implement and monitor corrective actions

Notify the legal department first → then decide whether to report

Complete an incident form and wait for the quality team to follow up

By documenting the initial corrective action plan only

Through follow-up audits, re-education, performance monitoring, and leadership oversight until outcomes are consistently met

By adding the corrective action to the annual training checklist

By relying on staff to self-report when issues recur

A written test administered during initial orientation only

Annual online training modules with automatic completion certificates

Structured orientation, annual competencies, direct observation, and focused retraining when gaps are identified

Peer-to-peer evaluations without leadership involvement

Following standardized medication administration processes, verifying patient identity, applying high-risk medication safeguards, and documenting promptly

Allowing experienced nurses to skip verification steps for routine medications

Conducting medication audits only after an adverse event occurs

Relying primarily on pharmacy to catch medication errors before dispensing

By requiring all concerns to go through a formal chain of command

By promoting a just culture where staff can report through incident reporting systems or directly to leadership and are supported when they speak up

By providing an anonymous suggestion box reviewed monthly

By disciplining staff who file reports that are later found to be unsubstantiated

To achieve a perfect score on every regulatory survey

To minimize legal liability for the organization

To ensure consistent, safe, high-quality care every day—with the focus on patient safety and outcomes, not survey performance

To create comprehensive documentation for accrediting bodies