The Situation

Picture a multi-specialty ambulatory surgery center that has operated for nearly a decade on a compliance model that worked — until it didn’t. Policies live in binders that haven’t been updated since the last accreditation cycle. Staff pull the compliance officer into hallway conversations for routine questions. When infection control procedures change, no one can confirm the update reached every department. The administrator knows a CMS survey is coming. What she doesn’t know is exactly where she’s exposed — and that uncertainty is the compliance risk.

The Gap Assessment

A KATKOSH engagement begins with a structured discovery call and a full regulatory mapping exercise. Every governing agency with jurisdiction over the facility is identified — CMS Conditions of Participation, OSHA safety standards, AAAHC accreditation requirements, state licensing, and HIPAA privacy and security rules. In a facility like this, that mapping typically surfaces gaps the team didn’t know they had: a shared policy folder with no access controls; documentation that hasn’t been checked against the latest CMS revisions; and no way for staff to get a sourced, documented answer in real time — so unverified hallway guidance becomes de facto policy.

The Build

Over roughly five weeks, KATKOSH designs a compliance system built around that facility’s actual procedures and current regulatory requirements. Role-based access is structured so front desk, clinical, HR, and billing each operate within their own authorized layer. A live compliance health score gives leadership real-time visibility across every department. Every governance rule is embedded into the system’s instructions — which is what separates a governed system from a generic AI tool.

What It’s Built to Deliver