Healthcare accrediting bodies are resuming or planning to resume onsite surveys that were suspended during the height of the COVID-19 pandemic. Quality improvement leaders should act now to ensure their organizations are ready for these critical assessments.
Regardless of the accrediting body, onsite surveys require long-range planning for compliance and also a practical approach to the actual surveyor visit.
The Joint Commission (TJC) suspended survey and review activity from March 16 through May 31 because of the public health emergency, notes Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, CJCP, associate nurse executive with accreditation and certification operations at TJC.
After resuming onsite events, detailed criteria were put into place indicating those counties that were considered lower risk, she explains. Healthcare organizations in those lower-risk counties, with surveys and reviews pending, were contacted to determine if they could support a survey or review. In addition to onsite events, a virtual survey option is in place for all programs, with the extent of available survey options dependent on CMS approval of these options for deemed programs, DiBlasi Moorehead notes.
As onsite visits resume, DiBlasi Moorehead says there will be some differences from how surveyors previously conducted their assessments. COVID-19 restrictions and requirements will be respected.
“During the public health emergency, and perhaps extending beyond it, surveyors and reviewers will work to maintain physical distancing while conducting the event and wear personal protective equipment [PPE] as required by the organization,” DiBlasi Moorehead says. “Technology will be used, as appropriate, to facilitate such activities as record review and to expand participation while maintaining social distancing. Surveyors and reviewers will work with organizations to modify agendas, as needed. Otherwise, the survey/review will remain the same.”
In addition to actual compliance issues that should be addressed on a continuous basis, quality leaders should consider how to organize the onsite event ahead of time, DiBlasi Moorehead says.
Healthcare organizations must prepare documents and performance improvement data to be made available for the survey. Review teams should be assembled ahead of the onsite event.
“Most healthcare organizations establish a process to record, gather, and regularly update survey documents so there is not a rush to pull the information when the team arrives,” DiBlasi Moorehead says. “Survey application information is updated regularly and submitted well in advance of the survey due date. Once a tentative agenda is shared, most organizations begin to look at individuals they would like to participate in survey activities and review expectations for those activities.”
Use Tools to Assess Performance
Healthcare organizations can regularly evaluate their performance according to TJC standards using dashboards of publicly reported data and associated resources, often posted to organizations’ extranet sites, DiBlasi Moorehead notes.
TJC also provides Heads-Up Reports that include high-risk standards with compliance strategies. The Focused Standards Assessment tool also is available for organizations to evaluate performance according to high risk and other standards.
“Becoming familiar with the Survey Activity Guide can help healthcare organizations prepare for a survey,”1 DiBlasi Moorehead says. “Establishing a relationship with the organization’s account executive is also a critical way to keep informed about survey process expectations. Staying current with issues featured in The Joint Commission’s publication, Perspectives, is helpful as well as contacting The Joint Commission’s Standards Interpretation Group for further clarification.”2
Using the Survey Activity Guide will help organizations prepare for each survey activity, DiBlasi Moorehead says.
The guide also lists the individuals who should participate in each activity. The tool includes a designated leadership session that allows the survey team to discuss how the team leads the healthcare organization on its journey to high reliability.
Additionally, The Survey Activity Guide includes a list of documents each healthcare organization should make available to the survey team shortly after its arrival. The document list contains policies and procedures, minutes from leadership committees, and performance improvement data.
“The form these documents take is up to the organization. Most healthcare organizations still use paper but some have uploaded documents to secure sites for the survey team to access,” DiBlasi Moorehead says. “This document list is not all-inclusive, so other documents may be requested during the course of the survey or review. It is best to provide only the documents that will answer the surveyor question or provide clarification.”
Do Not Provide Too Much Data
Providing too much information can backfire. Avoid dumping a lot of information on the surveyors in hopes of appearing especially thorough.
“If too much information is provided, and it is not clear how the information addresses the issue, a finding may unnecessarily result,” DiBlasi Moorehead cautions. “Indicating which part of a particular document answers the survey question may also be helpful.”
The most frequently cited standards vary from year to year, but DiBlasi Moorehead says there are some consistencies. For example, high-level disinfection and sterilization remain among the most commonly cited clinical standards. Providing a safe environment is a common non-clinical finding.
Lunch Is Nice, But Not Required
Hospital leaders may be uncertain about how much to interact with surveyors and how to be a proper host during the site visit. It is a common practice for organizations to provide lunch for surveyors/reviewers as a matter of convenience, DiBlasi Moorehead says. However, surveyors can pay for their meals, and it is not expected to provide lunch.
Regardless of whether the facility provides food, surveyors typically engage in a working lunch that includes team discussion and recording survey activities, without facility representatives participating. During this time, the organization leaders can take a break from the surveyors and survey activity.
When deficiencies are cited, organizations should follow the established Evidence of Standards Compliance process and timeline to respond to requirements for improvement.3 The healthcare organization’s account executive is present during the survey and can assist the organization in submitting this information.
