10 Steps to Prepare for a Successful Accreditation Survey

What do you and your staff conjure up when you think about accreditation, governmental or licensure surveyors visiting your center? If it's fear, dread, pressure, denial or even a wish to be temporarily transported to another planet, you aren't alone. Just the word "surveyor" makes many people shudder, but it doesn't have to be that way. As a facility manager, you direct and affect how your staff makes the environmental and organizational preparations for an accreditation survey, and you can also significantly impact how your staff prepares emotionally and psychologically.

I've been through five accreditation surveys and eight or more licensure surveys in my career and have found that the overwhelming majority of surveyors are extremely positive and helpful, rather than imposing or dictatorial. They're responsible for seeing that a facility is meeting its duties to the public as a safe, high-quality and secure place for providing public health care, and they represent organizations that have no desire to see the facility fail. Rather than seeing surveyors as opponents, I've come to consider them as partners and educators in the survey process.

I can just imagine what you are thinking! A partner? Oh sure. But if your facility's staff is well prepared and you demonstrate confidence in the staff and the facility's operations, you can form a truly positive relationship with the surveyors. In this article, I'll present 10 steps that you can use to prepare your staff mentally, emotionally and psychologically.

1. Model a positive attitude.
Just as children look to their parents in frightening situations to see if they should be afraid or not, staff members look to their leaders for reassurance and clues as to how well prepared they really are for an external surveyor's scrutiny. So remember: It's okay to occasionally go behind closed doors and stare at the headlights of the oncoming train; just don't let your staff see any of your insecurities. Your attitudes, words, and behaviors will set the tone for the survey preparations and the survey itself.

2. Expect success.
This step goes hand-in-hand with demonstrating a positive attitude. Your staff needs to hear ongoing, positive expectations from their leaders and they need to know that their managers trust them to be successful both before and during any survey visit.

To give your staff an ongoing dose of positive expectations, use positive rather than negative words-for instance, use when rather than if. Avoid giving messages in the negative, such as "If we don't improve our biohazardous waste process we won't get accredited." Rather, phrase the same message in the positive; for example: "We need to implement a new biohazardous waste process by next month to ensure that we meet these criteria." What they'll remember then, is "meet these criteria."

Take a cue from coaches of professional sports teams. You can be sure that in the pre-game pep talk, the coaches are never saying, "We just can't lose this game." Rather, they're telling their teams that they can win. You should do the same.

3. Begin preparations early.
Make it a part of your facility's mission to always operate in perpetual compliance with regulatory standards by developing an ongoing system to monitor and revise existing protocols, processes and policies. Also, incorporate ongoing monitoring and compliance into your facility's quality improvement process and documentation. We use a spreadsheet tool to monitor progress in clinical, business and environmental areas (for an example, go to www.outpatientsurgery.net).

A year before the survey is planned, put together a survey task force comprising leaders from different departments to start thinking about the survey preparations. Then, six months before the survey date, start preparing for the survey in earnest (six months should be more than enough time if you're already basically compliant with all the standards). Some of the areas that you may have to address, for example, are bringing personnel files up to date, ensuring that physician credentialing records are current, seeing that the staff has current CPR certifications, and ensuring that you have an effective and ongoing process in place to seek and remove outdated medications. Six months ahead, you'll also need to start bringing your staff up to date on specific issues and helping them understand what to expect on the day of the survey. Focus on identifying any new standards, organizing data in a logical and retrievable manner, educating new team members, and completing a mock self-appraisal survey.

4. Use your staff's professional knowledge and natural talents.
Your staff members are the ones closest to the real business of the facility, so use their expertise and professional knowledge to brainstorm, plan and implement policies and processes. Whenever possible, match the staff member's skills and talents to their assigned tasks.

Assign staff members to leadership positions and allow them to learn from each other. For example, you may want to assign the primary responsibility of ensuring compliance for patient education standards to a perianesthesia nurse. But don't forget to assign other staff from other departments, such as the business office or operating room, who must also deal with the same standards in some respect. Assigning team members from the other departments allows them to learn from the more expert resource person, gain confidence in their understanding of the salient issues, and apply the standards appropriately in their own departments. This helps to build teamwork and ensure that all regulatory standards are being applied throughout the facility.

