You can look at accreditation surveys as white glove inspections designed to ding your deficiencies or as opportunities for learning and growth. To help you take a more positive and proactive approach to the process, we sought advice from a group of administrators who have just wrapped up their facility's accreditation renewal or are currently in the thick of the preparation process. Their insights will have you ready to greet surveyors with calm, cool confidence.

The more time you can allocate to planning for a surveyor's visit, the better off you'll be. "Preparation for a survey should start the day after the previous survey ends," says James Elledge, RN, administrator and director of surgical services at McGee Eye Surgery Center, an affiliate of the Dean McGee Eye Institute in Oklahoma City, Okla., and a former surveyor. "This is when the feedback from the surveyor is still fresh, and you've not only gleaned any deficiencies in your facility's processes, you're also acutely aware of insufficiencies in your preparation."

Use the exit interview with the surveyor to start generating initial thought processes about how to best prepare for the next visit, says Mr. Elledge. "At this early stage, the survey planning is all being done informally, but it should translate into more formal preparation or organization at your next governing board or operations meeting," he adds.

Your board meetings and the painstakingly recorded minutes that accompany them are a key component of any thorough survey prep.

"When you're submitting your application six to nine months in advance of your survey, you're going to send the surveyor the minutes from the last two board meetings you had," says Jessica Rodriguez, MBA, CRCP-I, administrator of Metro Health OAM Surgery Center in Grand Rapids, Mich. "That means these meetings should focus on issues that are likely to apply to the upcoming survey."

For example, your minutes should clearly show you're abiding by your bylaws, that the group who meets is representative of your facility's staff and that credentialing and other key policies and procedures have been thoroughly reviewed and updated, says Ms. Rodriguez.

Holding regular meetings and a having a "spread-the-wealth" (don't take it all on yourself) approach to preparation are a big part of Ms. Rodriguez's survey prep strategy. "Around six months before our survey, we start building crosswalk binders — binders that show exactly how the facility is complying with specific standards — and holding monthly survey-readiness meetings," she says.

This process consists of Ms. Rodriguez assembling a team — an infection preventionist, a credentialist, some charges, a lead in the business office, someone from the quality improvement team — and divvying up the chapters in their accreditor's standards binder so that each person on the team is responsible for ensuring the facility is in compliance with specific requirements.

"We have everyone go through these agency standards and document exactly how we meet each of the standards," says Ms. Rodriguez.

For example, under the standard that requires facilities to treat patients with "respect, consideration and dignity," the crosswalk binder spells out how Metro Health uses curtains, separate bays and semi-private areas where patients go after registration as concrete examples of how it complies. The team creates these written records for each of the chapters within the accreditation standards binder.

Although Mr. Elledge agrees with spreading the wealth (his trifecta of survey preparation includes "organization, planning and teamwork"), he prefers a weekly education format. He first holds a meeting with his management team during which each manager has seven minutes to give a rundown on what they've accomplished in the past week, what they're working on and any glaring issues that have cropped up. He then repeats the process with members of the hospital's C-suite.

Preparation for a survey should start the day after the previous survey ends.
— James Elledge, RN

While the meetings aren't accreditation-based, the operational nature of them ensures any issues that would likely get the facility dinged on a survey are addressed as soon as possible. Plus, the timing of the two meetings is strategic. "They're designed so the first operational meeting flows right into the meeting with our leadership," Mr. Elledge says. "That allows me to take all of the practical info I was given from my managers and look at it with the C-suite from that 30,000-foot view."

Address potential survey issues in real-time on an as-needed basis. Metro Health addresses new standards as soon as they take effect. For example, the facility is about to be surveyed on its accrediting body's 2018 standards, but they're already set to react to new requirements. "As soon as this survey is done, they're probably going to release new standards for 2020," says Ms. Rodriguez. "We're immediately going to look at those standards and see if something needs to be updated or realigned with our own policies to comply," she says. "It's better to do that right away to make the next survey a little less stressful."

Arkansas Specialty Surgery Center follows a strict survey mindset on a daily basis, and consistently drills into its staff a see something, say something approach to compliance. "If a patient is ready for surgery, but hasn't had a history and physical done, our staff simply won't take them to the OR," says Ms. Love. That's just one example of the facility's commitment to compliance. Plus, they hold an in-service any time a significant policy change is made. "When our patient warming protocols were changed, we educated our staff and then conducted chart monitoring to ensure they were following the new guidelines," says Ms. Love.

Regardless of how you ultimately decide to prepare for your next accreditation survey, all the administrators we spoke with cited attitude and a willingness to take feedback without getting defensive as a critical factor in the process. As Mr. Elledge says, "At the end of the day, the surveyor's goal is to ensure your facility gives the best patient care possible." That's your goal, too. OSM