Pass Your Accreditation Survey With Flying Colors

Preparing for a surveyor’s visit requires a combination of effective protocols and policies with regular audits, education and training.

Accreditation is much more than a simple stamp of approval. It’s evidence your facility has met meticulous, nationally recognized standards of quality, patient care and safety.

Here’s what it takes to prepare your staff for a surveyor’s visit and pass the survey with flying colors.

Prepare, prepare, prepare!

Getting ready for a surveyor’s visit is not something you can cram for like a college exam; in fact, many facilities will spend months, or even a full year, getting surveyor-ready.

Seven Hills ASC in Las Vegas, a privately owned, freestanding multispecialty ASC with a cardiac catheterization lab, successfully navigated the accreditation and survey process last year by The Joint Commission (TJC). Although the ASC has been accredited since 2003, Tracy Helmer, BSN, MBA, CNOR, the facility’s administrator, still passionately believes in starting early to make sure his staff and facility are prepared. “If you stay prepared and you run a facility that is always survey-ready, then surveys are actually a very rewarding experience,” says Mr. Helmer.

Members of his staff maintain an active quality committee, which is responsible for going standard by standard and reviewing the ASC areas of compliance. “The committee distributes appropriate assignments among the members of the team,” says Mr. Helmer. “For example, we have a PACU nurse who is also the infection control officer responsible for looking at our infection control practices and tuning up any areas that may be deficient.”

At Holy Redeemer Hospital in Meadowbrook, Pa., OR Nurse Manager Traci Birnbaum, BSN, RN, CNOR, says the surveyor comes between March and May, so she and her staff are anticipating a visit any day now. As soon as the surveyor leaves, her staff immediately begins prepping for the following year’s visit. “Leadership starts with monthly meetings just after the surveyor has left, where we discuss our previous survey findings and areas for improvement,” says Ms. Birnbaum. “As it gets closer to our window of being surveyed, we will meet weekly.” She makes sure all her staff are trained on the proper procedure for everything. “We perform monthly audits that are scheduled in each department, so we can identify again areas for improvement. In addition, we have mock surveys that include maintenance, infection prevention and environmental services,” notes Ms. Birnbaum.

The COVID-19 pandemic added an additional layer of preparation, notes Mr. Helmer. “It was an added challenge trying to hit a moving target with COVID standards that were constantly changing. I do not think it is ever going to return to a pre-COVID level of preparation from the infection control side of things,” he says. But Mr. Helmer suggests figuring out which protocols are going to be the most relevant when the surveyor walks in the door. “You need to look at what your region is doing, as it could be very different from certain hotspots throughout the country. I would imagine that The Joint Commission surveys in those areas have a little higher focus on one thing or another, as it relates to COVID,” he says.

Another standard that received added focus due to the pandemic is how facilities handle emergency-management planning. “Nobody would have ever guessed that a pandemic status would befall the country, so one of the things that comes of that is known as a hazard analysis assessment, which controls the emergency-management-type operations you would potentially have to employ,” says Mr. Helmer. “Now, a pandemic health condition is one of those hazards, and it definitely did change how you plan for emergencies in relation to that, whether it is a staffing shortage, or an internal or external outbreak,” he says.

Facilities will fare better in an accreditation survey if they pore over their patient demographics, case mix and the types of procedures that may have a higher risk for infection, says Mr. Helmer. “You must look at all those things and fine tune them. For example, a high percentage of our cases are cardiology-based, so by doing those cases we already have a higher risk for a potential transfer or a patient who needs to have surgery. If we were going into it with the idea that we are just a basic, multispecialty surgery center that does not see those types of risky cases, we could easily miss something,” he says.

Mr. Helmer says ASCs now must be able to show that their internal processes for keeping staff safe and healthy are very robust. “You need to make sure you have a good employee health program that pushes vaccination and pushes best practices for keeping your staff healthy,” he says.

Address deficits

Surveyors are there to help facilities, and often suggest different and better ways to manage certain protocols. “It is not an adversarial relationship; they’re oftentimes very willing to help us with finding better ways of doing things,” says Mr. Helmer.

Following a surveyor’s last visit, Ms. Birnbaum says her staff took the necessary steps to improve their handling and storage of instruments. “There is a 25-pound weight limit for each container when storing and stacking your instruments, so in our instrument room, we purchased new shelves so we could house the appropriate amount of weight on each shelf. For the heavier trays, we put them inside metal containers instead of wrapping them to prevent tears,” says Ms. Birnbaum.

Her staff also improved upon their immediate use steam sterilization (IUSS) usage. “We now understand that IUSS should not be used for mere convenience, or due to limited instruments or equipment for the number of cases or procedures performed but rather for emergency scenarios,” recalls Ms. Birnbaum.

Infection control practices may top your accreditation preparation list, but don’t snooze on your credentialing efforts and documentation management. “Credentialing is a mixture of hopefully very good, efficient software and the human component of keeping up with the hundreds of physicians that you have,” says Mr. Helmer. While he says it can sometimes feel like herding cats to do things like nudge a doctor who forgot to submit something as trivial as his driver’s license, it’s worth it. After all, without this info the credentialing file is flagged. “It can be maddening when little things like that pop up during a survey, but they need to be addressed,” he says.

Lessons learned

REPETITION BUILDS CONFIDENCE The more exposure your staff has to survey activity, the better — it helps them become more confident and aware of what their responsibilities are.

Achieving accreditation shows your staff and patients that your facility sets high standards. “We want to make sure that we are giving patients the absolute best care and know that they can put their trust in our hands,” says Ms. Birnbaum.

Everything that healthcare facilities do is driven more and more toward quality delivery of care, says Mr. Helmer. “Quality-based metrics are really where health care should be and what is going to drive the healthcare field to continue to get better. Accreditation helps you to delineate that you are a quality facility, and that the practices you maintain on a daily basis are indicative of the high level of quality that you deliver,” he says.

And while your staff’s first instinct is to fear surveyors, help them understand the importance of accreditation. “Nurses care about the job they do, and they put the burden on themselves of making sure that they do the very best,” says Mr. Helmer. “Repetition builds confidence, so as time goes on, and they have more exposure to survey activity, they become more confident and aware of what their responsibilities are, and oftentimes will take it upon themselves to learn the new industry standards that are coming out or find new products that might help make their department more compliant,” he says.

One of the things he has learned from the process is that his staff is much more engaged than he may think. “Many times, I’ve been working with a surveyor and discussing a particular standard, and a staff member will share some insight on how they do something that really impresses the surveyor. Sometimes leaders get a little bit separated from the day-to-day clinical operations that go on, but it is always rewarding to see the innovation that comes from the staff,” he says. Last and certainly not least, be sure to reward your staff after the stressful accreditation process is over. “We usually eat a lot of pizza,” says Mr. Helmer. OSM