Accreditation & Regulatory Compliance

Regulators in the Lobby: Rise & Shine Reduces Findings

The Rise & Shine approach helps reduce findings, improves patient safety, and supports sustainable performance improvement.

In this blog post we're discussing how Rise & Shine–our latest regulatory compliance solution–can help hospitals deal with the tightened CMS rules on unannounced visits.

This approach helps reduce findings, improves patient safety, and supports sustainable performance improvement.


1.  The Tightening Grip of CMS Regulations

2. 7 Challenges Hospitals Face During Unannounced Regulatory Visits

4. Key Takeaways

5. What You Can Do Today to Reduce Regulatory Findings


Accreditation Regulator speaking to Doctor in Hospital LobbyPhoto: iStock Signature

In today's healthcare landscape, hospitals are facing increasing pressure from accrediting organizations like The Joint Commission and DNV.

The rules of unannounced visits from regulatory bodies have been significantly tightened by the Centers for Medicare & Medicaid Services (CMS) making it crucial for healthcare facilities to be constantly prepared.

The arrival of regulators is a daunting experience for hospital staff, and leads to heightened anxiety and disruption across the organization.

Below, we will delve into how Rise & Shine, a SAAS solution, can help hospitals effectively deal with these challenges by proactively reducing regulatory findings, improving patient safety, and promoting sustainable performance improvement.

The Tightening of CMS Regulations

Centers for Medicare & Medicaid (CMS) regulations have evolved over the years. Hospitals must navigate this stricter regulatory environment, which places a significant burden on staff to maintain compliance consistently.

Medicare & MedicaidPhoto: iStock Signature

7 Challenges Hospitals Face During Unannounced Regulatory Visits

The arrival of regulators is synonymous with increased pressure, as hospitals must ensure that they are ready to face scrutiny. Here, we will explore some of the challenges hospitals face during unannounced regulatory visits and how Rise & Shine’s Regulatory Preparedness solution can address and support them.

1. How to get All Departments Checked to Eliminate "Easy" Findings

Solution: Automation of Checklists When Regulators Arrive

Without well-designed automation, the volume of activities required to be quickly and effectively conduct checklists when regulators arrive is overwhelming.

Why it Works:

→ Rise & Shine steps in as a solution to alleviate this administrative burden, allowing hospital staff to focus on essential tasks rather than drowning in phone calls and paperwork.


2. Response to Unannounced Visits

Solution: Immediate Mobilization

Supplementing existing notification practices, Rise & Shine ensures that departments are immediately notified of impending regulatory visits through email and text alerts and provides immediate links to department specific checklists.

Why it Works:

→ This immediate mobilization enables staff to prepare swiftly and comprehensively.


3. Issues Fall Through The Cracks With One-Size-Fits-All Checking

Solution: Customized Checking for Each Department

Customization is key to avoiding a one-size-fits-all approach. Rise & Shine offers detailed checklists that are electronically loaded and customized for each department.

Why it Works:

→ Customizable checklists allow departments to address their specific needs and requirements, ensuring that compliance processes are aligned with the unique demands of each area. For example, if a department does not have eyewash stations, the checklist will not display eyewash-related questions.


4. Manual Tracking Does Not Allow for Real-Time Monitoring

Solution: Real-Time Monitoring

The real-time completion dashboard provided by Rise & Shine offers "total visibility into the status of checklist completion and issues discovered.

Why it Works:

→ This transparency ensures that all necessary tasks are completed promptly. It also enables immediate follow-up if any department is falling behind in their preparations.


5. The Difficulty of Manually Tracking Larger Issues That Require Follow-Up

Solution: Follow-Up and Correction

During the urgency of unannounced regulatory visits, making immediate corrections to identified issues is crucial. But, what about issues that need fixing but can’t be addressed right away?

Why it Works:

→ Rise & Shine's automation features  assists in managing items that cannot be corrected immediately, such as ceiling tiles or fire door closures. Integration with work order systems streamlines and expedites the process.


6. Reactive Fixing Isn’t an Effective Improvement Strategy

Solution: Automated Reporting of Performance Improvement (PI) Items

One of the standout features of Rise & Shine is its automated prioritization of high-failure items for PI teams.

Why it Works:

→ This shifts the focus from a "find and fix" approach to a continuous improvement mindset. It allows hospitals to address the root causes of regulatory findings, leading to improved outcomes.


7. Scrambling During Unannounced Regulatory Visit

Solution: Drills for Preparedness

Rise & Shine also offers the ability to conduct monthly drills, including unannounced ones. These drills ensure thoroughness in compliance checks and provide staff with the opportunity to practice and hardwire the processes.

Why it Works:

→ This proactive, monthly practice approach reduces the likelihood of regulatory issues arising during actual visits.


Two Nurses Running in the Hospital Hallway


Key Takeaways:

1. Regulatory Visit Changes Will Likely Increase Regulatory Findings

As CMS tightens the rules around unannounced visits, hospitals face a higher potential for increased regulatory findings.

2. Automation Provides Sustainable Process

Deploying an automated solution to address an unannounced regulatory visit provides a sustainable process that won't collapse from a lack of manual administrative support.

3. Proactive Performance Improvement

Beyond correcting immediate issues, a structure that easily identifies and launches performance improvement goals will result in improved regulatory outcomes.

4. Routine Practice

The ability to conduct drills ensures that hospitals are better prepared for unannounced regulatory visits.



As unannounced regulatory visit rules become significantly tightened. Rise & Shine Regulatory Preparedness offers hospitals a lifeline in these challenging times by streamlining processes, reducing findings, and ultimately enhancing patient safety.

By prioritizing automation, customization, and performance improvement, Rise & Shine is a vital tool in the toolkit of hospitals striving to maintain compliance and excellence in patient care.


Take Action Now: What You Can Do Today to Reduce Regulatory Findings

At Readiness Rounds we have taken our approach to hospital high reliability and built the Rise & Shine platform to support hospitals in achieving sustainable regulatory success.

We would be delighted to show you how this approach can be applied in your hospital.

Book a meeting below ↓

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