5. Provide adequate time.
The staff member who is addressing multiple patient needs from opening until closing of the center each day is surely not going to do his or her best with other assignments, and it is, in fact, unfair to expect that. Therefore, make sure you provide dedicated time for thinking, investigating, planning, and initiating processes and necessary changes. Set aside time for staff educational sessions so that every individual is current on the standards being assessed, potential problem areas, and the best way to respond to surveyors' questions. You may be able to squeeze in a planning session, for example, one afternoon when the OR schedule is particularly light or if the day ends early. In our health system (we comprise three ambulatory surgery centers), we run division meetings every month with representatives from each of the sites attending; as the survey day approaches, we increase the number of meetings to once every two weeks. We also typically have one mandatory Saturday preparation session six to eight weeks before the survey date for all team members. Remember that survey preparation can be both formal and informal-sometimes a 10-minute crash session to talk about a particular standard at one of the nurses' stations can be as important as a more formal, hour-long meeting.

6. Provide the necessary tools and education.
Ensure that staff members have open access to the survey standards and to policies, guidelines and educational tools. Give them access to as much data as possible to help them develop storyboards and other materials depicting the facility's quality initiatives and patient care outcomes. Having access to the tools and educational preparation helps staff members feel prepared, and feeling well prepared individually goes a long way toward decreasing anxiety. One fun method can be to tape up "potty points" in the restrooms each week ????-??? for a captive audience!

7. Be well organized during the preparatory stage and for the actual survey.
Team members feel more confident when their leaders demonstrate good organizational skills. Prepare agendas, handouts, audiovisuals, action plans and other meeting materials in advance. Maintain a master action plan identifying the "open" needs and the progress made over time. As staff members see the open items on the action plan dwindle, they will be encouraged and feel confident that the facility is becoming well prepared. Keep this plan living and changing as tasks are completed and share the progress with other leaders and all team members. The chart on page 21 is an example of several items on an action plan aimed at JCAHOcompliance.

Be sure to provide clear directions and incorporate frequent checkpoints for individual progress on tasks and process changes to eliminate surprises a few weeks before the survey. Periodic, predetermined checkpoints also provide a time for the team members and leaders to discuss issues, brainstorm ideas and ensure that all are in agreement about the outcomes being sought.

8. Hold individuals accountable for various tasks and process changes.
On one hand, staff members want to have as little to do with surveys and preparations as possible. But on the other hand, accountability breeds self-esteem. Provide help and support, but fight the urge to step in and take over for non-producers, even though it is often much easier to do that than it is to coach and assist the staff member. In the long run, however, this only undermines that person's sense of worth and erodes teamwork.

9. Commit your support to all staff members.
One of the greatest fears that a staff member may have before an important survey is whether or not he or she will be "the one" to make a mistake and prevent the facility from becoming licensed or accredited. Everyone naturally wants to be in the background rather than the forefront. But by verbalizing and demonstrating by actions that you support and have faith in each person, you can help to decrease the fear of individual failure.

The leaders should agree and state very clearly to the staff that survey preparations are a team effort and that individuals are not expected to be solely responsible for any area of concern. Let your team know that it is fine to say, "I don't know, but I know where to find out" when a surveyor asks a question they cannot answer. Also, let them know that one of their leaders will always be with the surveyor to support them.

You might be able to describe a prior experience with a surveyor that points out your own insecurities when you were a staff member, and how the ultimate outcome was not devastating to the facility as a whole. For example, in one of my prior locations, the facility went through a JCAHO survey with the only written recommendation being the result of an omission on the part of the director, not a staff member! Stories like that help reduce the fear of standing out in the crowd for many staff members.

It is also helpful to help the staff put an upcoming survey into perspective. What a team member may perceive as a horrible mistake or inadequate answer is often blown out of proportion in his or her own head. Make sure your team knows that you only expect them to do their best, not be superheroes!

10. Make it fun!
We have all read about or heard of the benefits of using humor to improve morale, lift spirits and open the mind to learning, so get those giggles going! Make preparatory meetings fun; use rewards to encourage participation. Create and name a mascot or develop a game built on knowledge of the survey standards. Use modified versions of Trivial Pursuit and Jeopardy to hold knowledge-based contests. Crossword puzzles, fill-in-the-blanks, and treasure hunts can be both educational and fun. I find that dollar bills and those new "gold" dollar coins are always motivational prizes for verbal quizzes! And chocolate ALWAYS works!

Remember to celebrate small successes along the way. When a subgroup or individual completes preparations for all standards in a particular area of concern, splurge for ice cream or have a prize drawing for the members of that subgroup. Put their names in lights or provide them with a nearby parking space for the week or the month. Don't forget the value of praise, particularly public praise, for a job well done.

As a facility manager, you have the primary responsibility to ensure that licensure, governmental certification and voluntary accreditation standards are met, and ultimately, the success or failure of the process rests on your shoulders. But by involving, supporting and encouraging your staff, you'll make the survey process a lot less nerve-wracking for everyone and ensure that you meet all regulatory milestones with flying colors.