An 800+ bed hospital in the South was experiencing significant leadership changes, including the transition of an interim Chief Executive Officer, Chief Nursing Officer, and many director- and manager-level interims. The hospital contracted with Compass Clinical Consulting to engage an Interim Regulatory Specialist in the Quality Department to provide leadership amid these transitions, while guiding the department toward its accreditation and compliance goals and providing support in the face of staffing vacancies and other challenges.

The Situation

Specifically, the Quality Department had been under interim leadership by two different individuals for two years, including another quality and accreditation leader from Compass. The department had also lost many staff members over this period, including the previous Compass interim, who, as director,  had managed the DNV GL accreditation process.

During this leadership change, the Interim Regulatory Specialist maintained the department function, led the organization through complaint responses, and established an action plan to prepare for future accreditation survey. She additionally used her Joint Commission (TJC) expertise to help the hospital understand the process involved in moving from DNV GL to TJC accreditation, and the resources and commitment that would be needed to eventually fulfill this goal.

Accreditation and Compliance Goals

At the onset of the engagement, the organization expressed the goals of supporting compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs), maintaining DNV GL accreditation readiness, and working with department and executive leaders to move the organization down the path toward TJC accreditation readiness.

The organization and the Interim Regulatory Specialist worked together to survey all clinical areas for CMS CoP requirements and DNV GL expectations, and provided reports to managers of the areas reviewed, as well as to the executive leader. The team of surveyors included the Interim, the Quality Coordinator for the area, a representative from facility safety, and the director of the operative area being surveyed. Results were summarized and reported to the Quality Committee. This step ensured that the organization had a baseline against which to measure its progress toward its accreditation and compliance goals.

Staffing and Leadership Vacancies

Within weeks of arrival, two employees of the department left the organization, and the other Compass interim director was replaced by someone who was retiring within 30 days. Upon the director’s retirement, the leadership role of the department remained vacant for several months. Additionally, one of three remaining employees was out of the department for three months.

The department would have floundered without adequate staffing and necessary leadership, so the Interim was asked to support the medical staff quality committee and keep the department running until a new director was identified.

Because the state of the organization revolved so much around the distractions of changes in leadership and reductions in force, there was little energy spent on identified issues. Examples of areas identified with potential to be escalated into more dangerous situations included the following:

  • Potential for privacy breaches
  • Potential for significant IC issues in operative/procedural areas
  • Medication management and security
  • Individualization of care plans

These problem areas required attention – and quickly – to ensure that the organization was able to provide safe, quality care.

Solution: Relationship Building, Process Changes, and a Focus on Compliance

The Interim focused on building relationships with key departments and communicating the risks associated with a failure to address the identified issues. The Interim participated in meetings, frequently visited units, participated in weekly Environment of Care rounds, and established a relationship with the division quality leader, which solidified a sense of trust within the culture in order to establish necessary changes.

With an established leadership presence, the Interim was able to effectively and efficiently guide the organization through its accreditation and compliance challenges, including a DNV GL complaint response and QIO complaint response. She also developed an action plan to prepare for and respond to DNV survey for certification of the stroke program in conjunction with the Stroke Coordinator and executive leader of the program; provided leadership for the College of American Pathology (CAP) inspection of the Laboratory; and supported the Transplant Coordinator in preparing for TJC recertification of the transplant program. Working with key medical staff and others, she prepared the organization for the survey.

Developmental and organizational changes within the department led to more efficient program development in the facility. The Interim made changes to the management of patient information and assisted in the development of the internal audit program. She updated the DNV GL survey response plan by redesigning roles and responsibilities, clarifying role expectations, and updating processes to address organizational changes. The Interim then met with key individuals to review the changes to the plan and ensure their understanding.

Additionally, the Interim prepared all documents related to the organization’s state license renewal and worked with the facilities department to ensure that the updated licenses were posted in all required locations when received.

The relationships that the Interim created and atmosphere of trust and enabled process and role changes to successfully take effect.


The Interim generated positive momentum for the organization through her leadership and quality expertise. The issues identified in the operative areas continue to be addressed and improved. The organization has also achieved buy-in from senior leadership to ensure that progress continues; specifically, the Senior Vice President over the area is invested in assuring continued improvement.

Additionally, as a result of the engagement, the organization has put processes in place to prioritize accountability and sustained compliance. Weekly mock surveys have been implemented, rotating through each of the operative areas. The Senior VP and the survey team meet regularly to review progress and identify additional resources and actions that may be required to address problem areas. Environment of Care staff also embraced the addition of a quality representative on the team surveys.

If you would like to find out more about the successes our interims have had in the ED or other areas and how your hospital can maintain safe, quality patient care, contact us at or (513) 241.0142.

Photo credit: Thinkstock / iStock

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