Ace Your Next Accreditation Survey


Preparing with a purpose will have you greeting surveyors with confidence.

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.

1. Welcome without waiting

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.

2. Know the standards

DRUG MONITORING Be ready to discuss the policies you have in place for medication storage, usage and security.

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.

  • Safety and security. Surveyors will review policies and procedures and make sure drills are conducted and designed to protect patients and employees from harm, according to Ms. Geier. She says they will also confirm that active shooter drills are conducted, and there’s limited access for approved employees only into the clinical care area of the facility.
  • Hand hygiene. Surveyors will watch employees’ hand hygiene practices without letting them know they’re being observed. Are they washing their hands after removing gloves? Are staff members observing their colleagues’ practices and reporting non-compliance issues? Do they have convenient access to alcohol-based hand rub dispensers? Do they know of places where additional dispensers should be located?
  • Medication management. Be ready for questions regarding your medication procurement, dispensing and security policies, says Kathryn Thompson, MSN, RN, CNOR, senior manager of clinical services and operations at Emory Clinic in Atlanta, Ga. She says surveyors will want to know what you’re doing to ensure the right medication and right dose is administered to the right person by the right route at the right time. Also differentiate medications with similar-sounding or similar-looking names (Tall Man lettering is a good option) and store them in clearly marked, non-adjacent drawers to avoid confusion.

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.

  • Pre-op time outs. Surveyors will observe the time out to make sure the surgical team discusses what your facility’s policy states should be covered during the safety check. They also confirm that staff take time outs seriously, that they’re engaged in the process and that there are no outside distractions.
  • Policies, procedures and paperwork. Bri Merriman, RMA, administrator at Crater Lake Surgery Center in Medford, Ore., says 2 surveyors spent 2 days at her facility. One surveyor inspected the facility’s infrastructure and maintenance contracts, while the other read over every sentence of the facility’s policies and procedures, making sure staff in-services were appropriate and current, and that employees had access to up-to-date competencies that met required standards. The surveyor also reviewed contracts with insurers and outside vendors (IT services, for example), the employee handbook, credentialing packets, benchmarking figures, quality improvement studies, and instructions for safe injection practices and proper sterilization techniques.

3. Expect the unexpected

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.”

4. Plan ahead

READY OR NOT Staff at Crater Lake Surgery Center prepared for what they assumed the surveyor would cover. As is the case during most surveys, there were some surprises.

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.”

5. Count on your colleagues

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.”

Positivity pays off

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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