CHA News Article

2015 California Hospital Survey Manual Now Available
Details new survey procedures and outlines complaint investigation processes

CHA has released the third edition of the California Hospital Survey Manual, which is intended to help hospital administrators understand and prepare for the licensing and certification survey process from start to finish. The publication explains important differences between state and federal surveys, provides tips on how to achieve a successful survey and outlines tasks that must be completed after the survey. Although state and federal surveyors may be the same people, there are differences in processes and potential outcomes. This manual will help hospitals understand the differences and describes the laws surveyors use to assess compliance. 

Significant changes to the survey process enacted recently and described in the new edition include:

  • Details on procedural changes to the survey process. In brief, the California Department of Public Health (CDPH) is no longer participating in Consolidated Accreditation and Licensure surveys. Hospitals that are accredited by The Joint Commission (TJC) will have two separate surveys: one by TJC (with or without the Institute for Medical Quality, depending on the hospital’s preference) and a separate “Relicensing Survey” conducted by CDPH. The relicensing surveys will eventually replace the Patient Safety Licensing Surveys and Medication Error Reduction Plan surveys. 
  • An expanded discussion of surveyor rights and restrictions regarding access to peer review materials, attorney-client privileged materials and Patient Safety Work Product. Explanation of changes to the Centers for Medicare & Medicaid Services (CMS) policies and procedures regarding investigating complaints against hospitals. Notably, some complaints are now referred by CMS to the accreditation agency for investigation. 
  • New charts and instruction sheets to calculate the amount of administrative penalties CDPH may assess, and that summarize the differences between a state immediate jeopardy deficiency and a federal immediate jeopardy deficiency.

To order the California Hospital Survey Manual and to learn more, visit