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The ABC+D of Plans of Correction: A Practical Guide for OBS Leaders

By: Rommie Johnson, MPH, PMP
Program Director

Posted: July 7, 2025

Every accreditation survey that identifies non-compliance with an ACHC Standard triggers an immediate need for a plan of correction (POC). Practices focused on office‐based surgery (OBS) operate with streamlined teams, tight budgets, and multi‐tasked staff—which makes a concise, efficient POC essential. ACHC provides a template to support that goal. Office-based organizations can adapt each POC component—Parts A through D—to fit lean staffing and limited resources.

ACHC issues a post-survey summary of findings—typically sent within ten business days of the final survey day—and you have ten calendar days to respond with your POC. Missing this deadline jeopardizes your organization’s timely accreditation. More importantly, a thorough POC demonstrates to your staff that you are serious about patient safety and regulatory compliance.

Writing a strong POC

A complete POC accomplishes four objectives. It:

1. Immediately corrects the deficiency (Part A).

2. Documents an internal approval (Part B).

3. Educates staff (Part C).

4. Establishes a sustainable monitoring plan (Part D).

As you read each section below, think of your own processes—whether you rely on paper charts or an EHR system—and tailor these steps to fit your workflows.

Part A: Actions taken to correct the deficiency (immediate & long‐term)

Part A focuses on two categories of actions: interim fixes to stop potential harm immediately and longer‐term solutions that prevent recurrence. For example, suppose your surveyor finds that “three of twenty medical records lacked patient discharge instruction sheets signed by the patient.”

  • Immediate action: On the day the summary of findings was received (Day 1), the nurse manager implemented a “no discharge without signature” protocol. Any patient chart missing a signature now triggers an immediate electronic alert in the EHR, preventing the chart from closing until the signature line is completed.
  • Long‐term action: On Day 3, the Quality Coordinator worked with IT to update the EHR template so that discharge‐instruction fields are auto‐flagged if unsigned. Additionally, the “Discharge Protocol” policy was rewritten to emphasize the nurse’s role in verifying signatures before patient release.

By specifying who completed each action and when (“Nurse Jackson, 6/1/2025” and “Quality Coordinator Martinez, 6/3/2025”), you give ACHC and other relevant regulators confidence that the deficiency was corrected, and that systemic safeguards have been built in.

Part B: Documenting Internal Approval

Part B requires clear documentation of who approved each corrective action. Staff in office-based settings may wear multiple hats, and it’s important to identify who assumed responsibility for specific changes. For our discharge form example:

  • Nursing leadership approval: Nurse Manager Alvarez reviewed and endorsed the “no discharge without signature” protocol on 6/3/2025.
  • Medical director sign‐off: Dr. Patel approved the updated Discharge Protocol policy on 6/5/2025.
  • Quality improvement committee: The QI Committee will sign off on the EHR template changes during the monthly meeting on 6/16/2025.

Concise email threads, meeting minutes, or electronic signature logs save time and ensure each Part A action is officially sanctioned. You can attach this evidence to your POC when it is submitted or indicate the date of expected approval if it occurs after your POC is due. Ensure that you clearly list each approver’s name, role, and approval date to eliminate any ambiguity.

Part C: Education—Ensuring everyone understands the new process

OBS staff juggle many duties, so education must be direct and time efficient. Craft Part C to answer three questions: who was educated, what was taught, and how you documented it. Continuing our discharge form scenario:

  • Who was educated: The RNs and LPN.
  • What education was provided: A 20-minute in‐service on 6/18/2025 will focus on the updated EHR discharge workflow.
  • Supporting evidence: Upload any relevant slide deck, along with a digital roster showing signatures from the attendees.

Within ACHC’s customer platform, you can store attendance rosters, slide decks, and even short video snippets of training sessions inside the POC folder. Education may occur beyond the 10-day window to submit the POC. In this case, indicate the expected date in the relevant part of the POC template and upload the final documentation as soon as it becomes available. When ACHC’s clinical review team reviews Part C, they can see tangible proof that your staff knows exactly what to do—and why.

Part D: Monitoring—Building a culture of ongoing oversight

Part D outlines how you will track compliance over time. Without a robust monitoring plan, even the best immediate fixes can unravel. As an example, your monitoring might include:

1. Chart audits: Beginning 6/9/2025, the Quality Coordinator will audit ten randomly selected discharge records every week for signature completion.

2. Targeted thresholds: Aim for 95% signature compliance for six consecutive weeks. If the rate drops below 90% in any given week, the Quality Coordinator convenes a focused huddle to find root causes.

3. Reporting structure: The Quality Coordinator will present monthly compliance percentages and trend graphs to the Quality Improvement Committee at the committee’s monthly meeting.

Specify who performs each monitoring action, how often, and the compliance threshold. This can be the same person. By setting an end date or reducing monitoring frequency based on achieving and maintaining the identified threshold, you show the intent of sustained compliance.

Leveraging ACHC tools to simplify your POC

ACHC’s internal platform equips you with audit templates, secure document upload, and automated reminders for POC deadlines. A few practical tips:

  • Upload updated policies directly: Label them clearly—e.g., “DischargeProtocol_REVISED_03102024.pdf”—so the review team can easily compare changes.
  • Track approval emails: Forward any approval emails into the platform’s POC workspace. This avoids hunting through your inbox when deadlines loom.

Final thoughts

A complete, thoughtful POC turns survey feedback into an action plan that strengthens patient safety and regulatory compliance. By structuring your POC via Parts A–D, you position your practice to minimize revisions from the review team and for long‐term success. Approach every deficiency as a chance to refine your systems, and you’ll find that executing a proper Plan of Correction the first time becomes a strategic advantage rather than a regulatory burden.

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