COMPLIANCE SERVICES
Support for leading compliance accreditations
Compliance Audits, Action Plans & Ongoing Support
Our streamlined approach ensures facility-wide regulatory readiness through three critical phases. We begin with a rigorous compliance audit to identify potential vulnerabilities, followed by the development of a strategic corrective action plan. Finally, we provide ongoing management to maintain high standards of patient safety.
Key Responsibilities for Compliance Services Provided by SMCI
Document regulatory assessments across sterile processing, OR, and EVS teams.
Coordinate facility and staff preparation for regulatory and accreditation surveys, strictly managing operational readiness and alignment with current policy standards.
Standardizes and maintains all operational policies and sterile processing workflows to ensure total alignment with the latest AORN, AAMI, QUAD A, AAAHC, and Joint Commission regulatory requirements.
Tracking indicators and reporting corrective actions
Coach leaders and staff on clinical workflows, providing hands-on training to maintain daily operational standards
We turn our findings into a clear, step-by-step action plan tailored to your facility. Each recommendation includes what needs to change, who is responsible, and realistic timelines. We focus on practical fixes that strengthen day-to-day compliance, close accreditation gaps, and improve your readiness for both scheduled and unannounced surveys.
Outline Clear Practical Next Steps to Strengthen Compliance and Survey Readiness
After reviewing your policies, workflows, and documentation, we pinpoint specific gaps or risks that could lead to citations, safety issues, or missed accreditation requirements. We prioritize these findings by level of risk and impact, so you know exactly where to focus first to strengthen compliance and protect your patients, staff, and organization.
Identify Gaps or Risks
We meet with key leaders and frontline staff to understand how care is delivered and how responsibilities are shared. At the same time, we review your documentation—policies, logs, training records, and credentialing files—against current accreditation standards. This helps confirm what is working well and reveals any gaps that could impact survey results or ongoing compliance.
Interview Key Staff & Check Documentation Against Accredidation Standards
We carefully review your written policies and procedures alongside how work is actually done day to day. By comparing your documentation to real workflows, we can spot gaps, inconsistencies, or risks that might lead to survey findings. This helps ensure your policies are practical, followed by staff, and aligned with current accreditation and regulatory standards.
Review Policies & Observe Day to Day Workflow
Onsite Compliance Review Process
THE JOINT COMMISSION
The Joint Commission is an independent, not-for-profit organization that accredits and certifies healthcare organizations and programs in the United States. Its standards focus on patient safety, quality of care, and continuous performance improvement across the entire facility, including sterile processing, operating rooms, and environmental services.
DCH
DCH (Department of Community Health) oversees licensing and regulatory standards for many healthcare facilities. DCH requirements help ensure that organizations meet state rules for patient safety, quality of care, and proper operations, and they often align with or support national accreditation standards.
OSHA
The Occupational Safety and Health Administration (OSHA) sets and enforces workplace safety standards to protect staff from injury and illness. In healthcare and sterile processing settings, OSHA requirements cover areas like bloodborne pathogens, hazardous chemicals, personal protective equipment, and safe work practices to reduce risk for employees and patients.
QUAD A
QUAD A (formerly AAAASF) is an accrediting organization for ambulatory surgery centers and office-based surgical facilities. QUAD A standards emphasize patient safety, infection prevention, and high-quality clinical care, helping facilities show they meet strict, nationally recognized requirements for safe surgical and procedural environments.
AAAHC
The Accreditation Association for Ambulatory Health Care (AAAHC) is a leading accrediting body for ambulatory surgery centers and outpatient facilities. AAAHC standards focus on patient safety, quality of care, and continuous performance improvement, helping organizations demonstrate that they meet rigorous, nationally recognized requirements.
We start by assessing your current policies, practices, and survey history. Then we identify gaps, prioritize risks, and build a customized compliance and credentialing plan for your facility, with clear steps, timelines, and staff responsibilities.