Alleviate the Anxiety of Unannounced Surveys

Six steps that will prepare you for those stressful pop-up visits.

When I transitioned into the role of ASC Administrator, the prospect of an unannounced survey loomed as one of the most daunting challenges.

Coming from a nursing background, I held a deep-seated commitment to deliver the highest quality and safest patient care. The mere thought of facing a survey deficiency and falling short of this standard churned my stomach. For me, acing a survey became not only a validation of the ASC's excellence but also a personal measure of my own performance and competence in my role as an administrator.

Perhaps you, too, have experienced the anxiety that comes with an unannounced survey. It's a feeling to which many administrators can relate, but it's important to recognize that you don't need to live in constant fear of these evaluations.

I've learned a few strategies over the years that have helped me navigate surveys with less stress and greater ease and confidence.

Get familiar with accreditation standards. I realize your first response to this may be, "well, obviously." However, despite seeming like common sense, these requirements are often overlooked or not fully implemented in practice. I remember attending a conference where the speaker effortlessly answered audience questions by referencing precise section numbers from the accreditation manual from memory. This example highlights the importance of thoroughly familiarizing yourself with accreditation standards, and I highly encourage you to do the same.

Form a committee. Don't handle this solo; teamwork is essential! Establish a dedicated team comprising representatives from various departments that is responsible for accreditation readiness. Collaborate to review accreditation standards, pinpoint gaps, formulate policies and procedures, coordinate educational sessions and ensure thorough documentation review.

Perform regular environment of care rounds. Conduct routine environment of care rounds to assess facility infrastructure, equipment functionality and safety measures. Address any identified hazards, maintenance issues or compliance deficiencies promptly. Utilize a standardized checklist to ensure consistency and to detect any recurring issues.

Focus on staff training and education. Invest in staff training and education programs to enhance awareness of accreditation standards, regulatory requirements and best practices. Conduct regular training sessions covering topics such as infection control, emergency preparedness, patient safety protocols and compliance with HIPAA regulations.

Get organized (and stay there): Prevent any "where's my keys?" moments by establishing and maintaining organized documentation. Searching for documents during a survey can be stressful, so ensure you know where to find items that surveyors may ask about, such as quality improvement initiatives, policies and procedures, staff credentials and medical records. Consider creating a table of contents for documents with multiple sections to facilitate easier navigation.

Conduct mock surveys. Simulate accreditation surveys through mock survey exercises conducted internally or with the assistance of external consultants. These simulations help identify areas of noncompliance, gaps in processes and areas needing improvement. Use the feedback obtained from mock surveys to refine policies, procedures and workflows.

Remember, while the prospect of surveys may initially evoke unease, with preparation and teamwork, it becomes an opportunity to showcase your ASC's commitment to excellence and continuous improvement. OSM