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Prepare Like a Pro for Your Accreditation Survey
5 ways to stress less when the surveyor comes calling.
Kendal Gapinski
Publish Date: March 3, 2015   |  Tags:   Accreditation
accreditation process WHAT — ME WORRY? A staff that's knowledgeable on the accreditation process can pave the way for a smooth survey.

Accreditation surveys can rob you of your patience, your fingernails and your sleep, but it doesn't have to be that way, not if you follow these 5 tips to ensure your facility is always survey-ready. If what the experts say is true — that constant preparation is the way to stress less when surveyors arrive — then you've got nothing to worry about.

1. Coach your staff
Ensuring your staff is ready for surveyors — and quashing fears of the unknown — is key to a successful survey. Patricia Thorbin, RN, BS, CPHQ, director of quality improvement for Watson Clinic in Lakeland, Fla., says sending employees to continuing education programs hosted by accrediting agencies or consultants prepares them like nothing else can. "It helps them to have a framework," she says.

When surveyors walk around, they'll be asking your staff questions on their job descriptions, policies, initiatives and other need-to-know items, says Kim Reeser, BSN, RN, CAPA, assistant nurse manager at the Reading Hospital in Reading, Pa. Ms. Reeser takes answers to questions asked during previous surveys, like current hospital initiatives or the name of the regulatory officer, and makes them available by placing them on the hospital's website or in cards kept in employees' name badges. "It's all about making that information very accessible and handy," says Betsy Adams, MSN, RN, CPAN, nurse manager at Reading Hospital.

Monthly meetings dedicated to discussing policy changes and other potential survey questions can also keep your staff on their toes, says Elodia Flores, RN, BSN, CASC, vice president of operations at Outpatient Healthcare Strategies. Another tip? Hire a third party to come in a few months ahead of time and perform a mock survey to spot potential dings and prepare everyone for the real deal, she says. "You have to include your employees," says Ms. Flores. "There needs to be alignment in your facility from top to bottom."

prepping for accreditation ALL TOGETHER William Teague, quality improvement analyst, Sheila Coile, RN, quality improvement supervisor, and Patricia Thorbin, RN, BS, CPHQ, director of quality improvement at the Watson Clinic work on prepping for accreditation.

2. Sync policies
Surveys typically require you to show that you have a policy to meet every standard set by the accrediting agency, and that you regularly update and review those policies. Not an easy job, experts say. "That's where the majority of the time prepping for the survey is spent," says Ms. Flores. She suggests you make it palatable by "taking it (the standards) chapter by chapter, month by month, and spread it out so it doesn't become cumbersome."

Ms. Thorbin used a team of staff members and a little help from Microsoft Excel to match standards and policies for her last survey. She created a spreadsheet that listed every accreditation standard, then sent it out to unit leaders in charge of the clinic's various policies. Those leaders then had to find a policy for their unit that met the standard, and link it to that policy in the spreadsheet. That enabled Ms. Thorbin to ensure that all standards were met and policies didn't conflict. She also created a "road map" listing all of the agency's standards and where to find each corresponding policy. She placed that document on individual flash drives for the surveyors, simplifying their job. "The easier you can make their life, the better," she says.

Ms. Adams says digital technology has been a huge help to the hospital, which recently switched to electronic health records. All policies are organized digitally. She can access them with a couple of swipes on a tablet "instead of flipping through paper charts," she says. Ms. Flores recommends offering your policies in both paper and digital formats for surveyors who "aren't as tech-savvy."

3. Keep your facility in top shape
Surveyors will be looking at everything, from missed supply expiration dates to the cleanliness of your walls. Regularly scheduled inspections help keep your facility in tip-top shape, experts say.

Ms. Thorbin says that while management-led walk-throughs were held more frequently leading up to the survey, her clinic also has a year-round schedule dictating when each department, like maintenance and environmental services, must go around and check for deficiencies. A similar practice is done at Ms. Adams' hospital, where every month environmental services walks around to look for any issues and check in with staff on problems like work orders that need to be completed. Every 6 months leaders from the hospital's environmental services, facilities and safety departments perform a thorough walk-through with the hospital's regulatory officer and inspect for non-compliances, says Ms. Adams.

Daily checklists are also an easy-to-manage option, says Ms. Flores. At her previous facility, she says, every staff member was given a daily assignment — like checking medication cabinets or supply expiration dates — a month at a time. At the end of the month, they had to write a short report listing any problems. "If something came up in the report, we could fix it before a survey ever took place," says Ms. Flores.

Correcting problems as they appear helps to avoid potential dings and the sharp costs of last minute repairs. "The secret is that once you get everything in shape for the survey, make sure it stays that way," says Ms. Thorbin.

4. Focus on CQI projects
QI studies are an essential part of many ASCs' accreditations, but can often seem "intimidating," says Ms. Flores. Try breaking them down into bite-size chunks, she says.

First, look at your center and find an area you can improve on (issues like on-time starts and infection rates are great options). Then, gather a small team of staff members to help you brainstorm solutions and set a goal. Implement those solutions, documenting your process using your accrediting agency's suggested format, Ms. Flores says. When the time period of the study is over or your goal is met, present your findings to your governing board — so surveyors can see in meeting minutes that leadership was involved — and write a report. "We tried to complete one every 3 months," Ms. Flores says. "It was simplified, so it didn't make it difficult."

Benchmarking is another practice accreditors will expect. Compared to the internal goals of a QI program, benchmarking is a way of comparing your facility to national or regional standards, says Ms. Thorbin. The idea is similar to QI studies, she says, but you instead turn to outside agencies, like specialty organizations or CMS, to define your goals. Several of these groups offer benchmarking programs for a fee that are designed to aid your process.

QI requirements set by the Joint Commission vary from other ASC-focused agencies, but it's still expected that you demonstrate you've completed quality improvement programs. Ms. Adams says that the hospital's EHR system tracks any internal studies and benchmarking, and can easily generate reports with the studies' findings. "With the electronic health record, that information is right at our fingertips," says Ms. Adams.

5. Be a good host
You're not the only one stressed out, as surveyors face long days and endless travel. Consider these short tips to make the survey process more pleasant:

  • Supply travel tips. Consider reaching out to your survey team ahead of time to offer help in planning the logistics of their trip. Providing information on the closest airport, transportation options, and hotel and restaurant suggestions starts you both off on the right foot, says Ms. Thorbin.
  • Set aside space. Ms. Flores says you should have a designated work area for surveyors. In Ms. Thorbin's clinic, that means they are located in a secluded area in her wing of the building where they can easily access bathrooms and a break room.
  • Offer snacks. Surveyors may work through lunch, so having grab-and-go options all day long keeps them happy and well-fed, says Ms. Thorbin, who offers a light continental breakfast as well as a quick lunch and afternoon snack to accreditors.
  • Involve doctors. Ms. Flores says it's important to show that your docs are also interested in rules and regulations. "What I find is if the medical director or doctors are present and interested and meet with surveyors, that can go a long way," she says. "It shows that they're interested and they care."

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