1. The Expectation Triad Healthcare Engineering Consultants Regulatory Compliance: “Ensuring that all of the required standards are being met”

2. Regulatory Compliance - Common Issues Management Plans Healthcare Engineering Consultants Seven Essentials: 1. Description of each element of performance 2. Responsibilities from staff to governing body 3. Performance improvement process 4. Risk assessment 5. Inclusion of all facilities 6. Reference to applicable policies 7. Summary of the program only - not a policy rewrite!

3. Regulatory Compliance - Common Issues Healthcare Engineering Consultants Orientation and Ongoing Training  Personnel must be able to demonstrate knowledge  Now in HR.2.10, 2.20 and 2.30  Typical topics include: Safety policies and security issues Hazardous material and infection control topics Emergency procedures, including utility failures Fire procedures Medical equipment-related topics Utility systems/ clinical connection Patient safety goals

4. Regulatory Compliance - Common Issues Safety Officer Requirement  Appointment of a safety officer  Annual evaluation of the management plans  Annual program evaluation  Integration of the patient safety program (required by the “Leadership” chapter) Healthcare Engineering Consultants

5. Regulatory Compliance - Common Issues Creation of the “Multi-Disciplinary Improvement Team” Safety committee membership Meeting requirement Communication to leadership Annual reporting to the governing body Healthcare Engineering Consultants

6. Regulatory Compliance - Common Issues Healthcare Engineering Consultants