Is Your Facility Survey Ready? 3 Key Steps to Prepare
BY BECKY DVORAK MBA, MSN, BSN, RN
Senior Vice President, Clinical Services
Is your unit prepared for a survey? If you can answer yes, you are a part of an exceedingly small group of hospital leaders.
Survey readiness is a subject that most hospitals only talk about when they are in their “window” for a survey. When you are in your “window” everyone starts becoming increasingly anxious. Leaders do not take vacations, staff becomes hypersensitive to any new face that walks on the unit, and life at the hospital typically becomes full of panic. Everything must be hurried up and finished yesterday!
Surveys do not need to be such a worrisome time. They are an opportunity to “toot your own horn,” and to show the surveyors all the exceptional work that you and your staff have accomplished.
Exceptional surveys do not happen overnight, you must prepare for them. Preparation is the key to a great survey.
How to be survey ready all the time
Step 1: Know your State, Federal and Accrediting agency (Joint Commission/DNV/HFAP) regulations.
Knowledge is power. While we as leaders may not always agree on what the regulations state, we still must follow them. Regulations are in place for a reason. They are there to protect our patients and us as caregivers. One of the biggest downfalls for leaders is when they are not entirely knowledgeable of the regulations and/or do not follow them.
Step 2: Know your own policies.
Policies and procedures are written for a reason; sometimes it is a regulation from CMS, your state, your hospitals accrediting agency (JC, HFAP/DNV) or your hospitals own procedures. Policies are in place to help guide the care we provide, in a consistent, quality driven manner. There are times I am on units and the staff tell me that they do not know how to access polices, they do not know what the unit policies say or the ever classic, “Huh, I have no idea what you are talking about.”
Surveyors always ask for your hospitals policies and in turn question staff about those policies. It is particularly important that you and your staff are able to speak to the policies of your hospital.
Step 3: Prepare yourself, prepare your unit.
Audit your charts: Audits are crucial because they uncover where your vulnerabilities are. Are the physicians signing off on their orders in a timely manner, are the nurses completing the patient response after giving a PRN medication, are the techs documenting every 15 minutes in a varied pattern? These questions are easily answered by reviewing your charts. You do not want to be in the “hot seat” with a surveyor when they find your nurses, techs and physicians are not consistently following policy. I call that “low hanging fruit” as it is easy for us to fix and yet easy for surveyors to find and give a citation.
Walk-through your environment: All staff should be completing a walk-through every single day. The walk-through helps us to discover what the surveyors are going to see. If there are items in the hallway, doors left propped open, or the unit needs to be cleaned you can identify those issues before surveyors walk in the door and have time to address them. A walk-through should not take a lot of time; make it a routine every morning before you get busy with your day-to-day activities.
Prep the staff: I recommend ongoing discussions about staff expectations and survey preparations. The more it is discussed the more comfortable everyone becomes.
Remember survey readiness is an ongoing job, not only for leaders, but all staff!
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