There should be ongoing education and discussion with peers and staff about the maintaining a compliance program within the facility:

1. Do periodic audits yourself and talk with staff regularly about compliance
2. Put compliance items in a checklist and be ready to talk with your Board about them
   • This will help with your governance to the Board and from a management perspective it will help with your storytelling to inspectors should any issues arise
3. Make sure you’re aware of the areas that the Ministry will be inspecting
4. Be ready to speak to and address any non-compliance
5. Be vigilant with post-incident mobilization
6. Interacting and reporting: have compliance on your agenda when you’re reporting to your Board (verbal reports & discussion or more complex matrix style approaches)
7. Make sure your conversations with the Board have minute notes being taken
8. Start simple and then build up more complexity around your approach to compliance

Next Chapter:

Accreditation

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