Accreditation survey. These two words elicit many different reactions, but everyone agrees that preparing for and undergoing a survey is time-consuming, stressful, and sometimes unpleasant. Sometimes, the overwhelming question is, where do you start? "My first recommendation is to read the manual," says Stephen C. Anderson, RN, MBA, a consultant with Joint Commission Resources in Oakbrook Terrace, IL. "If someone doesn’t read the manual, he or she misses some fundamental concepts of the survey process that will cause problems."
In addition, mark up your standards manual, suggests Jerry W. Henderson, RN, CNOR, executive director of the Surgicenter of Baltimore in Owings Mill, MD. Henderson’s facility is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) in Wilmette, IL, and she has served as a surveyor for AAAHC. "Standards in the AAAHC manual are set up in priority order, so a same-day surgery program manager can tell which areas should receive the most focus," she says. "When I get my manual, I go through it standard by standard and use the margins to make notes of how my facility meets each standard."
For example, for standards related to a patient’s right to participate in his or her own health care decisions, Henderson makes a note that her facility has a policy on informed consent, a patients’ rights policy, and that patients’ rights are posted in visible areas within the facility.
Impress surveyors with preparation, organization
The key to a successful accreditation survey is organization, according to accreditation experts. Your same-day surgery program should have clearly defined mission, values, goals, and objectives, says Stephen C. Anderson, RN, MBA, a consultant with Joint Commission Resources in Oakbrook Terrace, IL.. "Then make sure you have a planned systematic process to identify and solve problems," he says.
Ensure your employees know what the policies and procedures are, Anderson says. When a surveyor asks an employee how something is done, you don’t want the employee to use phrases such as "we usually," or "we often," or "I guess we," or "I don’t know how others do it, but I," he says. "The answer that should be given to the surveyor should start with our process is,’ or our policy is,’" he explains.
A good way to start preparing for a survey is to develop an internal checklist, Anderson suggests. In the ambulatory care manual for the Joint Commission on Accreditation of Healthcare Organizations, there is Appendix B, which is a checklist for policies that must be addressed, he points out.
Unfortunately, there is no checklist for hospital-based programs, but they can create one based on the standards manual, he adds. Make sure that you have up-to-date organizational charts, policies and procedures, and patients’ rights programs, Anderson says. "Most importantly, make sure you have organized the information so that it is easily available to the surveyor," he says. For example, set up your policy book in sections that correspond to the accreditation manual and use tabs to clearly identify the sections, Anderson suggests. "This will reinforce the impression that you are prepared and will not waste any of the surveyor’s time," he says.