9 Things CNOs Think They Know About Survey, But Don’t
So, your hospital accreditation site visit is coming up in a year or two. Do you feel prepared? Yes? But are you really? What if you had a simple list of items you could reference to double-check that? You’re in luck, you are holding that list in your very hand (or, on your computer).
A trio of highly experienced surveyors, Kathy Beydler, RN, MBA, CNOR, CASC; Rosie Ross, RN, BS-HCA, MBA; and Phil Meyer, RN, MHA, BSN, RNFA, highlight nine areas outlined below that may need a second look or extra attention before the day of your site visit.
1. Preparing for Survey vs. Maintaining Preparedness for Surveys
Some facilities may engage in a flurry of activity to prepare their accreditation survey. It’s best to approach survey preparedness as a process that is ongoing and continuous, not a one-time event. This one-and-done attitude may create a frantic environment resulting in staff being unprepared, having expired supplies, or, worse, hiding things. Certainly, maintaining preparedness can be a challenge logistically. But doing so in-between visits will avoid the stress that comes with rushing through the process last minute and lessen the chance of adverse findings.
2. Overlooking Sterile Processing
Sterile processing (SPD) is one of the most critical areas in healthcare. However, administrators often have very little knowledge of what SPD does and because the department isn’t a revenue generator, it tends to drop down on the list of priorities. But failing to assess SPD status risks adverse findings in your survey, patient safety, and revenue loss should an infection occur.
3. Forgetting to Make Regular Appearances in Clinical Areas
A CNO has a great deal of administrative responsibility, but letting months pass without stepping into clinical areas is a mistake, especially when a survey visit is on the horizon. Create a habit of visiting the OR regularly to provide support to leadership and staff.
4. Out of Sight, Out of Mind
Is your storage room unorganized? How do you store sterile items? Are your sterile supplies in date or expired? Does the area require ventilation? These are “out of sight, out of mind” line items that might get overlooked without proactive focus.
5. Not Understanding Policies and Requirements
Not only should every staff member be familiar with hospital policies, procedures, and accreditation standards, but they need to exhibit understanding by their practice.
6. Neglected Staff Education and Competencies
Did you know that an OR nurse needs to know how to clean the OR in the absence of cleaning personnel? Is your staff prepared for a lidocaine toxicity reaction from their patients? Mandatory competencies are specific and CNOs may not be aware of them all. This can set the stage for non-compliance.
7. Lack of Disaster Preparedness
Within the last few years, surveys have increased emphasis on disaster preparedness. In the blink of an eye, a mass casualty event can deluge a hospital with patients that need acute care. CMS now requires surgery centers to have a plan in place to handle these kinds of incidents along with area hospitals. COVID has also stressed the need to be poised to act; be ready to answer questions about how your facility handled the pandemic.
8. Underutilization of Mock Surveys
Hospital and surgery centers don’t perform mock surveys as often as they should. But a “dress rehearsal” is a great opportunity to catch anything in your environment of care that requires updating. That second pair of eyes is invaluable to help prepare for the real event.
9. Careless Language
During a survey visit, staff will be asked a multitude of questions. Be aware of the wording you use and answer questions in precise language. Avoid using words like “sometimes” or “usually.” Be as clear and direct as possible.