Assign Area Leaders
Compliance and site visits will be better if leaders assign specific employees as team leaders for special accreditation areas, suggests Ajimol Lukose, DNP, RN-BC, a surveyor with the Healthcare Facilities Accreditation Program (HFAP) in Chicago. She also is nursing director at Swedish Covenant Hospital in Chicago. For example, HFAP divides accreditation into chapters. Lukose advises assigning a leader for each one. The leader compiles all necessary policies, contracts, and other dividers in a binder specific for that chapter.
“I see that sometimes when I ask if they have a policy, they go running around looking for it. Others can say, ‘yes, here it is in the binder,’” Lukose says. “I conduct surveys, but I also am at a hospital that gets surveyed, so I see both sides of it. When I am surveyed, I have all my binders and documents ready, and I am familiar with each standard in the manual.”
Restraints a Common Problem
Each leader also should prepare their department staff members to be familiar with quality targets and projects in that department, along with policies and the applicable standards.
“The deficiencies I often find in inpatient settings involve restraints, which is a heavily cited area. The leaders must review all the restraint charts,” Lukose says. “I can tell when I go to an organization, and the leader says ‘yes, we know this is an issue, and we’re working on it,’ vs. when I go to a hospital, and the leader is surprised at what we see when we look at the charts. Even if there is an issue with restraints, we want to see that you are aware of it and have an action plan to address it.”
Another common problem involves contracted services. Any contracted services, such as laundry, food service, or laboratory services, must undergo an annual evaluation.
“When I see the annual evaluation is missing, and I see that quality monitoring is not done for the contractor services, that is a problem,” Lukose says. “They are surprised when I ask if they have quality evaluations. In some quality organizations, the quality department will have all of the contractors on a spreadsheet showing all the contractor surveys, the date, and the quality indicators. That makes it so easy to review.”
At other organizations, Lukose asks for that information on the first day, but it may not have been provided until several days later because the hospital staff were scrambling to compile it.
Infection Control Cited Often
Infection control is another key area for an HFAP site survey. Lukose says many healthcare facilities fall short in this area, sometimes much to the surprise of quality leaders who thought they had instituted a good infection control program. The supply storage room is a common problem area in infection control. Sterile items, expiration dates on supplies, and cleanliness issues often result in deficiencies.
“Many high-performing hospitals have a routine rounding by the unit manager, with their staff, once a week or once a month to check these areas. Include the staff so they know what to look for,” Lukose says. “A common problem I find is with the patient nourishment refrigerator, which may have outdated food, open containers without any dates, and staff food. We cite them for all those things.”
Crash carts also can be problematic, according to Lukose, with some not showing any documentation that they have been checked for several days.
Board Minutes, Patient Records
The patient care record is an important part of a review, and Lukose says hospital leaders should conduct random audits. The plan of care is a crucial part of the chart, along with the history and physical. Lukose says she sometimes finds staff members are surprised that charts do not include the history and physical.
“Another area some hospitals fail is when the board minutes are not approved, or the quality report and plan are not submitted to the board. There should be documentation that the board reviewed and approved the quality report and plan,” Lukose says. “Also, if they use agency nurses, the file on the nurses should be ready for review, including the orientation checklist and evaluations. Frequently missing is the periodic evaluation of the agency staff.”
On the day of the site visit, HFAP surveyors expect to be greeted, provided a workspace, and each surveyor should be accompanied by a contact person, ideally the chapter leader, who will take the surveyor from one department to another and make introductions, Lukose says. The contact person should provide the surveyor with a phone number in case information is needed when they are separated by breaks or meal times.
HFAP surveyors engage in working lunches, on their own, so they can discuss survey issues confidentially. “We want the organization leaders to know we are there to help them. Yes, we are there to monitor their practices, but we are also there informally to help them and provide onsite consultation,” Lukose says. “Sometimes, the staff see us and run away, but we are there to teach them and help them, too.”
Site Survey Is a Project
A site survey should be approached like any other project, with a written project plan that assigns particular duties and responsibilities to different people and departments, says Michael W. Johnson, MA, CAP, managing director for behavioral health with the Commission on Accreditation of Rehabilitation Facilities (CARF) in Tucson, AZ. There should be deadlines, expectations, and someone assigned to manage air traffic control over the whole operation.
“An original survey ratchets up the tension, and people get motivated, but if you’ve been accredited for some time, then people can get complacent. You may have systems in place that are adequate for getting accredited, but this is really an opportunity to take a deep dive into your organization and seek the avenues for performance improvement,” Johnson says. “This actually helps you as a leader in advancing your organization if you use this as an opportunity to advance and better care for the people you care for.”
Hospital leaders may scan through accreditation requirements and say, “yes, we do that,” Johnson notes. But proving that to a surveyor during a site visit is a completely different challenge.
“There is occasionally a disconnect from organizational leadership and what is happening on the ground. The organization leaders are confident they are doing everything we expect, but then those on the frontline have a hard time showing that,” Johnson says. “The pandemic has disrupted everything, so the additional strain and the accommodations that have been made with telemedicine and everything else can create problems. You might have configured that telemedicine plan in three days, because you had to, but you might not have thought of everything required to ensure quality is not impacted.”
