Do environmental, health and safety (EH&S) regulations at your hospital sometimes take a back seat to Joint Commission requirements? Is there ever confusion about which department is responsible for certain EH&S reporting and inspections? Do you feel like EH&S requirements may be slipping through the cracks? A gap analysis can help.
Capaccio recently conducted a gap analysis at a large Boston area hospital to determine what EH&S regulations were potentially being overlooked, or perhaps not assigned to anyone. The gap analysis was also able to show which of the hospital’s EH&S requirements were directly related to the Joint Commission elements of performance. In making this connection, the hospital greatly reduced the duplication of efforts by using existing programs already developed to meet the elements of performance.
Conducting a gap analysis is valuable because the hospital not only receives a list of all of its applicable EH&S regulations but also insight into how those requirements may link to Joint Commission standards. Furthermore, it provides an inventory of regulations that can be used to assign responsibility and ownership to help ensure that there are no surprises when the facility is inspected by a local, state or federal agency. This inventory can be taken one step further with a regulatory calendar that provides a detailed schedule of when submittals are due and permit renewals required. A gap analysis will make your facility run more efficiently, help ensure all EH&S requirements are being met, and also save both time and money.
To view a small sample of a regulatory matrix that would be delivered as part of the gap analysis click this link:
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If you have any questions or would like additional information about our gap analysis services, please contact Bill Potochniak at 508-970-0033 ext. 134 or firstname.lastname@example.org.