Celebrating Nurses’ Monumental Impact
There is a myriad of ways to participate in National Nurses Week, which is celebrated May 6-12, from honoring your staff RNs with a gift or event to taking steps to let...
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By: Nicole Azzara
Published: 11/14/2019
Most surgical administrators dread the day. You know the one. It’s the morning you get the call that an accreditation surveyor is in the lobby waiting to analyze every detail of how your facility runs, from front door locks to discharge directions.
Knowing what to expect during a survey and focusing on preparing your staff — and yourself — for what’s likely to be covered during the white glove inspection are keys to earning more distinctions than dings. The following advice from administrators who passed their inspections with flying colors and insider’s tips from an accreditation surveyor will have you heading into surveys confident that you’ll be ready to handle whatever comes your way.
The most important thing to remember when greeting your surveyor is to make sure they’re not left sitting in the reception area for too long before they get started, according to surveyor Ann Geier, RN, MSN, CNOR, CASC, chief nursing officer at Surgical Information Systems in Alpharetta, Ga. “Any longer than 10 minutes, and the surveyor will believe something is wrong,” she says. “It’s OK to let staff know when the surveyor arrives, but surveyors expect everyone to be ready to go and don’t want to wait around.”
It’s also important to provide surveyors with a private and spacious (if possible) room to serve as their temporary workspace. “Don’t put surveyors in a staff break room because it’s a public space, and they don’t want to be interrupted while they work,” adds Ms. Geier.
The surveyors will be following their organization’s standards, so be sure to familiarize yourself with the expectations of the accrediting body that’s conducting your survey. (Accreditors should be able to provide you with a survey preparedness guide.) Still, the best way to prepare for a survey is to maintain the required standard year-round.
Individual surveyors have their own styles and areas they tend to focus on, but addressing the following topics is a good basis for preparing for your next survey.
Ms. Thompson, who led efforts to prepare for an accreditation survey at Northside Hospital in Atlanta, her former place of employment, suggests having a policy in place that accounts for all medications that are stored and used, how leftover amounts are disposed of and a customized method for ensuring high-alert medications are tracked and stored in a secured location. She says surveyors also check to make sure crash cart medications are fully stocked and up to date, and ask for justification of overstocked medications. Keeping an abundant supply of drugs that are in constant shortage is a valid reason, for example.
Of course, things will come up that you wished you knew about beforehand. Ms. Merriman found this out when surveyors conducted a building inspection. “On my first survey, because it was a new facility, we missed some building codes and minor things like not having a safe distance between a fire alarm pull station and the floor,” she says. “I wish the [accreditor’s standards were] more descriptive about what they wanted you to follow.”
Have a good understanding of how every aspect of your facility works, including seemingly obscure things like your voicemail system. “I found out surveyors call the main line after hours to check if the phone greeting is appropriate,” says Ms. Merriman. “They wanted to see if they could reach someone on-call and made sure the normal business hours were mentioned on the recording.”
Leadership at Northside Hospital created an Excel spreadsheet to help organize what needed to be done before the accreditation survey. “We listed accreditation standards in one column and noted if we were meeting those standards in another,” says Ms. Thompson. “If we weren’t meeting a requirement, we noted what had to be done to meet it, who would make sure we did, and by when.”
Her preparation and planning began about 6 months before the expected survey date. Working that far in advance helped with implementing the changes she needed to make before the survey was conducted. Ms. Thompson says staff have to be educated about meeting accreditation standards, and constantly reminded about the importance of doing so until the surveyor arrives.
“Staff get busy and forget, so for example, we had somebody in charge of observing them to see if they complied with hand hygiene protocols,” says Ms. Thompson. “The assigned observer kept statistics about hand hygiene compliance and reported to the staff where our goal was and what improvements we had to make. Education, implementation and acclimation proved to be very important.”
Above all, don’t try to prepare for an accreditation survey on your own. “Our quality control nurse and clinical managers were integral to the process,” says Ms. Thompson. “We’d go over the preparation’s progress on a weekly basis and, if there was anything that needed to be done, they would take care of it.”
Staff need to be current on all policies and procedures, but so do you. Don’t focus too much of your attention on one area of needed improvement at the expense of other subjects that need to be covered.
Ms. Thompson wishes she had spent more time going over the particulars of her facility’s malignant hyperthermia carts and response protocols. The surveyor reviewed the inspection log for the cart, looked where the rescue medications were kept and checked to see if the staff had performed regular response drills. “I expected the surveyor to talk to the other staff members about our protocols, but she questioned me the entire time,” says Ms. Thompson. “I prepped my whole team because I was the manager, but I was the one she talked to the most.”
Ms. Thompson says one of the most important things to remember about accreditation surveys is that the process is not about punishing you for doing wrong, but to see how you can improve your work environment. “It wasn’t as grueling as I thought it would be,” she adds.
Ms. Geier agrees that the survey should be collaborative, not confrontational. Surveyors will seek information through direct observation, review of policies and interviews with staff and providers, but they’re not out to “get you,” she says. Don’t be afraid to speak up if you have ideas for how to improve your practices. “They’re not just looking for things that you do wrong, but also for what you do right,” explains Ms. Geier. “They want to learn about ways to improve accreditation standards.”
Also remember that kindness and generosity go a long way. “Little courtesies like giving surveyors the business cards of the staff members they talk to is a nice touch,” says Ms. Geier. “Also, having medical directors present during the survey shows they have an interest in what’s going on and makes a good impression.”
During your next survey, be prepared to provide surveyors with the information they want, but don’t forget to show off your facility and staff, and don’t hesitate to share your passion for them both. OSM
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