Challenge
While Ellenville Regional Hospital, a Critical Access Hospital (CAH) in Ellenville, New York, had a strong regulatory compliance record, leadership knew that past success does not guarantee future readiness. Regulations evolve, staff turnover creates knowledge gaps, and operational processes shift—all of which can lead to compliance vulnerabilities.
Hospital CEO Steve Kelley understood the high stakes of survey preparedness:
- A poor survey outcome disrupts hospital operations, forcing leadership into crisis mode and diverting focus from patient care.
- Negative findings can damage reputation and staff morale, affecting recruitment and retention.
- Regulatory compliance reflects overall quality—hospital boards, leadership teams, and frontline staff need confidence that they are meeting the highest standards.
“A bad survey can throw an entire organization into crisis mode. Instead of focusing on patient care and strategic growth, leadership is forced to react, scramble, and fix issues that could have been addressed earlier. That’s why survey readiness isn’t just a compliance task—it’s an operational necessity. By taking a proactive approach, we protect our reputation, support our staff, and ensure we’re always delivering the highest standard of care.” — Steve Kelley, CEO
Ellenville Regional Hospital wanted to ensure its entire organization—from leadership to frontline staff—was confident and fully prepared for its next survey. They turned to Stroudwater Associates for expert guidance.
Solution
Stroudwater’s Clinical and Quality team brought a structured approach to Ellenville’s survey readiness project, ensuring the hospital was prepared for CMS, The Joint Commission, and New York State Department of Health (DOH) standards.
Key Steps in the Process
- Comprehensive Policy & Procedure Review – Stroudwater assessed 30+ key compliance areas, ensuring hospital policies reflected the most up-to-date regulatory requirements.
- Mock Surveys & Staff Training – Stroudwater simulated real survey scenarios, allowing staff to practice responses, reduce anxiety, and correct deficiencies before surveyors arrived.
- Tracer Methodology – The team followed a patient’s journey through the hospital to ensure documentation, processes, and compliance protocols aligned with Conditions of Participation (CoP) and accreditation standards.
- Regulatory & Compliance Enhancements – Special focus areas included:
- Emergency Department (ED) compliance & trauma-informed care
- New York State domestic violence screening requirements
- Health equity & diversity, equity, and inclusion (DEI) initiatives
- Affiliation & transfer agreements required for CAHs
“Survey readiness isn’t just about passing an inspection—it’s about ensuring that every department, every process, and every team member is aligned with best practices. The insight from Stroudwater gave us the confidence to know exactly where we stood. Instead of making assumptions, we had a clear, data-driven understanding of what was working well and where we could improve. That level of clarity is invaluable, not just for surveys, but for sustaining a culture of quality and excellence.” — Ashima Butler, COO
Results
Ellenville Regional Hospital emerged from the process better prepared and more confident than ever.
Key outcomes included:
- Early identification of potential compliance risks, allowing the hospital to correct issues before they became citations.
- Increased staff confidence, ensuring employees at all levels were equipped to respond effectively during a survey.
- Daily, monthly, and quarterly compliance checklists that institutionalized survey readiness as an ongoing process, not a last-minute scramble.
- A clear roadmap for continuous improvement, reinforcing a culture of quality and patient safety.
“Surveys are public record. You don’t want to cut corners—it impacts reputation, compliance, and staff morale. This process isn’t just about passing a survey; it’s about being a high-quality organization.” — Steve Kelley, CEO
Why This Matters for Hospital Leaders
Ellenville Regional Hospital’s experience demonstrates that survey readiness is not just about compliance but operational excellence. Hospitals that proactively prepare for accreditation surveys:
- Reduce the risk of corrective action plans, which can require months of additional monitoring and reporting.
- Create a culture of continuous improvement, ensuring staff always meet the highest standards of patient care.
- Strengthen the hospital’s reputation, supporting recruitment, retention, and community trust.
Ellenville Regional Hospital and Stroudwater collaborated to turn survey readiness from a stressful obligation into a strategic advantage—ensuring compliance, protecting its reputation, and empowering its staff for long-term success.
