How To Succeed During an Accreditation Survey (take small bites of the elephant – you WILL be full!)   

As many organizations have learned in recent months as regulatory bodies get back on track with triennial and overdue on-site visits, survey readiness must be ongoing because an unannounced visit from a regulatory agency can and should be expected any day of the week. Above my desk, I have the quote “It’s better to be prepared than to get ready”. I live most days as the eternal optimist; however, I do empathize with organizations that struggle to blend survey readiness with their other priorities. No one said it would be easy, but it’s required, and the reason is that we are in the business of patient safety. 

When we think about this topic, many things come to mind, mainly all of the tasks that are generated when surveyors arrive on-site, as well as the months/weeks before. You send out emails to staff and leaders about what to do, what not to do, preparatory documents, SWAT checklists for the floors, chart review guides, etc. but we need to dive a little deeper and ask ourselves what makes one organization sparkle during accreditation surveys, and another just survive – tormented and exhausted but living and breathing? From years of countless surveys, I can tell you that it’s a complicated process with many iterations, but there are organizations that get it right most of the time due to their mission, vision, values, and culture. 

Successful organizations have a mindset and an awareness that helps them manage complex processes and medical care and an understanding of human factors engineering and human error. When organizations acknowledge the difference between errors of omission (errors made when we did not act when we should have) and commission (errors that happen when human actions and decisions led to the error) they will design their procedures and processes to limit errors. They will design safer systems that aid staff in making the right decisions, whether it’s customized electronic record documentation and workflows or having the resources where and when staff need them to be successful. They perform task flow analysis at the front line, observing the steps and where staff are perhaps vulnerable to making mistakes, then they will determine how to redesign the work and processes to facilitate efficiency and a goal of zero defects. This should never be done in a silo; leaders will talk to the staff, because they know their process best, then determine what is needed to streamline a safe process, maximize the potential of staff, and identify preventable errors so they can be addressed right away to avoid an adverse event or regulatory finding. 

The focus should always be on the patient and the staff that care for patients (both clinical staff and patient care support!) therefore leaders need to actively listen to these subject matter experts, establish a culture of mutual respect, and value their ideas and suggestions for best practices and processes. If this partnership is genuine and observable to surveyors, then better survey outcomes and improved patient outcomes will result. 

• Role definition and performance expectations are clearly understood by staff. “Standard work” is put in place by many Lean organizations, but what does this mean? “In Lean manufacturing, standardized work is a means of establishing precise procedures to make products in the safest, easiest, and most effective way based on current technologies”. This is loosely translated in healthcare to mean that most individuals could read this document and understand the steps and tasks and why they are important to performance. Not all organizations use standard work, but likely they use some type of document to define expectations. When a new employee is hired, they should be oriented in the exact same way as the previous employee using the same standard of work. Staff (and leaders) succeed when they understand expectations and have clear performance outcomes. This is especially important for multi-hospital systems where staff may float to other locations. Fewer defects in care will occur when steps are in writing and staff are guided to do the right thing. 
• Who owns this real estate?? Everyone who works on that unit or in that department is the owner of their physical environment, not just the manager. Therefore, all staff have a duty to reach out to managers and senior leaders for their concerns to be heard or to intervene right away if hazards exist to support safer care of the patient and each other. They should feel empowered to put in Facilities work orders or call their Environmental Services colleagues. Mutual respect is essential; when a department or unit manager takes the time to round with staff and identify problems that need addressing, staff will engage and trust their leader. Keeping the environment “first impression ready” will lead to a successful survey. 
• Policies! Ensure that policies are developed, thoughtfully implemented, and reviewed on a triennial basis (or more frequently depending upon State regulations). They should also be updated as needed to reflect current regulations and evidence-based practices. As mentioned earlier, some hospitals follow lean management principles and utilize “standard work” vs. establishing procedures in all policies. Just remember that surveyors adhere to standards and regulations, however, they do not dictate what your policies and procedures say, just that you need to have them and that you need to adhere to them every time. 
• Inter-departmental relationships. It takes a village as they say, and establishing open lines of communication across departments, clinical and patient care support departments, is crucial! All departments are connected, and none is an island. As mentioned earlier, all employees should feel empowered to report when they see a chip in the floor or a wall that is damaged because it has been hit too many times with a gurney, a door that doesn’t latch, or a rusty IV pole. I could go on and on… the point is, we all need to speak up when it impacts safety. It has been my experience that leaders have greater respect for those that speak their minds and have solutions to problems they encounter. A successful survey is contingent upon teamwork, creating collegial relationships, and helping each other every day of the week, across all shifts. 
• Accountability for behaviors and interactions. Behaving respectfully and professionally are non-negotiables in any industry, but especially in healthcare. When an employee is snarky or flippant with a surveyor or with a colleague, staff may need to be reminded of their line of work with necessary consequences. We not only serve patients, but we serve each other. The role does not matter, senior director, nurse, physician, safety officer, etc. All staff are expected to follow a code of conduct that positively reflects the organization and demonstrates a culture of respect. At the end of a survey, it warms your heart when a surveyor says that they would love to be a patient in your facility (or an employee) because their interactions with staff were so overwhelmingly positive. 
• Performance outcomes and visual management. Goals should not be created by leaders in a vacuum and shared in a high-level board meeting. Measurable outcomes and goals should be developed collaboratively with front-line staff and be visible on the unit or in the department. Teams should ask themselves: What problems are we trying to solve? What are we struggling with? Where are we falling short of providing excellent care? How are we sustaining previous citations/findings from a survey? Many organizations call problems “gems” because they are so valuable when discovered. Then the team proceeds to thoughtfully solve the problems. Successful leaders and organizations are open and transparent with their staff. They share their successes and failures and constantly discuss ways to improve.

Ongoing survey preparation is an “all hands-on deck” approach and is run by leaders who get their hands dirty and hold staff accountable for performance. No organization wants a survey with pages of citations, rather they strive to be proactive and identify improvements when they see them – avoiding findings. Surveyors are required to cite it when they see it. Staff should have the mindset that they will fix problems when they see them and partner for success with their colleagues. 

Enjoy the journey and take in your surroundings; when you see the beautiful view at the top, you’ll feel empowered to keep up the effort to get there time and time again. 

References:

New England Journal of Medicine (NEJM) Catalyst. What is Lean Healthcare? 2018 April 27. What Is Lean Healthcare? | NEJM Catalyst 

Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. 2023 May 2. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29763131. Medical Error Reduction and Prevention – PubMed (nih.gov)

U.S. General Services Administration (GSA) Technology Transformation Services. “Task Flow Analysis” https://methods.18f.gov/decide/task-flow-analysis/