SURVEY SUCCESS Study the accreditation standards ahead of time and ensure you have a policy in place for each one.

Who better to ask how to ace an accreditation survey than the surveyors themselves? That's right, we went right to the source, interviewing 4 surveyors to find out their top tips for making the survey process run more smoothly for them and for you. As you'll see, there's much more to a successful survey than having all of your documentation in order.

1. Know why you're being surveyed
Seems elementary, but know what type of survey you're having. Is it Medicare deemed status, re-accreditation or a first-time survey? Each has its own process and set of standards, so prep accordingly. For example, an early-option survey is for newly constructed surgical centers that may require accreditation for third-party reimbursement, and a 6-month wait for a survey would entail financial hardship. Surgery centers that are already Medicare certified, as well as those seeking initial Medicare certification, may apply for a Medicare deemed status survey.

2. Time your surveyor's arrival
Unannounced surveys typically occur within a set period of time. You can get a good idea of when your survey is coming by tracking this window — for example, you're 3 months into the 6-month timeframe — but make sure that you're ready for the visit starting on day one, says Sandy Berreth, RN, BS, MS, CASC, a surveyor with the Accreditation Association for Ambulatory Health Care (AAAHC).

'I remember last year I went on a survey and they were 1 month into their 6-month window. The administrator looked at me and said 'Oh, we didn't expect you,' and I said, 'What do you mean you didn't expect me?'' says Ms. Berreth. 'People go onto these community websites and see other administrators saying that we won't come within that first month. But don't believe it. Be ready.'

The Joint Commission has an extranet site called Joint Commission Connect that can provide clues that your survey is on the horizon.

'The site is active by 7:30 a.m. every day. If your survey is happening that day, the website would warn you if you log in that morning,' says Steven D. Chinn, DPM, MBA, MS, CJCP, a Joint Commission surveyor. 'Additionally, the Commission posts biographical information on your surveyor and a draft of the survey plan well before the actual survey occurs. So, when you see that information in the portal, that's the first signal that you're in the survey hopper and it's coming.'

3. Give them space to work
Jan Kleinhesselink, RN, BSHM, CPHQ, surveyor for AAAHC and the Accreditation Association for Hospitals/Health Systems (AAHHS), isn't picky about where she works, so long as she has some sort of workspace. A spare office, unused cubicle, converted consultation room or even a patient pre-op bay will suffice. 'As long as we have something to put our computer on, we're usually happy,' she says.

It sounds simple enough, but having a secure place to work makes the process more efficient. 'In one worst-case scenario, we were basically working out of our rental car in the parking lot,' says Dr. Chinn.

And don't forget to share the Wi-Fi password — Ms. Kleinhesselink notes that she needs Internet access to fill out paperwork. 'If it's an announced survey, I'll call and ask about it ahead of time,' she says. 'Some will say that it's not very reliable or fast, and that's a good thing to know so I can download the documents I need to have onsite.'

4. Organize your policies
Checking that your policies and procedures meet the accreditation agency's standards takes up the bulk of most surveys, so ensure you have a policy in place for each one. 'Our accreditation is like an open-book test,' says Gary M. Brownstein, MD, vice president of education for the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). 'We have the standards spelled out, so we expect our facilities to be in compliance 100%.'

You can make the process even easier by getting electronic copies of the agency's standards, adds Ms. Berreth. This lets you keyword search the standards, so you can quickly see if you have a corresponding policy in place. You'll also want to follow the agency's directions closely. 'Make note of the standards that say you must have a written policy, because surveyors will always ask for it,' says Ms. Kleinhesselink.

Organizing your survey documents into a binder takes time, but it saves your surveyor a headache later on. 'The Joint Commission's list of required survey documents is well-known to the facility. So, if that list has the facility's floor plans listed as the first required document, it helps to have that first thing in your binder,' says Dr. Chinn. 'When the facility has it all organized and it's easy to reference, it makes the first hour so much easier.' Have a few copies of these documents on hand in case you have a team of surveyors, he adds.

5. Ask for a mock survey
Having the accreditation organization perform a mock survey is a low-pressure way to look for deficiencies before the real deal, says Dr. Chinn. And don't forget about the small stuff. 'When we go in and do an inspection, we look at everything. Their infection prevention measures, where the fire extinguishers are, are the medications in date,' says Dr. Brownstein. 'If there isn't a case going on in the OR, we're also checking on the equipment. We often ask them to turn it on, just to ensure it's working.'

6. Be prepared to trace a case
Your surveyor will often want to follow a case from the time the patient is checked in at the front desk to the time he's discharged with his escort. During this time, the surveyor will be looking to see whether staff is abiding by best practices, as well as whether you're following state and federal regulations and properly documenting procedures.

'The surveyor will ask to see your caseload to see which one looks like the best one to trace,' says Ms. Berreth. 'If I were running an organization, I'd make sure that the case the surveyor chooses has the best pre- and post-op team on it, and that the OR team is ready and knows what it's doing.'

7. Get staffers ready for questions
Surveyors will likely question your staff on various facility practices. While some facilities hold morning huddles or weekly review sessions to prep employees, the key is to show them where to find the answers if they aren't sure, says Ms. Kleinhesselink. 'It's always better to say 'I don't know' or 'Let me find out' to the surveyor than it is to make something up,' she says. 'As long as they can look up the answer in your policies, that's usually what we're looking for.'

8. Don't forget lunch
Most surveyors we spoke to say that if the facility isn't ordering in lunch, they likely won't eat or will rely on a few stashed granola bars to make it through the day. Get lunch delivered, since the surveyor will often want to work through lunch, says Dr. Chinn.

'One organization I went to had a basket full of snacks and chocolates that they put on my desk,' adds Ms. Berreth. 'As a surveyor, it doesn't change your mind, but it does show that the facility is prepared.'

9. Make staff available
Having the right staff and leadership available during key times keeps you and your surveyor on schedule. The surveyors say they'll likely want to meet with your medical director and department heads at some point, often during the end-of-survey conference. Ms. Kleinhesselink notes that it's especially helpful to have a staffer available to help her review medical records and other documents. 'We give the administrator the agenda first, so that they have an idea of what they'll be doing on their end,' she says. 'So, if we want to look at a certain policy later that morning, but the surgery schedule means that the person we need to speak to isn't free, it helps to know that ahead of time so we can modify it.'

10. Consultative, not confrontational
If you get dinged on the survey, consider reaching out to the organization for more information or help on what to do next. 'If there are any questions concerning the deficiency, the facility has the right to query the board,' says Dr. Brownstein. 'We want it to be fair and we want them to meet the standards.'

While it can be a high-tension time, the surveyors stress that that's not the goal. 'We want it to be a learning experience,' says Ms. Kleinhesselink. 'We want it to be consultative and help you achieve a higher level of excellence, not be a scary thing.' OSM