Survey Without Tears: How to Ace Your Hospital Accreditation

 

5 Key Points

  • Have a point person who will gather the team together and take the lead on discussing performance standards and provide guidance on what to expect during the survey process. 
  • Before the real survey, conduct a mock survey to reveal deficiencies and implement improvements.
  • Coach and prepare your staff through in-services, regular rounding, and questions of the day during morning huddles. 
  • Be congenial and honest. Don’t argue about findings; offer additional information or use the formal appeal process.
  • Main areas of survey focus include infection prevention, universal protocol, medication management, Pointofcare testing, and patient safety.

 

Full Conversation

How long have you been a surveyor?

Nine years. I enjoy it very much. After 200+ surveys, I still see things I have never seen before that I can share with others. I have complied all of that experience into my 2021 Survey Survival Guide. I wrote this to help prepare OR staff for surveys in a simple way that can be quickly referenced. The booklet, which fits nicely in the pocket of your scrubs, contains crucial information organized by subject area that surveyors will expect your team to be well informed about. 

What is the purpose of a survey and how often do they occur?

Accreditation is a way to look at an entire facility to ensure patient care standards are being met. Also, if a facility wants to receive Medicare, Medicaid, and most private insurers, they must be accredited.

The Joint Commission and AAAHC (Accreditation Association for Ambulatory Health Care) conducts surveys every three years and the DNV-GL is annualHowever, they can show up anytime to survey a facility.

All of them can survey both hospitals and surgery centers, but the DNV-GL and Joint Commission primarily serves hospitals, while AAAHC mostly focuses on surgery centers. 

Given the fact that a surveyor can show up at any time, should facilities have ongoing survey preparation?

Yes, it should be. But it can be difficult because a hospital is a large organization that has daily needs and it’s hard to constantly focus on survey preparation. Typically, facilities will wait until around six months to a year before their survey to begin preparation. If it’s a three-year cycle and there is a correction plan in place from the previous survey, surveyors may wait until the next scheduled time.

All of the accrediting facilities want to see continuous quality improvements over your last survey. Leadership should communicate to staff that, while they are already doing a good job, the accrediting body is looking for continuous opportunities for improvement. Engage staff and ask: what things can we do better? What are you concerned about? Get them involved, everything can’t just come from the top down. It’s definitely challenging to find the time, but once you get a high level of staff involvement, you will have their buy-in.

What are some common missteps facilities make during preparation for surveys?

Not fully understanding what the standards arenot having your staff preparedcoaching people to hide the truth, and arguing with the surveyor. 

Staff needs to know what to say and how to talk to a surveyor. I have had people say to me during survey preparation, “I’m just going to hide.” That is the very last thing you want your staff to do. You want them front and center and this will absolutely impress the surveyor. If your people are not afraid and they come out and explain what they do and how they take care of patients, that alone will make a positive impression on the surveyor and in the end, make for a more successful survey.

Not lying to a surveyor seems elementary, and it doesn’t happen often, but it does happen. People have lied to me. Surveyors have an instinct where they can tell you are not being honest. If we think you’re hiding something, it’s a red flag. If you’re not honest about one thing, what else are you not being honest about? We will dig deeper and it will be painful for everyone.

Appeal a finding later or show additional information at the moment, but do not be confrontational with the surveyor. That is a mistake.

Does that mean you won’t get adverse findings? No. The way you take care of patients may need improvement, but the fact that you have been forthright and prepared your staff will go a long way. At one of my previous DNV surveys, I gave out my Survey Survival Guide, prepped OR leadership, and the staff, and when it came time to answer the surveyor’s questions, I put the new OR manager, who had been there for only three months, upfront and she took over. That surveyor told me over and over what a great job she did.

At another facility, I arrived at the surgery center and the surgical technician met me in the hallway, introduced themselves, and said they were going to be scrubbing the case I would be observing that day and how glad they were I was there. That blew me away because I had never had anyone come and greet me.  

A facility has some adverse findings. Is this the end of the world? What’s next?

The worst that can happen is your facility shutting down. But that is extremely rare. It is also rare to find any facility with no findings at all. There are going to be adverse findings or deficiencies. I like to view them as opportunities for improvement. Surveyors have fresh eyes, they have been to many facilities, trained in the standards for patient care. They will see things differently than the people that are there every day. 

When findings are found, the next step is a plan for correction. If it’s a Medicare survey, you submit that plan to the accrediting company, who will report the findings to Medicare. If it’s non-Medicare, those findings will show up next time so the next surveyor will look for it see if it has been addressed.  

An example of a finding would be unlabeled syringes. The plan of correction might include education and competencies provided to staff and physicians and updating policy and procedures. Those changes will be placed in your quality improvement minutes if that’s appropriate for your facility. Then the next time the surveyor comes, they will check to see if you made the corrections, updated practices, and note any deficiencies. 

What are some ways to limit the number of findings during a survey? 

The best way is to make sure leadership and staff are prepared and understand what the requirements are. Everyone has to be on the same page. If you don’t have a road map, and someone to lead that, the process will be difficult to navigate.

For a hospital, the director of quality leads initiatives for survey preparation. For the perioperative department, it falls to the director of surgical services because they will best understand how the OR works and what the vulnerabilities could be.

In addition to a correction plan, what else happens post-survey? 

Leadership needs to monitor what is being done to make sure you remain compliant with your plan and that you are meeting standards. A team approach is definitely needed to address deficiencies. 

How can stress be minimized as a facility approaches survey? 

Be prepared. If people know what is required of them, if you’re watching one another, doing mock surveys, doing rounding, evaluating your processes, you will feel confident and say, “Bring it on, let’s go.” We, the surveyors, are people too and are generally healthcare providers. It should be a collegial process, not punitive. I will give positive feedback and will recognize the excellence that I see. But standards have to be met. I’ll share with people as I go along so that when you get the report, there will be no surprises. Leadership should be positive and tell the staff what a great job they are doing, while also being direct about what improvements are needed.  

For a surprise survey, it’s obviously different. When it’s first announced, people will have a little heartburn about that. But again, if you’re continually prepared and staff is doing what they need to do, you don’t have anything to worry about. Just welcome the surveyor and show them the excellent care you provide for patients. 

 

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