Consider how much variance there is in usual procedures to adapt to the “new normal” and be prepared to show how those changes are carefully structured to ensure patient safety and care quality.
Once the surveyors are on site, Johnson advises helping and responding — without smothering them. “Don’t hover. A lot of hand-wringing ratchets up the stress for you and the survey team, too, and you don’t want that,” Johnson says. “That’s not good for either party at the end of the day.”
Johnson notes healthcare organizations can benefit from asking one of their quality leaders to become an accreditation surveyor. “The investment by the organization is simply allowing that person to leave for a few days a year, but the return on that investment can be pretty significant in terms of thinking about how to prepare and develop strong systems,” Johnson says.
Virtual Surveys for Some
CARF and some other accreditation organizations are currently conducting virtual surveys. Most are expected to resume onsite surveys soon, says Brent Snyder, DNP, RN, CEN, NE-BC, regional vice president for clinical quality and compliance at Altus Houston (TX) Hospital. These virtual surveys are essentially video conferences with facility leadership and content experts regarding accreditation standards, he says. During these video conferences, surveyors review the organization's documents and policies and discuss facility operations with the leadership.
Preparation is key to success with any accreditation survey, whether virtual or onsite. Accreditation organizations usually will send a list of commonly reviewed documents ahead of the survey. Preparing all documents for presentation to surveyors will make the survey proceed much smoother and usually decreases the number of non-conformities.
“Best practice is to always be survey ready. At a minimum, the accreditation agency will give the organization a survey window, usually approximately 30 days,” Snyder says. “This window period is crunch time from many organizations.”
Some preparation is long-term, such as policy and procedure review, quality management, and environment of care preparation. These items should be worked on for months to years before the accreditation agency arrives. Other preparation can be handled in the short term, such as gathering documents, quizzing staff, and rounding on the units to make sure they are clean and organized.
Do Not Talk Too Much
Once the survey date arrives, remind everyone about the need to provide the information surveyors need but not more than requested. It is easy to create new avenues of inquiry that might not turn out well.
“The most common pitfall I have seen is giving too much information. Just try and answer the question the surveyor asks. Don’t elaborate into unrelated or unnecessary areas,” Snyder says. “This usually results in surveyors investigating issues that were not even on their radar.”
In the same vein, make the right people available to the surveyors, but do not crowd them with top executives and too many people who might say the wrong thing. The surveyors mostly will want to talk with clinicians, not executives.
Preparation usually includes education on common survey questions. Surveyors like to ask the staff about high-risk/low frequency events, such as caring for suicidal patients, restraints, moderate sedation, and malignant hyperthermia.
“We usually quiz staff and provide education prior to arrival,” Snyder says. “We also remind staff to keep their departments clean and organized, keep clutter out of hallways, and remind them of other things surveyors commonly look at.”
Prepare Binder of Documents
The hospital should prepare the right documentation for surveyors and not scramble to obtain documents in response to their queries. Surveyors usually like to review policies and procedures, meeting minutes for required committees, organizational charts, proof of required education completion, employee performance evaluations, environment of care rounds, risk assessments, and patient charts.
“We usually prepare a binder with all requested or commonly reviewed documents. With documents that are kept electronically, we usually just show them the electronic version,” Snyder says. “They do not usually require their own copies of documents; they prefer to see how the originals are kept and organized.”
Too much documentation is problematic if the documents are conflicting or unorganized. As long as the documentation relates to the accreditation issue at hand, surveyors will welcome a thorough explanation.
The most commonly cited issues are environment of care, such as firewall penetrations or some new National Fire Protection Association requirement that the organization was not aware of. Recently, accreditation organizations have been focusing on infection control standards during their surveys because of the COVID-19 pandemic.
After the survey is complete, the accreditation organization meets with site leadership to review the findings. These findings are sent to the organization in writing within 10 days. The organization has 10 days to prepare its corrective action plan and send it to the accreditation agency.
“Surveys seem to proceed smoothest when the organization is clean and organized. Any organization who provides requested documents that meet surveyor standards in a quick and efficient manner seem to have good surveys,” Snyder says.
“Be prepared,” he adds. “Know the accreditation standards and have documented proof that you are meeting them.”
- The Joint Commission. Survey activity guide. January 2020.
- The Joint Commission. Standards online submission form.
- The Joint Commission. Accreditation management skills: Developing an effective Evidence of Standards Compliance. 2015.
- Michael W. Johnson, MA, CAP, Managing Director for Behavioral Health, Commission on Accreditation of Rehabilitation Facilities, Tucson, AZ. Phone: (888) 281-6531, ext. 7101. Email: email@example.com.
- Ajimol Lukose, Healthcare Facilities Accreditation Program, Chicago. Phone: (312) 920-7383.
- Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, CJCP, Associate Nurse Executive, Accreditation and Certification Operations, The Joint Commission, Oakbrook Terrace, IL. Phone: (630) 792-5800.
- Brent Snyder, DNP, RN, CEN, NE-BC, Regional Vice President, Clinical Quality and Compliance, Altus Houston (TX) Hospital. Email: firstname.lastname@example.org.