Ace Your Accreditation Survey

How much easier would it be to prepare for an accreditation survey if you could see your facility through the eyes of a surveyor? Joint Commission accreditors Jay Afrow, DMD, MHA, and John Milazzo, MD, FACS, provided that unique perspective for hospital and surgery center leaders during concurrent sessions.

Dr. Afrow said surgery center administrators must read accrediting organizations' latest standards and elements of performance, and check to see if their states' requirements are more stringent. Prepare a "Ready To Go" folder that includes a facility organizational chart, description of committee structures, environment of care team meeting minutes for the previous 12 months and a list of services provided. A sample agenda for the day of the survey is a nice touch, too.

He says that during a survey, it's OK to not know all the answers ("We will notice things you have never seen," he said). Don't take the survey personally: Surveyors are reviewing systems, not individuals. Feel free to ask questions. "Surveys should be interactive and educational," he said. Finally, if your surveyor asks for materials, collect them as soon as possible.

Many of the same principles apply in the hospital setting, said Dr. Milazzo. He stressed the importance of maintaining date- and time-stamped medical record entries, and ensuring that verbal orders are authenticated within time frames specified by law and regulations.

— Mark McGraw