Accreditation Inspection Insights


Hard work and plenty of preparation helped us ace our survey during the pandemic.

Now's this for stressful? A surveyor from one of the main accrediting agencies knocked on our surgery center's door early one morning in October 2019. The surprise visit came on a day packed with cases and within a week of each of us taking on new administrative roles. It was also eight months before our official survey was scheduled to take place.

We handled the surprise visit like pros, mostly by being confident in our operations, and we welcomed suggestions the surveyor gave us. Those suggestions, in fact, prepped us for the official survey, which occurred last June. Prepping for a survey and passing it during the pandemic wasn't easy, but here are a few of the valuable lessons we learned along the way.

  • Everyday excellence. Incorporating accreditation standards in your day-to-day work is the best way to ensure your center is ready for a spot inspection or one that's scheduled months in advance. The ultimate solution is to have good practices in place along the way.

Continuing education is key to making that happen. Don't put it off because you don't have a survey due for three years. Rather, act as if the survey is coming up soon, so you don't wind up cramming for the inspection. We have an online education platform and staff members have to participate in an annual curriculum. We tweak it slightly each year to keep it fresh, but it includes boilerplate material covering OSHA standards, how to handle biomedical waste, hand hygiene practices and fire safety compliance. Our thought is we don't have to worry about whether staff is up to date on accreditation standards if they're educated on the current versions each year.

WRITTEN RATIONALE Maintain a list of websites and other documents from organizations that recommend best practices to show surveyors why you've instituted new protocols.   |  Amanda Harris

We didn't postpone the survey because of the pandemic, which was an option for us, because we figured if we got through a survey in the middle of a pandemic, we could get through anything. But it also meant we didn't know if the surveyor was going to arrive with increased expectations because of COVID-19.

As it turned out, the surveyor didn't come in with a particular emphasis on pandemic-related practices, although he did observe the temperature checks we performed on patients and our masking practices. Just to be sure, we kept a COVID-19 book on all the changes we made in response to the recommendations our facility received throughout the pandemic. Maintaining a separate binder is less unwieldly than putting pandemic-related information in our main policy book.

We let the accreditation agency's handbook and our previous surveys guide our preparations. We track all notifications of changes to the handbook, then change and track our practices accordingly. Surveyors always ask what we've done to address their notations for areas of improvement during previous surveys, so we presented documentation on the tweaks we made to our credentialing files, physician referrals, peer review processes and pathology reconciliations.

An important point to remember is that not every surveyor will be from your state, so they won't always be familiar with the local standards you're following. If you're doing something different than you were doing during the previous survey, be ready to provide the reason why you're doing it — a government document, a study or a link to a website — and you'll be in good shape. Don't say, "Well, I remember reading an AORN guideline that said we should start doing this." You need to explain why you made changes, and which organization recommended them.

Time to prepare. Start planning for your next survey at least six to nine months in advance. We worked with a consultant who walked through our facility. She made a list of issues we needed to address, including how we filled out our charts and other medical records. We had a lot of down time during the pandemic, and made good use of it to prepare for the survey. We made to-do lists based on the consultant's recommendations, and allowed some staff members to come in and work on bringing our paperwork up to speed.

BACK TO WORK Furloughed employees at North Pinellas Surgery Center were brought back during the COVID shutdown to prepare the facility for its accreditation survey.   |  Amanda Harris

In addition to the facility-specific recommendations, the consultant spoke to us about which issues accreditation surveyors were making points of emphasis, as well as some issues directly resulting from COVID-19. For example, she told us surveyors no longer approve of cloth chairs in waiting rooms, so we replaced ours ahead of time.

When we conducted mock surveys, it was very helpful to have the accreditation handbook handy and attach our own policies to the relevant chapters to make our responses easier to locate. Also refer to copies of past survey results, along with notes from surveyors regarding the topics they emphasized and their recommended improvements. It also helps to meet with physicians at this time to get their buy-in on changes that might need to be made. When meeting with physicians, present the accreditation guidelines and the updates that need to be made to your current protocols, so you can justify operational changes with specific reasons.

  • Teachable moments. The unannounced inspection and feedback from the consultant provided valuable insights that we used to prepare for the survey. While the October 2019 surprise visit was stressful, it ended up being a really good experience that got us laser-focused for the official survey in June 2020. We explained to the surveyor that we weren't new to the center, but we were both adjusting to our new roles. She gave us several good suggestions to help us move forward with confidence.
CONSTRUCTIVE CRITICISM Surveyors are often willing to provide useful tips and advice that your team can use to work more efficiently and effectively.   |  Amanda Harris

Many involved credentialing, as well as tips on how to keep employee files, quality improvement and performance improvement studies up to date. The simplest of tips, such as putting employees' dates of hire on the outside of their personnel folders, wound up saving us time — not to mention added one practice we knew the formal surveyor would be glad to see eight months later. The surveyor who conducted the surprise visit told us, "If you know better, you do better." She was satisfied with the bones of our operation and was more than happy to make suggestions for needed improvements. She said to view her advice as a way to build on already sound practices, which made the advice easier to accept and implement.

A couple years ago, our state health department offered a free inspection of our infection prevention practices. We readily accepted, even though it exposed our center to another set of critical eyes who might not like what they see. We were confident in our practices, so we signed up for the inspection, which turned out to be extremely helpful.

Make sure your center is survey-ready at all times by incorporating standards into your daily work.
— Anissa Harris

The state officials explained the health department's rules and regulations, and gave us advice that saved us time and money. For example, we were sending expired medications offsite to be destroyed, but learned from the officials about an inexpensive way to neutralize and dispose of expired medications in-house. Because we signed up for this state survey, we learned things that led to infection prevention being one of our strongest areas in our formal accreditation inspection.

One final note: Remember that every surveyor is different. Some want the staff to be there with them the entire time, while others want to review pertinent information on their own. Be prepared for a variety of styles and scenarios. If your daily practices are consistently competent and you make good use of your time to prepare for your next survey, you'll be well positioned to pass it with flying colors. OSM

Related Articles

December 6, 2023

Renovating a facility to accommodate the many spine procedures that can now be performed in outpatient settings often involves a digital makeover in the form of...