We identify every regulatory gap in your organization — before your accrediting body does — and give you a clear, prioritized plan to close them.
The most expensive survey findings are the ones your organization could have found and fixed before the survey. Regulatory standards change constantly. TJC launched Accreditation 360 in January 2026, eliminating hundreds of old standards and introducing 14 new National Performance Goals. CMS updates its State Operations Manual continuously. Most healthcare organizations do not have the internal bandwidth to track every change, assess every gap, and prioritize every risk. The result is citations for problems that were visible — if anyone had looked.
Summit QCG conducts a thorough gap analysis that maps every applicable regulatory standard against your current policies, practices, documentation, and staff competencies. We tell you exactly where your gaps are, how serious each one is, and what you need to do about it — in priority order.
We go through your applicable accreditation and regulatory standards one by one and assess where you are compliant, where you are compliant on paper but not in practice, and where genuine gaps exist.
Not all gaps are equal. We risk-stratify every finding so your team knows what to fix immediately, what to address this month, and what can wait.
Sometimes organizations are doing the right thing but not documenting it in a way that satisfies a surveyor. We identify both practice gaps and proof gaps.
Every gap comes with a specific recommendation, a suggested timeline, and a clear owner — so the work gets done rather than sitting in a binder.
Standards evolve. What was compliant twelve months ago may not be today. An annual gap analysis keeps you current and continuously survey-ready.
You know exactly where you stand — and you fix what matters before the surveyor finds it.
Schedule a free 30-minute consultation with Dr. Dan Twizelimana to discuss your organization’s needs.
