CDPH’s New Hospital Relicensing Survey Webinar
Important changes begin March 2016

Webinar Recorded Live February 18, 2016


Changes are coming!

The California Department of Public Health (CDPH) will launch its new general acute care hospital relicensing survey in March 2016. The new relicensing surveys will be unannounced and hospitals will be surveyed every three years, as required by law. This survey may include elements of the Medication Error Reduction Plan and Patient Safety Licensing Surveys, which will no longer be individual surveys, as well as other Health and Safety Code and Title 22 requirements. Most survey teams will be at your hospital for one week.

Make sure your facility is prepared by learning what’s changed, what to expect when a survey team arrives, and what you can do to prepare now and during the survey to ensure a successful outcome.

Faculty include CDPH’s project lead for the new survey process and the training of state surveyors, and staff from CHA’s clinical services and legal team.

Gather your survey team and listen as a group!

Recommended for:

Licensing and accreditation managers, CNOs, quality and infection control managers, pharmacists and pharmacy directors, on-site administrators, house supervisors, legal counsel, compliance officers and risk managers


What’s changed? Overview of the new GACH survey process

  • What are the goals of the survey?
  • Who comprises the survey team?
  • What does the survey process consist of?
  • What information do surveyors look at prior to arriving at your hospital?
  • What areas will surveyors evaluate?

Inside look at the survey process

  • Pre-entrance activities of surveyors
  • Entrance and exit conferences
  • Methods of investigation: observation, record review, modified tracer methodology, interviews
  • Patient sample size/selection
  • Areas of particular concern and focus; substantiated complaints; past deficiencies
  • Under what circumstances would a CDPH survey become a federal CMS survey?
  • Process if deficiencies are found
  • How administrative penalties are determined
  • New timeline for CDPH to complete the 2567

How to prepare your hospital for a survey

  • Documents and files to prepare in advance, including program flexibility approval letters
  • Who should serve on the hospital’s survey team and who else needs to be readily available?
  • How to prepare staff
  • How to address concerns about a surveyor or survey team

Resources — what’s available from CDPH and CHA


Patricia Dixon, RN, is responsible for training state surveyors on the new hospital relicensing survey process and serves as project lead for the development of the survey. She has more than 20 years of service with the California Department of Public Health’s (CDPH) Licensing and Certification division.

David Perrott, MD, DDS, is CHA’s senior vice president and chief medical officer. Dr. Perrott’s responsibilities include all clinical issue areas, including the Center for Hospital Medical Executives, California Alliance of Hospital-Physician Organizations, and the Certification and Licensing Committee.

Debby Rogers, RN, MS, is vice president of clinical performance and transformation at CHA. She previously served as deputy director for the Center for Health Care Quality at the California Department of Public Health, as well as CHA’s vice president for quality and emergency services.

Lois Richardson, Esq., is the author of CHA’s California Hospital Survey Manual — A Guide to the Licensing & Survey Process and the Consent Manual, as well as a number of other CHA publications. She has served as a legal resource for the association for more than 20 years, primarily as legal counsel and most recently as vice president of privacy, and legal publications and education.


In addition to the webinar, hospitals may want to purchase CHA’s California Hospital Survey Manual — A Guide to the Licensing & Survey Process. Updated to include the changes to CDPH’s relicensing survey process, this helpful manual is a must-have for all California hospitals. To learn more or to order the manual, visit