Many organizations use mock surveys to test their compliance with accreditation requirements, addressing the standards from CMS, The Joint Commission, DNV GL Healthcare, the Commission on Cancer, the College of American Pathologists, and other groups.
The pretend surveys may reassure the organization that compliance is good and it is ready for a real survey — or it can unearth deficiencies that should be corrected before they result in real penalties. In most cases, it is a mixture of both: some reassurance about where the organization is strong, and some issues to improve.
How much leaders take away from the mock survey depends largely on how it is conducted, and what action the organization takes with the information revealed. Mock surveys (sometimes called an internal audit) should be a primary quality improvement and compliance tool in any healthcare organization, says Patrick Horine, chief executive officer at DNV GL Healthcare, in Milford, OH, which offers hospital accreditation.
Before DNV GL created its accreditation organization, its consulting group conducted mock surveys for member hospitals.
“You never know when a real survey is going to happen, and a mock survey keeps you ready. You could have an unannounced survey from an accrediting organization, or it could be a state survey in response to a complaint,” Horine says. “It’s always good to be in the mode of readiness for a survey, and a mock survey is a key step in achieving that.”
DNV GL conducts annual surveys, and a mock survey can play an important role in maintaining compliance with requirements and ultimately a state of readiness for surveys.
“We require this of our hospitals. This should be an integral part of the quality management system,” Horine says. “It can be structured in different ways but tailored to identify areas of concern or known noncompliance in the past to ensure actions taken have been sustainable. It can be really eye-opening.”
Engage Staff in Survey Process
A mock survey can engage staff in the process and help them gain insight into other aspects of the organization. Ideally, staff members should not audit their own areas.
“We don’t want people auditing their own areas or asking questions that they can answer themselves. It’s better if they are unfamiliar with that area and require staff members there to explain things,” Horine says. “You don’t want to get yes or no responses. If the questioner knows the material as well as the staff member being interviewed, there can be a lot of half answers and the interviewer nodding that they know the rest.”
Of course, the mock surveyors should not be completely unfamiliar with the compliance issues. They should prepare by studying applicable policies and procedures so they can craft their questions appropriately, even if they are not as intimately familiar with them as other staff.
A mock survey can be facility-wide, or it can focus on a particular department or compliance issue. Any known inconsistency is a good candidate for a targeted mock survey.
“You can go a mile deep and a foot wide by focusing on a particular issue or department, or you can go a foot deep and a mile wide by looking at your entire organization,” Horine says. “Mock surveys play an important role in helping everyone be attentive because we all know that after a real survey, everyone relaxes and waits for the next survey to roll around before they get serious again.”
Look for Inconsistency
An important goal should be identifying where inconsistency exists throughout the organization. Questioning staff about a certain issue or policy can reveal how much their responses vary and whether any efforts to improve consistency are working.
“When you look at a survey report, whether it’s from us, Joint Commission, CMS, or anyone else, a lot of what you see is that the hospitals are not following what they said they were going to do,” Horine says. “Rather than going through a checklist, going through the motions ... you might be better off identifying where shortcomings are and focusing on them. That can make this process very effective.”
Conducting a few mock surveys every year keeps staff on their toes and makes it possible to focus on important areas. Horine recommends making the mock survey feel as real as possible, pushing staff out of their comfort zones and challenging them to explain what they are doing to comply with specific requirements.
The mock survey can help staff members develop the confidence they need to answer questions from a real surveyor. Proper preparation can erode anxiety.
“People understand their jobs well but when challenged to explain it, or when they’re asked to explain a policy and how they comply with it, they can freeze up. It’s better that happens in a mock survey than with the real thing,” Horine explains. “That’s why you want to make the mock survey feel as real as possible. If you go at it as a casual exercise, you won’t get much out of it. A realistic approach can help reduce anxiety and get people more comfortable putting their policy compliance in their own words.”
The only way a mock survey might be different from a real one is that leaders can encourage staff to speak up about their uncertainty over policies and how to execute them, or any other concerns that apply to the issue in question. Normally, administrators would not encourage staff members to hand over compliance issues on a silver platter to a surveyor. However, during a mock survey, managers should encourage staff to report uncertainty or a lack of compliance.
