Creating a continuous readiness program for accreditation requires understanding the organization’s current state to identify gaps and tailor the program effectively.
Option A (Assess current organizational practices related to on-site survey and regulatory visits): This is the correct answer. The NAHQ CPHQ study guide states, “The first step in developing a continuous readiness program is to assess current practices to identify strengths, weaknesses, and gaps in compliance with accreditation standards” (Domain 4). This ensures the program addresses the ambulatory surgery center’s specific needs.
Option B (Conduct individual, systems, and focused tracers across the organization): Tracers are a tool for readiness but should follow an initial assessment to target relevant areas, making this a secondary step.
Option C (Develop an education program for leaders and staff about continuous readiness): Education is important but premature without understanding current practices to tailor the content.
Option D (Review setting-specific regulatory and accreditation requirements): While important, reviewing requirements is part of the assessment process. Assessing practices first provides context for applying standards.
CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.7, “Develop programs to ensure accreditation readiness,” emphasizes starting with an assessment of current practices. The NAHQ study guide notes, “An initial assessment of organizational compliance practices is critical to designing an effective continuous readiness program” (Domain 4).
Rationale: Assessing current practices provides a baseline for designing a tailored readiness program, aligning with CPHQ’s systematic approach to accreditation preparation.
[Reference: NAHQ CPHQ Study Guide, Domain 4: Performance and Process Improvement, Objective 4.7., , , , ]
