SOS: Summer of surveys tests NC hospital

Leadership buy-in key to success

One survey every three years is trying enough. But for Novant Health's Presbyterian Hospital in Charlotte, NC, that would have seemed like a vacation. Between June and August of this year, the hospital had a Joint Commission survey, a CMS survey, and the regular biannual visit from the local health department. Getting through the ordeal with success depended on many factors. Making physical changes to the area used by those running the survey was detailed in last month's Hospital Peer Review.

But it was more than just the physical setup that helped things run smoothly. Paula Swain, director of accreditation and regulatory for Novant Health/Presbyterian Healthcare says that the attitude, assistance, and attention paid by hospital leadership to the situation made all the difference. Her feeling was echoed by Sheila Moore, RN, BSN, MHA, MBA, vice president of professional services at Presbyterian Hospital. "We didn't kick everyone off and say, 'Hey, we'll see you when it's over.' We were there through it all. We did not let it happen in a vacuum. We made sure that if someone needed something from us, they got it."

Every tour done by surveyors and their guides was followed up with a report to leadership to see if there were hot-button trends, to ask for help, and to receive kudos. "We weren't just tucked away in a command center," Moore says. Those daily debriefings included summations from the Joint Commission and CMS during the respective surveys. They often took on a pep-rally atmosphere with the focus on the "big game" the next day.

Swain says leadership was near instantaneous when something was needed. "If surveyors asked for something, we could reprioritize. We worked as a group with a great degree of camaraderie." So if there was a question about whether H&Ps were in some charts during one tour, the briefing would illuminate it, and the command center would focus on making sure that every chart was complete; if one exit sign was not lit up, all were then checked.

"We know that the commission looks for patterns," says Moore. "If they find it once, they will point it out and use it as a learning opportunity. If they see it somewhere else, though, they will start looking for it. The briefings and our tight communication helped us to eliminate any appearance of patterns."

The fact that Presbyterian staff were so on the ball, so quick to make any needed repairs or changes, the way that surveyors treated them also changed, says Swain. "We were so operationally woven together that if they asked, we had it. We were wish granters — accurate, on target, and efficient. And so if we said we did something, they believed us. That kind of trust is earned."

Elizabeth Steger, RN, MSN, vice president of patient care services says they worked hard to create surveyor/guide teams that worked well together so that trust could be built.

Turning every no into a yes

Leadership also made sure that everyone knew that they would move heaven and earth to help them achieve goals. So when an engineer found a sprinkler system was malfunctioning, and someone from construction said there were no parts, and someone else said there was no labor to get it done overnight, Swain says leaders made sure that every "no" turned into a yes, and by the next morning, the system was fixed. Moore says the key was to let people say their "no," but then attack the problem "one bite at a time, asking what it will take to make it happen."

The willingness of leadership to back up others flowed the other way, too. Moore says that when there was an issue with a clock used in dialysis that she was trying to fix but could not, "all these people from materials management and construction came together to brainstorm the issue and come up with a solution."

That teamwork across job functions led to a level of trust that was new, Moore says. "You never wanted to be the one who was responsible for a finding. There was accountability and ownership, and people who are proud of what they do, and want to do the right thing, want to do it whether someone is looking or not. We worked so hard that all of us were invested in the outcome."

That cross-function cooperation continues. People who worked together for five or 10 days, who didn't know anything about each other's jobs before, now have additional resources for problem solving.

The gift of presence

Leaders can be change agents, says Swain, but it takes more than a single person. Moore says there isn't "a more inspirational leader than [COO] Amy Vance, but even she needs help sometimes. It takes all of us together."

Vance says that the idea that leadership wouldn't be an active participant in surveys is surprising. "Why wouldn't I be part of it? But it had apparently never happened, that a leader had sat down with interest, passion, and concern," she says. "Magical things happen when leadership is present. It is not that I did anything — there were teams to do everything. But my presence made a difference. And that was an awakening itself."

She says another element of the success came from transparency. There was "a no-holds-barred telling of it all," says Vance. "Leaders often paint a negative picture that can fracture morale, or they are such overenthusiastic cheerleaders that their view is seen as unrealistic. For me, and our leadership team, being honest and transparent meant that it was okay for the whole team to follow suit. They believe in you, trust in you, and know you will walk through fire for them. So they will for you."

Moore says that at the end of the survey, The Joint Commission presented a stack of papers that was maybe a half an inch thick, and they told her that it was the thinnest packet they had ever given out, regardless of the size of the hospital. "We are an old building, and surveyors were here for more days and hours at a time than we had ever experienced. But there was not a single finding related to patient care standards in behavioral care. Dialysis was usually an area of weakness, but it was a strength this time. We expected a much thicker packet."

The whole process was, admittedly, stressful. But it was also fun. "Yes, fun," Moore repeats. "We had withdrawal afterwards. People made extreme sacrifices; they missed family events; they cancelled vacations. But there was camaraderie that continues now."

Joy Greear, MBA, MHA, vice president of professional and support services agrees that the experience was entirely positive. "I think it was good for so many people to be involved, to see the surveyors in action and on site. We were all connected to this process, and that gave everyone a personal accountability. A bond was created; there was networking; new relationships were forged. I think we got more problems solved in the survey than in the entire previous year — just from the networking that happened."

For more information on this topic, contact:

  • Paula Swain, Director of Accreditation and Regulatory Novant Health/Presbyterian Healthcare, Charlotte, NC. Telephone: (704) 384-8856. Email:
  • Sheila Moore, RN, BSN, MHA, MBA, Vice President of Professional Services, Presbyterian Hospital, Charlotte, NC. Telephone: (704) 384-4000.
  • Amy Vance, Chief Operating Officer, Presbyterian Hospital, Charlotte, NC. Telephone: (704) 384-4000.
  • Joy Greear, MBA, MHA, Vice President of Professional and Support Services, Presbyterian Hospital, Charlotte, NC. Telephone: (704) 384-4000.
  • Elizabeth Steger, RN, MSN, Vice President of Patient Care Services, Presbyterian Hospital, Charlotte, NC. Telephone: (704) 384-4000.