Stay calm through the survey process, says Paula Russo, RN, the president of Ambulatory & Accreditation Solutions in St. Petersburg, Fla. Don't argue points with a surveyor - even if you think the surveyor is wrong. "There is an appeal process for that," she says. And if a surveyor asks you to clarify something and you don't have the answer at your fingertips, Ms. Russo says the best response is: "I don't know, but I will research that and get the answer for you."

Sounds simple enough, right? If you're about to undergo your first accreditation survey, the message is the same no matter which accreditor you use: Accreditation bolsters processes, patient safety and ultimately the quality of your organization. Here are some tips for preparing for survey.

At the beginning
Nursing directors and administrators we talked to agree that the first step to prepare for your initial survey is to obtain the accreditors' standards manuals and visit their Web sites, which are chock-full of information (see "About the Accreditors").

"Review the standards of the accrediting agency when completing the application and more than one time before the survey," says Ms. Russo. "Complete a self-evaluation document from the accrediting agency before the survey, and do a physical walk-through in your facility with those standards."

For those seeking Joint Commission accreditation, you'll find an ambulatory program link with a six-minute video to illustrate the survey process at writeOutLink("www.jointcommission.org",1). The site also lists typical questions that surveyors ask, which can help to ameliorate the anxiety of the unknown. The link also lists a sample survey agenda and list of documents to have on hand when a surveyor shows up (writeOutLink("www.jointcommission.org/AccreditationPrograms/AmbulatoryCare/Accreditation_Process",1)).

At AAAHC's Web site (writeOutLink("www.aaahc.org",1)), you'll find background and survey information as well as the application for survey, which the accreditor suggests you download and fill out six to eight months before survey. Make the information as comprehensive as possible to prevent delays in processing it, suggests AAAHC.

Likewise, the AAAASF's standards manual, which you can find at www.aaaasf.org, is literally a checklist of requirements that outline how to comply in time for inspection day.

From you on down
Accreditors and survey center leadership agree that survey preparation is not a centralized activity restricted to the facility administrator or chief OR nurse. These days, the accreditors' surveyors expect all staff to understand accreditation standards requirements.

"Have a mock survey and involve all staff members, including anesthesia," says Ms. Russo.

Joint Commission surveyors track compliance by tracing a patient's entire care process by observation and questioning all who treat the patient. "For a small to mid-size facility, we talk to just about everyone, such as the front-desk staff, the person who sterilizes instruments and down the line," said Michael Kulczycki, MBA, CAE, the Joint Commission's executive director of the ambulatory care accreditation program.

Surveyors engage physician-owners in the process, as they are sometimes involved with data collection. Note that the Joint Commission survey is not a peer review process. Surveyors won't observe an actual surgery, for example. They may, however, watch the start of surgery to ensure compliance with the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person surgery, says Mr. Kulczycki.

"Surveyors will, as appropriate, take an opportunity to talk to one of the anesthesiologists on staff or a surgeon in between cases," he adds.

At Atlantis Outpatient Center in Lakeworth, Fla., each department was in charge of a standard area to study, to talk about whether they meet the standard and how to go about it, says Connie Hillman, RN, the center's administrator. The ASC is a gastrointestinal and pain management center with four GI rooms and two operating rooms. The center, which opened in October 2004, underwent its first accreditation survey (via the AAAHC) in May 2006.

Everyone at the center received a copy of the AAAHC's accreditation handbook, says Ms. Hillman. Staff built their policies and procedures around the standard requirements.

"Department members read through the policies and asked, ?Is this what we do?'" says Ms. Hillman. "If not, we changed the criteria."

For example, as Atlantis Outpatient Center performs pain management cases, staff learned that for patients who undergo more than five procedures (such as chronic neck pain that leads to back problems), the center must place a care plan in the front of the patient's chart to demonstrate the entire care process, says Ms. Hillman. The AAAHC wanted a flow sheet to offer a synopsis so that staff don't have to weed through the entire chart.

John Newkirk, MD, PhD, a long-time AAAASF inspector and owner of Columbia Plastic Surgery in Columbia, S.C., will ask for the center's policy and procedure manual and looks for the attestation statement proving OSHA compliance and protocols for emergencies. He asks for the surgical log to ensure it is current. He selects half a dozen cases and asks for the charts.

The accreditor as advocate, not adversary
Dr. Newkirk often finds deficiencies that he can correct on the spot. For example, the narcotics log must be bound so no one can remove the pages. It's as simple as going to Kinko's for page-binding services, he says.

Likewise, some facilities aren't aware of new medications they must stock. But they can easily obtain those at a nearby pharmacy to comply with the mandates, adds Dr. Newkirk. He also pores through medications. "Sometimes I'm surprised that some drugs in the crash cart are expired," he says. "I'll tell staff what they can throw away."

It's a good idea to look not only for the obvious hot spots - such as inappropriate drug abbreviations and expired medications - but also for the structural details, such as the appropriate tiles for a floor and separation barriers between clean and dirty areas in utility rooms, says Dr. Newkirk. "While some issues are easy to clean up, having to tear up and replace a floor is more difficult."

Patients must also sign off to give your facility permission to use their chart for peer review purposes. "I found eight records at one center that did not contain the consent for medical records review," says Dr. Newkirk.

Ms. Hillman agrees that accreditation results in formalizing forms and moving away from casual documentation. Atlantis Outpatient Center staff reorganized credentialing forms by adding a step to sign off on physicians' requested services. They included a check box to designate "approved" or "disapproved," says Ms. Hillman. "Accreditation took our programs to a higher level."

Staff at Bergen Ambulatory Surgery Center in Saddle Brook, N.J., received a better understanding of patient safety overall, through preparing for and undergoing the Joint Commission survey, says Gloria Huter, RN, CNOR, CSPDT. The multispecialty center with three ORs and nine PACU beds was surveyed in October 2006.

"The details about the floors being clean are still important, but they focus on how you take care of the patient," says Ms. Huter.

For example, staff learned to obtain the scope of medication information before the patient arrives for surgery, since medication reconciliation is a new Joint Commission National Patient Safety Goal. The medication information is recorded on a separate document (a one-page sheet) and kept in patients' medical records. The patient receives a copy of the sheet when he arrives and the nursing staff educates him about the effects of the medications he takes.

"The sheet is a great tool for everyone, as well as for educating the patient," says Ms. Huter. "Checking up on yourself and giving nurses and physicians all the information they need enables us to give better care and prevent mistakes. This is what systems do."

When reading through an accreditor's standards, it's important to ascertain which ones apply to your facility, says Ms. Hillman. For example, some centers handle more lab work than Atlantis Outpatient Center, so the center requires a pre-op nurse who can appropriately screen patients who've undergone testing at other centers.

"I have someone now who is dedicated to calling patients and making sure they are the right candidate for us, which came out of our quality improvement studies (a AAAHC requirement)," she says.

Networking can be a wonderful exercise. "If I'm not sure about an aspect of the survey, I can call on some friends in the area at various centers," she says.

Finally, "don't offer any information; let the surveyor ask," says Ms. Russo. "Remember that you have elected to become accredited and the surveyor is there to provide guidance and educate, so that facilities provide safe and high quality healthcare to customers."