This article reviews the critical importance of having leadership and physicians supportively involved in accreditation, quality of care and patient safety issues.  While that is a well established/accepted principle, the real point of this article is its emphasis upon the responsibility that accreditation, patient safety, and quality improvement professionals (e.g., PI/QI Directors, Joint Commission Survey Coordinators) are encouraged to take for LDR/MD involvement. To that end, the article also suggests several strategies for achieving this to include:
• Make sure LDR and MDs are familiar with the new Patient Safety Systems chapter and use it to help them see and support the connection between accreditation compliance and patient safety.
• Use LDR/MD input to develop a formal plan for continuous survey readiness and ongoing standards compliance
• Keep LDR/MD routinely informed of the facility’s compliance status/issues, but utilize the Intracycle Monitoring (ICM) process and Focused Standards Assessment (FSA) to help prioritize their focus, time and attention.
• Facilitate a greater understanding of compliance and patient safety for LDR/MD through frontline experiences such as participation in mock tracers and Adopt-a-Unit programs.
Tip: Effective plans for continuous survey readiness and ongoing standards compliance are 3-year plans and are not limited to the 6 months before anticipated survey.  [SPHCC recommends such plans include a compliance status check by an external entity (e.g., central office, sister hospital, etc) at months 9, 18  and 27 with a mock survey at month 30]