Surviving Accreditation Surveys


Realistic practice sessions and constant self-assessment will prepare your staff for the day the surveyor shows up in your lobby.

When Robert Bray, MD, learned that DISC Sports and Spine Center in Newport Beach, Calif., achieved accreditation for the fifth consecutive year, he was already looking forward to the next one. The neurosurgeon and founder of DISC says the center uses the high mark of achievement as a benchmark for how to over perform until the next time his facility is surveyed. It’s also become a way DISC distinguishes itself professionally when it comes to both safety and quality patient care. “The focus of the survey is on quality and safety, allowing us to grow,” says Dr. Bray. “Accreditation keeps you on track to make sure you’re not only meeting but exceeding protocols that change constantly.”

To date, DISC’s ambulatory surgery center serves as an operating hub for more than 30 physicians specializing in neuro, spinal and orthopedic surgery. And while thousands of outpatient centers around the country are currently accredited, only a handful of high-level spine centers like DISC are included on the list. Though going through the accreditation process is completely voluntary, it bolsters an outpatient center’s reputation by being able to meet rigorous standards while demonstrating a commitment to high-quality patient care.

Dr. Bray believes accreditation helps attract patients who are very engaged with selecting both their doctors and surgery centers. “Over the years, patients have become much savvier in checking out the background of doctors and facilities,” he says. “Accreditation is something that is truly recognized as a national benchmark.” 

Dr. Bray also points out the survey itself provides educational opportunities to improve best practices and meet guideposts for patient care and service. While not all surgical centers are always eager to welcome outside analysis, there are myriad ways to ensure that essential accreditation standards are met long before a surveyor steps through the front door.

Kathy Beydler, RN, MBA, CNOR, CASC, literally wrote the book on preparing for accreditation surveys. Her “The Survey Survival Guide: Pocket Guide to Survey Success” was created specifically for healthcare professionals as a way to navigate the entire process. She tapped into her experience on both sides of the survey world as a nurse and surveyor to provide a blueprint of how to realistically meet the marks.

With more than 30 years of experience in health care (and two decades in leadership), Ms. Beydler has become a trusted resource in the industry by using her insights to help impact patient care in positive ways. She regularly works with outpatient facilities to conduct mock surveys to help them prepare for the real thing. As such, she’s learned a lot about the process — what works, what needs the most improvement and how miscommunication can be the unnecessary and, at times, dangerous cause of a lot of problems.

Infection prevention is currently a major focal point of all surveys, particularly in light of what’s known about COVID-19. Shifts in survey metrics tend to be the result of two factors: changes in community health (the pandemic) and cases that have attracted the attention of the CDC, Medicare and Medicaid, such as the endoscopy center in Nevada that reused syringes on patients. As the news sent shockwaves through the healthcare industry a few years ago after several patients contracted hepatitis C — one died — the center was shut down, a doctor was jailed and additional oversight into the processes that led to the fatal flaws was enacted.

“Because of what happened,” explains Ms. Beydler, “new requirements were established,” including a new campaign: “One needle. One Syringe. One Patient.” She says these extreme situations tend to lead to stricter guidelines and more accountability focused on patient safety.

Of course, the challenge of keeping up with the latest protocols can be daunting. It’s precisely what inspired Ms. Beydler to launch the Survival Guide, which breaks down the complexities in a format that’s both portable and easily accessible. The book is organized by subject areas with specific answers to questions that a healthcare team needs to know, such as infection prevention (including updates for COVID-19), medication management, quality improvement, point-of-care testing, patient safety and tips for talking to a surveyor.

An important part of Ms. Beydler’s approach is conveying how critical it is to build relationships with surveyors and to cooperate with the surveying process itself. She has the unique perspective of someone who works in health care and who is charged with conducting accreditation surveys. She’s also very public about her struggles after a routine surgery went wrong and she experienced sepsis. Her long road to recovery has become a focus of her consultations, a living example of how patient care can go wrong when guidelines are ignored. “When you are a surveyor,” she says, “the challenge can be in how you get your message across.”

A positive way to look at a survey is knowing surveyors are there to improve patient care.
— Kathy Beydler

As someone who has conducted both mock and real surveys, she says her style is to be friendly and to put healthcare professionals at ease. “My goal,” she says, “is to make surgical care the best it can be for the patient.”

Areas of interest

POSITIVE REINFORCEMENT The best surveyors focus on the good a facility is doing in addition to pointing out areas of needed improvement.

While surveys can be complex, taking into consideration both the front lines and back office aspects of health care, there are certain areas that tend to become the focus again and again, such as safe injection practices and medication labeling. In recent years, an emphasis on proper instrument care has also changed the way surveyors consider the sterilization and handling of tools. “If they’re not cleaned and processed properly,” says Ms. Beydler, “you have an opportunity to spread infections.”

Infection control became and continues to be an important focus during the pandemic, with more attention than ever being paid to COVID-19 policies and procedures, such as how patients are being screened for infection, visitor guidelines and vaccination requirements.

