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Post-pandemic reality check: Regulatory compliance isn’t on autopilot

Healthcare CEOs need to ensure their organizations are re-establishing regulatory compliance as a priority to reduce risks to patient safety and their reputation.
Quality & clinical operations
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CEOs expect that leaders — from department heads to executive teams — are well-versed in the regulations that govern their areas of responsibility, and that compliance is actively managed. It’s a reasonable expectation. But in today’s post-pandemic environment, is it grounded in reality?

Across the country, we’re seeing a different story unfold.

There has been significant leadership turnover at all levels. Many frontline staff providing care today were educated, trained and hired during the pandemic — an era marked by constrained clinical education, limited mentorship and overwhelming operational demands. We can’t ignore that the learning environment simply wasn’t the same. And in many cases, it couldn’t be.

At the same time, regulatory oversight shifted. Centers for Medicare & Medicaid Services (CMS) issued waivers and suspended numerous regulations to keep systems functioning during the public health emergency. New leaders stepped into their roles under those relaxed conditions, and in some cases, have never operated under the full weight of pre-pandemic regulatory expectations.

Now, CMS and accrediting bodies have returned to business as usual, but many organizations haven’t recalibrated.

The assumption that compliance is under control may no longer hold true. And that introduces risk — compliance risk, reputational risk and patient safety risk.

So where do we go from here?

This is a leadership issue. CEOs must ensure their organizations are not only operationally sound but also regulatorily compliant. That requires:

  • Assessing the current state of compliance knowledge and infrastructure
  • Reinvesting in leader and staff education with a focus on regulatory expectations
  • Creating systems of internal accountability and continuous readiness
  • Supporting a culture where compliance is not an event, but an embedded discipline

This isn’t about checking boxes — it’s about protecting the integrity of our organizations and the safety of those we serve. Compliance can’t be assumed. It must be owned. And that ownership starts at the top.

What are the benefits of recognizing and acting on regulatory compliance as a value add to organizational operations versus just checking the box?

  1. Patient safety and quality of care
    • Standardization of practices: Compliance ensures that healthcare providers follow evidence-based guidelines and protocols, minimizing errors.
    • Continuous improvement: Regular audits and feedback, driving a culture of quality enhancement.
    • Safe environment: Regulations mandate the safe use of equipment, medication handling, infection control and more.
  2. Legal and ethical accountability
    • Risk mitigation: Following regulations reduces the risk of malpractice, litigation and penalties.
    • Ethical practice: Ensures providers respect patient rights, privacy (e.g., HIPAA) and ethical treatment standards.
  3. Financial stability and reimbursement
    • Eligibility for funding: Compliance with standards (e.g., CMS, The Joint Commission) is often required for Medicare and Medicaid reimbursement and insurance payouts.
    • Avoidance of fines: Non-compliance can lead to costly penalties or loss of operating licenses.
    • Operational efficiency: Streamlined, compliant operations reduce waste and improve billing accuracy.
  4. Reputation and trust
    • Public confidence: Patients and the community see accredited organizations as trustworthy and credible.
    • Professional recognition: Compliance often enhances the recruitment and retention of skilled healthcare professionals.
    • Competitive advantage: Accreditation can differentiate a facility in a competitive market.
  5. Organizational culture and workforce morale
    • Clear expectations: Compliance frameworks establish roles, responsibilities and expectations.
    • Empowered staff: Training and guidelines help staff act confidently and safely.
    • Culture of accountability: Accountability promotes transparency, ethical conduct and continuous education.

Regulatory and accreditation compliance isn't just about meeting external rules — it's a strategic framework that elevates healthcare delivery, protects patients and providers, and sustains the overall health system. Healthcare leaders must reframe compliance from a reactive obligation to a proactive operational imperative to strengthen their ability to deliver high-quality care, maintain public trust and weather future challenges with confidence.

Author
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Principal, Regulatory and Accreditation Advisory Services
Diana Scott brings more than 35 years of healthcare experience to her role as principal of Vizient’s Regulatory and Accreditation Advisory Services. She oversees a team that delivers expert guidance in the Centers for Medicare & Medicaid Services Conditions of Participation, The Joint Commission (TJC) accreditation, and compliance with federal... Learn more