Want to avoid the financial and public relations ramifications of adverse survey results? Watch out for these “symptoms” of regulatory vulnerability:


  • Significant Board time is focused on finance, with little attention to clinical issues, outcomes, or patient and physician satisfaction. Even if scores are presented, little useful discussion follows.
  • Data-rich reports are loaded with numbers, measures, and graphs but do little to convey real clinical information. Clinicians rarely, if ever, provide Board presentations or engage in discussions about quality and outcome measures for patient care.
  • The Board never receives any bad or concerning news on clinical care, even though all hospitals have suboptimal performance, never events and or near misses. Negative news is camouflaged or hidden.
  • Board training and development does not include any focus on the core mission, provision of safe, quality patient care.


  • Information flow is tightly controlled or choked off from dissemination. Direct reports are discouraged from cross-organizational discussion or problem-solving.
  • Only one voice (CEO, COO, Board Chair) is ever heard at management and Board meetings, with little discussion or questioning of the information presented.
  • Clinical leaders (CNO, CMO, Chiefs of Service) present information, but rarely participate in the discussion at leadership meetings. Discussion and Q&A sessions are rare and discouraged.

Medical Staff:

  • Hospital leaders manage the Medical Staff, speaking for them and minimizing their involvement.
  • Medical Staff organization is highly siloed, with little cross-departmental communication and low participation on interdisciplinary teams.
  • Only a few dominant Medical Staff leaders control organizational representation, governance structure, and committee assignments.
  • There is little turnover or new blood evident in medical staff leadership; the same few people cycle through positions of authority.


  • Data always looks “good,” with little critical information suggesting opportunities for improvement.
  • Outcomes and data are focused on earning accolades and awards, rather than on directly improving patient care.
  • Data is not used to change practices initiate process evaluation.

In the end, regulatory compliance is about more than numbers. It is about communicating patient needs and hospital performance to provide patients with the highest quality of care. Paying close attention to the warning signs will help your organization ensure that it continues to comply with regulations that are designed to encourage just such communication to assure the provision of safe, quality care.

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