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Mock Surveys Done Right
Tips for helping your staff ace their most important test.
Aaron Kocsis
Publish Date: October 1, 2008   |  Tags:   Accreditation

Mock surveys should feel like the real deal. Challenge your staff. Learn to speak the accreditation language. Target flaws in your clinical care and fix them. Above all, realize that patient safety is the driving force behind the mock survey process. You want to provide the highest possible level of care, not just maintain your accreditation status. Here are my top tips for running effective survey dress rehearsals, culled from putting my hospital's surgical teams through their accreditation paces. When actual surveyors show up in our lobby with dreaded clipboards in hand, we'll be ready. Can you say the same?

1. Divide and conquer. Don't attempt to coordinate a mock survey all by yourself. Work with members of your surgical teams who express interest or demonstrate expertise in specific segments of clinical care. Charge them with reviewing the accreditation standards that fall within their areas of interest and hot-button issues you need to address during mock surveys. For example, I focus on environmental concerns during operating room reviews. The director of our hospital's Center for Quality Outcomes focuses on medication issues during mock surveys. Three nurse clinicians, the hospital's patient safety coordinator and a staff assistant complete our accreditation review team, each bringing unique skill sets, backgrounds and expertise to the mock survey process.

2. Walk the walk... You can't prepare your staff for an accreditation survey with e-mailed memos or chart reviews conducted behind closed office doors. Get out from behind your desk, walk the halls and observe your staff in action. Each Thursday we fully review one clinical department in our large teaching hospital.

3. ...and talk the talk. Communicate with staff about their daily responsibilities and relate them to your facility's policies and procedures, just as accreditation surveyors will do during their on-site reviews. Observe your staff in action to ensure they're completing required tasks, then ask pointed questions about their performance. Do they know the accreditation standards that dictate their actions? It's also at this time that our nurses often identify processes they feel need improvement and make suggestions for change. We replaced open-ended questions on surgical documents with checkboxes to help capture documentation, thanks to a compelling argument made by a nurse during a recent mock survey.

Positive and constructive interactions with your staff are crucial aspects of the mock survey process. Frontline teams will get a chance to respond to questions they'll likely field on survey day, and just as importantly, they'll learn how to handle themselves in the interview hot seat. Don't ignore that very important skill. Staff well-versed in what they do and why they do it might fold under pressure, unable to articulate information they've recited countless times before. Putting staff to the test with challenging questions during mock surveys helps them develop poise and confidence. That's one of the main reasons your mock surveyors need to make the dress rehearsal feel like the real thing.

4. Give notice. Yes, accreditation surveys are unannounced and, yes, mock surveys should mirror the actual event, but you also want to promote a team approach to prepping your facility and staff. Give your staff a few days' notice before invading their space. That courtesy lets your key people clear their schedules so they can accompany the mock survey team on their tour of the ORs. Having the mock surveyors enter the surgical environment with a familiar face will convey the right message: We're all in this together.

Choose a case for your review team to trace. The head of the mock survey team should introduce herself to the patient and explain why so many masked faces are interested in the case. Patients typically welcome extra sets of eyes focused on improved staff performance and surgical safety protocols.

5. Stay on the path. Using the tracer methodology will prepare your staff for the review method used by actual surveyors. It will also let your mock survey team observe direct patient care as well as your facility's environment of care. That's important: You need to ensure universal protocol is followed in pre-op and the OR, but you should also look for the seemingly minor infractions that end up costing facilities full accreditation.

Your staff is correct in thinking that accreditation surveyors want to see staff actively communicate to confirm the surgical site and the patient's identification. However, they're also paying particular attention to the proper documentation of the timeout in the patient's chart.

Check the readiness of crash carts. Look for general housekeeping issues. Inspect shelves and equipment carts for expired supplies or medications. Review surgical documentation for completion and accuracy, confirming, for example, that patients' H&Ps are included in op reports. Also be sure to watch for surgical teams trying to get a jump on finishing paperwork before cases conclude. Those head starts are major violations of accreditation standards that you'll want to catch and correct before accreditation surveyors do.

6. Speak the language. Be sure accreditation standards are centrally located and easily accessible to your entire staff. You may not consider yourself an expert in all things accreditation, but have an open door policy with respect to the survey process. Research the correct answer to an inquiry you can't immediately answer, relay it to whoever posed the question and post the information on a communication board or share it during your next staff meeting. A question voiced by one is probably wondered about by many more.

Throughout the mock survey — from clinical observations to requests for corrective actions — refer to the accreditation standards you're measuring your facility against. Drill down so you can link them to the elements of performance that serve as their building blocks. For example, a surgical timeout is an accreditation standard; documenting the timeout in the op report is an element of performance — it's one of the steps you must take to fulfill the accreditation standard.

By using accreditation terms and standards, your staff will develop a better understanding of an accrediting body's expectations, the reasons behind accreditation requirements and the key phrases and buzzwords surveyors are sure to use during their on-site reviews.

7. Learn from mistakes. Mock surveys are most effective if you record your observations. We developed worksheets that match the expertise of each mock survey team member. Checkboxes (compliant? not compliant?) appear next to itemized accreditation standards. Overall, our surveys reach maximum efficiency and effectiveness because of the worksheets; we're sure to expertly review the entire surgical process by focusing individual attention on separate aspects of clinical care.

After the mock survey, our review team enters its findings into an online database, which automatically generates a report of our review and e-mails it directly to the managers of recently surveyed departments.

The reports identify oversights that must be addressed and corrected before accreditation surveyors arrive for the real survey. They also link to accreditation standards that correspond to our requests for corrective action. The OR manager relays our review to her clinical team, works with them to address our concerns and submits an electronic corrective action document to our database within 30 days of receiving our report.

We used to recommend corrective actions, but have found the staff gets more out of a mock survey by working through accreditation-related problems on their own. They develop a greater understanding of accreditation requirements by referring to and working off the standards that should guide their daily performance. It also became evident that we had recommended corrective actions that looked good on paper but didn't mesh with frontline reality. Trust your staff. They have the firsthand experience and ability to develop the best solutions to the problems you'll need to address before taking that call about clipboard-toting visitors waiting in your lobby.

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