Ace Your Next Accreditation Survey

The surveyors will be following their organization’s standards, so be sure to familiarize yourself with the expectations of the accrediting body that’s conducting your survey. (Accreditors should be able to provide you with a survey preparedness guide.) Still, the best way to prepare for a survey is to maintain the required standard year-round.

Individual surveyors have their own styles and areas they tend to focus on, but addressing the following topics is a good basis for preparing for your next survey.

• Safety and security. Surveyors will review policies and procedures and make sure drills are conducted and designed to protect patients and employees from harm, according to Ms. Geier. She says they will also confirm that active shooter drills are conducted, and there’s limited access for approved employees only into the clinical care area of the facility.
• Hand hygiene. Surveyors will watch employees’ hand hygiene practices without letting them know they’re being observed. Are they washing their hands after removing gloves? Are staff members observing their colleagues’ practices and reporting non-compliance issues? Do they have convenient access to alcohol-based hand rub dispensers? Do they know of places where additional dispensers should be located?
• Medication management. Be ready for questions regarding your medication procurement, dispensing and security policies, says Kathryn Thompson, MSN, RN, CNOR, senior manager of clinical services and operations at Emory Clinic in Atlanta, Ga. She says surveyors will want to know what you’re doing to ensure the right medication and right dose is administered to the right person by the right route at the right time. Also differentiate medications with similar-sounding or similar-looking names (Tall Man lettering is a good option) and store them in clearly marked, non-adjacent drawers to avoid confusion.

Ms. Thompson, who led efforts to prepare for an accreditation survey at Northside Hospital in Atlanta, her former place of employment, suggests having a policy in place that accounts for all medications that are stored and used, how leftover amounts are disposed of and a customized method for ensuring high-alert medications are tracked and stored in a secured location. She says surveyors also check to make sure crash cart medications are fully stocked and up to date, and ask for justification of overstocked medications. Keeping an abundant supply of drugs that are in constant shortage is a valid reason, for example.

• Pre-op time outs. Surveyors will observe the time out to make sure the surgical team discusses what your facility’s policy states should be covered during the safety check. They also confirm that staff take time outs seriously, that they’re engaged in the process and that there are no outside distractions.
• Policies, procedures and paperwork. Bri Merriman, RMA, administrator at Crater Lake Surgery Center in Medford, Ore., says 2 surveyors spent 2 days at her facility. One surveyor inspected the facility’s infrastructure and maintenance contracts, while the other read over every sentence of the facility’s policies and procedures, making sure staff in-services were appropriate and current, and that employees had access to up-to-date competencies that met required standards. The surveyor also reviewed contracts with insurers and outside vendors (IT services, for example), the employee handbook, credentialing packets, benchmarking figures, quality improvement studies, and instructions for safe injection practices and proper sterilization techniques.

Leadership at Northside Hospital created an Excel spreadsheet to help organize what needed to be done before the accreditation survey. “We listed accreditation standards in one column and noted if we were meeting those standards in another,” says Ms. Thompson. “If we weren’t meeting a requirement, we noted what had to be done to meet it, who would make sure we did, and by when.”

Her preparation and planning began about 6 months before the expected survey date. Working that far in advance helped with implementing the changes she needed to make before the survey was conducted. Ms. Thompson says staff have to be educated about meeting accreditation standards, and constantly reminded about the importance of doing so until the surveyor arrives.

“Staff get busy and forget, so for example, we had somebody in charge of observing them to see if they complied with hand hygiene protocols,” says Ms. Thompson. “The assigned observer kept statistics about hand hygiene compliance and reported to the staff where our goal was and what improvements we had to make. Education, implementation and acclimation proved to be very important.”