Volume 2025 | No. 2
SURVEYOR
SLEEP
NOTES
Compliance tips for:
It’s not enough to collect data and analyze it for trends (as required by twice yearly summary described in SLC6-1A). The organization must then identify areas where it believes it can improve, set a goal for improvement, identify and implement a change/corrective action to achieve the goal, remeasure, and report on results. When the goal is achieved, the team must be trained so that the improvement is sustainable. When the goal is not achieved, another corrective action is expected. These activities are documented annually in a comprehensive PI report.
Nerd Newbies (understand the requirement)
■ Audit documentation of PI activities for:
Nerd Apprentices (audit for excellence)
ٝ A description of indicator(s) to be monitored/activities to be conducted. ٝ Frequency of activities. ٝ Designation of who is responsible for conducting the activities. ٝ Methods of data collection. ٝ Acceptable limits for findings or thresholds. ٝ Who will receive the reports.
ٝ Written plan of correction when thresholds are not met. ٝ Plans to re-evaluate if findings fail to meet acceptable limits. ٝ Any other activities required under state or federal laws or regulations. Note: These are the required elements for SLC6-2A but the PI annual report will not be complete without their inclusion. ■ Conduct staff training on the Performance Improvement Program to ensure engagement and investment.
Nerd Trailblazers (prepare the path for others)
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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