Licensing and Certification Survey Basics Webinar CD

Webinar Recorded Live August 21, 2012
Program Rated 4.1 out of 5 by participants


The survey process is complicated. Hospital survey staff must be prepared to switch gears at a moment’s notice when the surveyors walk through the door. Often, many questions arise when confronted with an unannounced survey. Whether or not the survey goes smoothly will depend heavily upon knowing:

  • What kind of survey will take place — state or federal
  • Which of the many different laws, regulations or guidelines will be considered
  • Which staff should be alerted and involved with the surveyors
  • Who the surveyors could interact with and why
  • What the surveyors can and will ask for

This webinar provides clear and concise direction on licensing and certification surveys. Presenters from legal, surveyor and hospital backgrounds offer practical information and procedures to help survey veterans, or those new to the process, respond with confidence.



Recommended for

Chief nursing officers, compliance officers, risk managers, survey and accreditation managers, quality managers and in-house legal counsel.


Licensing v. certification v. accreditation — what’s the difference?

State surveys

  • Survey types — consolidated accreditation and licensure (CALS), complaint-driven, self-report, patient safety licensing (PSLS), medication error reduction plan (MERP)
  • Which laws apply — Health and Safety Code, Title 22
  • Administrative penalties and appeals

Federal surveys

  • Survey types — certification, complaint-driven, validation
  • Which laws and guidelines apply — CoPs, State Operations Manual, Interpretive Guidelines
  • Immediate jeopardy — federal and state differences

The surveyor’s perspective on the process

  • Starting off right — the entrance conference
  • Documents review — what surveyors may ask for
  • Interviewing patients and staff
  • Exit conference — clarifying expectations, next steps

How hospitals can prepare and respond to survey

  • Develop your process — employee training, documentation, mock surveys
  • Interacting with surveyors — appropriate responses
  • Survey in progress — alerting key staff, escorts, daily debriefs

After the survey

  • Communicating survey results, steps to address issues
  • Addressing 2567s, plans of correction
  • Documentation and continuous improvement


Jana Du Bois is vice president and legal counsel for the California Hospital Association. Ms. Du Bois has a broad foundation of health law experience, including serving as in-house counsel for a large integrated hospital health system and regulatory counsel for state public health and managed care departments. Prior to becoming an attorney, Ms. Du Bois was a registered nurse for over 10 years.

Cheryl Gann, RN, MBA, CPHQ, is senior director of Patient Safety and Regulatory Readiness, in Corporate Quality for Scripps Health in San Diego. Ms. Gann is responsible for patient safety, risk management, accreditation, and licensure activities across the Scripps Health system. In addition to improving patient safety, reducing medical errors, and coordinating compliance, she also teams with other organization leaders to address and resolve patient safety issues and elevate the standard of care. 

David Perrott, MD, DDS is senior vice president and chief medical officer for CHA. His responsibilities include all clinical issue areas, including the Center for Hospital Medical Executives, Healthcare Quality Committee, the Medication Safety Committee, and the Joint Committee on Accreditation and Licensing. He is actively involved in the California Hospital Patient Safety Organization, and was recently appointed to The Joint Commission (TJC) Board of Commissioners.