Skip to Main Content
Skip Navigation Links
Magnet Logo

Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 9

Christina Costello

The Pace of Regulatory Change

By Christina Costello, M.Ed.

“Just because everything is different doesn’t mean anything has changed.”1
Irene Peter’s quote about change describes our world in 2011. Although we are documenting a bit differently, we continue to provide high-quality patient care.

So, how did we get here? Two key legislative acts have impacted Children’s Hospital recently, the stimulus bill and the health reform law.

The stimulus bill was signed into law in 2009 and included funding intended to increase the use of electronic health records (EHR) by physicians and hospitals. Federal funding is now being provided to hospitals that implement “meaningful use” electronic health record systems. With our recent implementation of advanced clinic systems (ACS) and computerized physician order entry (CPOE), we are experiencing the benefits of technology. Our electronic medical record:

  • is more organized,
  • has standardized terminology,
  • provides accessibility to the healthcare team,
  • provides clinical decision support and
  • increases communication across the continuum of care.

The health reform law also impacts the Hospital; this law ensures that all Americans have access to affordable quality healthcare. We have already begun to see changes to payment and tax regulations, the implementation of reporting on quality measures, and reform to the delivery of care.

With these efforts to revamp healthcare, regulatory agencies have been asked to assume additional responsibilities. The greatest burden of implementing these laws falls on the Centers for Medicare and Medicaid Services (CMS). The agency is responsible for the distribution of funds and providing oversight, while continuing to perform its duties involving Medicare, Medicaid, and the state children’s health insurance program, as well as many other functions. Also in 2010, the California Department of Public Health (CDPH) announced their plan to revise regulations related to adverse event penalties, privacy breach penalties, and to complete a systematic review of Title 22. Recently, President Obama issued an executive order directing each regulatory agency to establish a plan for ongoing retrospective review of significant regulations. This review will focus on the elimination of rules that are no longer justified or necessary, and consider strengthening, complimenting or modernizing rules where necessary, and if relevant creating new regulations.

Since The Joint Commission (TJC), CMS, CDPH, as well as other regulatory agencies can arrive at any time and without notice, our ultimate goal is to demonstrate safe, quality patient care. The Complete Quality program provides you with the tools you need to assess our procedures and practices in order to evaluate the quality and safety of patient care, meet our regulatory requirements, and create a safe environment for our patients, staff and visitors. 

As new and/or changing regulations are passed, our strategies and tools to assess readiness will keep you informed of changes impacting patient safety and quality. These strategies provide a comprehensive assessment of our compliance through our annual periodic performance review (PPR), policy and procedure management, and tracer program. The tracer program provides just-in-time educational experiences and an opportunity for you to tell the patient’s story and demonstrate your knowledge of our systems, processes and procedures.

With increased regulatory emphasis on patient safety, infection control and quality, The Joint Commission has enhanced their on-site accreditation survey to include the second generation tracers. These tracers are a deeper and more detailed exploration of a high-risk process or area. During a patient tracer, a surveyor may observe a practice or process that warrants a more in-depth evaluation. Much like a system tracer, all aspects of the process will be assessed. Surveyors will ask, "Why are things being done this way?" They will be looking for indications of risk, such as a lack of standardized process or leadership oversight, decentralized process or patterns of non-compliance. These are indicators that could lead to further exploration. The focus will be on high-risk processes or procedures that have a significant potential for impacting patient safety, such as:

  • cleaning, disinfection and sterilization of medical instruments, devices and supplies,
  • high-risk medication use, and
  • “telling the patient’s story” using our electronic medical record.

 A recent successful CDPH patient safety survey was an early indicator that demonstrated we are on the right track with our compliance efforts. This survey largely focused on patient safety and infection control. Staff was well prepared and we received favorable results. As we look towards 2012, we can expect TJC and CDPH medication error reduction plan surveys. In preparation for these surveys, our tracer program will be focusing on three specific areas: infection control, medication management and electronic documentation. You can expect to hear and read more about these topics in the months ahead.

Being prepared for a survey is a shared responsibility and our success depends on everyone. It is your responsibility to know standards, polices and processes throughout the Hospital, but especially in your own area. Continue to perform your job well and be ready to explain your role in the continuum of care. The primary focus of regulatory readiness is to enhance our culture of safety and quality. Thank you for your attention to complete quality and patient safety!

Remember, “Keeping Kids Safe = Ready for Survey!”


1Irene Peter. (n.d.). Retrieved August 2, 2011 from Web site:


CMS and Health Reform: A Health Affairs Blog Roundtable;; Chris Fleming; April 13, 2010

US Department of Health and Human Services; Executive Order, Preliminary Plan for Retrospective Review of Existing Rules; May 18, 2011

Economic Stimulus: The HITECH Act of 2009;

The Impact of the 2010 Health Reform Law on Hospitals; The National Law Review;

Luizzo, A, Scaglione, B; “Aspects of preparing for a “no prior notice” regulatory audit”; J Health Prot Manage. 2010; 26(1):14-20.

The Joint Commission: The Source; May 2011; Volume 9, Issue 5, pg 1 & 9; “In Focus: A Closer Look at Joint Commission Second Generation Tracers”

The Joint Commission: The Source; May 2011; Volume 9, Issue 5, pg 6-8; “Tracer Methodology 101: Second Generation Tracer for Cleaning, Disinfection, and Sterilization of Equipment”

Rodgers, Debby; California Hospital Association; “CDPH Plan to Revise Title 22”;; December 23, 2010



In This Issue

A Recipe for Advanced Clinical Systems

Code of Ethics for Nurses

Champions… A Key to Success

Optimizing the Wound Healing Environment

Electronic Documentation

The Pace of Regulatory Change

Alphabet Soup in the Ambulatory Division

Shared Governance: PICU Skin Care Program

Striving for Excellence in Children's Asthma Care

Patient Satisfaction Comments