Regulatory and Accreditation Compliance
Sources of authority
Regulatory compliance is layered. CMS Conditions of Participation set the floor: §482.12 governs the governing body, §482.22 governs medical staff organization, bylaws, and privileging. Accreditation (The Joint Commission, DNV) can confer deemed status, but accreditation does not replace state licensure law or scope-of-practice rules. NCQA standards apply to credentialing verification organizations and health plans. HCQIA and the NPDB impose federal reporting duties.
Keeping the program survey-ready
Build a crosswalk from each applicable standard to the policy, form, or report that proves it. Track standard revisions, state rule changes, and scope-of-practice updates. Review bylaws and privilege forms on a defined cycle and after any regulatory change. Keep evidence of PSV, committee minutes, rationales, and expirables in retrievable form.
Worked example
A hospital's bylaws list a provider category as eligible for active staff, but state law does not license that category to perform the procedures in the privilege form. Reasoning: state scope governs regardless of what the bylaws say. Correct by revising the bylaws and the privilege form, verifying licensure, and documenting the governing body's action. Accreditor approval of the form does not cure a state-law problem.
Traps that cost marks
Assuming accreditation equals legal compliance; missing state-specific reappointment or hearing requirements; failing to update policies after a standard revision; producing a policy without evidence of implementation; and treating a survey as a documentation exercise rather than a practice review.