For example, when the Centers for Medicare and Medicaid Services came out with new vaccination requirements for healthcare workers, a system needed to be put in place to track each employee’s vaccination status. In fact, every healthcare organization in the country now needs to track those who have been vaccinated and boosted, as well as staff with medical or religious exemptions.

It might seem simple enough, but Ms. Beydler admitted that a major issue in most hospitals and outpatient centers is a lack of communication between departments and even within leadership. “It’s about the relationships you build with other departments,” she says, a process that begins with daily meetings, updates and tracking of the most important aspects of patient care.

For example, she collaborated with infection preventionists at a hospital on the West Coast on how to best curb staph infections by writing policy and ultimately educating the staff on testing and prevention. Everybody wants to be successful, says Ms. Beydler, and one of the benefits of having a consultant advise a healthcare organization is that they can bring fresh eyes to a process where the smallest mistake can easily get overlooked.

What surveyors see

During her tenure as a surveyor, Ms. Beydler has seen a lot of attempts to avoid the inevitable. Her best advice for healthcare workers and leadership is to be open and honest, and to never try to avoid dealing with surveyors. Believe it or not, it happens. “Staff members will say they won’t be on site the day of a survey,” says Ms. Beydler.

For a surveyor, this usually signals that they need to take a closer look at those peoples’ departments. It turns out avoiding surveyors puts even more focus on issues that someone may be trying to hide. “The best thing to do is to greet surveyors openly,” says Ms. Beydler. “People should be proud of the work they do and show the surveyors what they’re doing.”

Another red flag: lying to a surveyor. “Surveyors have a sixth sense and we have to look deeper and dig when that happens,” explains Ms. Beydler, “which makes the job more difficult for everyone involved.”

If there is a problem that has been identified, a good rule of thumb is to highlight how it’s not only been recognized, but also how staff is working to remedy it. Ms. Beydler says that goes a long way toward making a good impression and showing that a healthcare organization is doing the work to improve patient care.

“A positive way to look at a survey is knowing surveyors are there to improve patient care,” she says. “My goal is to encourage people who work in health care to provide the best patient care they can. If an injection process could cross contaminate, you need to know that. But staff members also need to be encouraged and appreciated.”

Mock surveys can be a critical tool when preparing for a visit from a surveyor. While conducting these surveys within a health system and compiling reports can be challenging and time consuming, it can also become a proactive way to identify both successes and issues that need to be addressed in advance of the actual survey.

Running through the process several times before the surveyor shows up for the real deal can help you fix potential problem areas. “Mock surveys are a way to reassess your routine practices,” explains Ms. Beydler.

She says the biggest benefit of a mock survey is having an expert in their field take a closer look at what healthcare providers are used to seeing every day. They can catch issues that might be overlooked and prevent small problems from becoming much larger ones. For example, during a mock survey Ms. Beydler was conducting at an outpatient center in the Northeast, safe injection practices were called into question. “I walked in and immediately saw things that were not correct,” she says, including the failure to properly label medications.

When the issue was caught, the center had been paying a pharmacy consultant upwards of $10,000 a year to provide oversight to its medication management practices. “The consultant didn’t catch it,” says Ms. Beydler, noting that the outpatient center was grateful to be able to correct the problem. “I had the fresh pair of eyes that allowed me to recognize the issue and have it addressed.”

Ms. Beydler says the focus should always be on problem areas as well as successes during both real and mock surveys. She and other surveyors look closely at what needs to be improved, but also at what’s done well. “Anyone can tell you what you’re doing wrong,” she says. “You want a surveyor who can encourage you and provide positive reinforcement of what you’re doing right. Everyone wants to be successful.”

Respecting the results

Dr. Bray says outpatient centers should ultimately be on the same page as surveyors if they want to succeed in treating patients. “Keeping up with the benchmarks has allowed us to remain successful, even during the pandemic,” he explains.

DISC was ahead of the curve when it came to infection control, having installed smart HEPA filters a decade before the pandemic. Dr. Bray credits this move with working to not only meet but exceed industry standards. He says it’s working well. When patients were afraid to go to hospitals during the height of the pandemic, DISC experienced a 200% increase in case volume.

“We did that with no lapse in our accreditation scoring,” he says. “Yes, there’s an immense amount of prep each time you come up for review, but we make sure we’re up to date the best we can. We take it very seriously and try to live by that year to year.”

Dr. Bray says he appreciates DISC’s accreditation status being made public so that patients can have confidence in the work he and other surgeons are doing. “They know we’re not operating in the Wild West,” he says. “Patients see what accreditation is and they respect it.”

In fact, he encourages fellow surgical professionals to be just as enthusiastic about the surveying process as he is. “If you are truly a place that wants to do things right, accreditation will lead to good results,” he says. “Realize the marks you are obtaining aren’t easy, but they’re worth it.” OSM

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