Not Just a Checklist
A pitfall to avoid with any survey is making it a list of items to check off. Asking “Are you compliant with this policy?” is unlikely to reveal much useful information. Still, hospital leaders can tell themselves they conducted a mock survey and scored well. Little is gained.
“A lot of people are going to say ‘We’re compliant. We have no issues in this area,’” Horine observes. “The documentation is limited, and you don’t know if maybe the staff is not clear about this policy and you need to bring in someone who can explain it better.”
A more effective approach is to focus on specific issues of concern and require staff members to describe their compliance with the policies and procedures.
“Hospital leaders are intuitively aware of what those issues are, the areas where they hope a real surveyor doesn’t ask too many questions. A mock survey should be not just a survey to standards, but a survey to practice,” Horine says. “What are we doing, and is it effective? In some cases, you may find that you need to go back and rewrite the policy.”
Uncover Good Compliance
Mock surveys are a good way to help practice continuous readiness, says Rosanne Passeri Farrell, MPA, BSc, RN, CJCP, FACHE, principal consultant with Joint Commission Resources (JCR). The mock survey can be a full rehearsal for the real survey. Administrators can uncover information that is not readily available on a day-to-day basis.
When JCR conducts mock surveys, they often uncover positive news about the organization, but it is not uncommon to find areas of noncompliance, too.
“In some cases, we find that the organization is meeting the standard, but we can offer ways to improve that,” Farrell says. “We offer recommendations that are evidence-based guidelines so they know that these are the best ways to meet the standards and understand them. I think it helps organizations have a better understanding, but you can sometimes read the standard and not recognize all the ways you can meet it.”
In addition to uncovering issues that might need attention, putting a mock survey team in the hospital helps staff understand how the process of a real survey is going to work. Farrell notes that now, many hospitals are part of a health system. Thus, a mock survey can affect other facilities beyond the one in which it was conducted. The findings can be passed on to others in the system to look for applicability.
“We also have conducted mock surveys in several of a system’s hospitals to provide system-level reporting, showing how they are doing as a system and perhaps how one hospital has a really good process that could be shared by the others whose practices are not up to par,” Farrell says.
A mock survey from JCR begins before the surveyors arrive at the facility. Surveyors identify the services offered at the facility and how the mock survey should be structured, including the kind of consultants from JCR who should be present. Consultants are available for a wide range of specialties.
The consultants develop an agenda, collect the necessary documents, and plan the schedule. When the consultants arrive, the survey is conducted almost entirely like a real survey from TJC.
“I would say there is one difference. We do encourage [staff] to feel free to ask questions,” Farrell says. “Our purpose is to help them to understand, to educate them.”
Patterns Can Be Dangerous
The most significant issues found in a mock survey would be those in the red section of TJC’s SAFER Matrix, those where the risk of harm is high. Mock surveyors may discover these issues, which need immediate attention. Other issues may not be as dangerous. However, if a pattern emerges, those issues still may require immediate attention.
“There are areas that consistently fall into high risk. Infection control is one example,” Farrell says. “Environment of care comes up frequently, too, because it can be very complex to maintain a safe environment for an organization, especially since many of the hospitals have old infrastructures.”
Farrell notes some staff can be embarrassed if they do not know the proper response to questions. She says JCR consultants always focus on education and avoid anything that might sound critical or judgmental.
Best Practice for Compliance
Mock surveys are a best practice for helping organizations identify areas of noncompliance, no matter what deeming authority the hospital uses, says Paula Brandon, RN, vice president of quality and clinical support with Community Hospital Corporation (CHC), based in Plano, TX. CHC conducts mock surveys for its member hospitals.
In addition to revealing potential problems, the mock survey can help staff members understand how to interact with surveyors. Many staff have never spoken with a regulatory compliance officer or surveyor.
“We try to help them build their confidence as we’re conducting the mock survey, helping them realize that they really do know about the subject matter and that they don’t have to be afraid to interact with a surveyor,” Brandon says. “If it’s done on a regular basis, it helps the organization maintain their survey readiness. Sometimes, when you’re not focused on compliance every single day, you can miss things.”
CHC explains to hospital leaders that the primary benefit of the mock survey is to bring in a new set of eyes to look at their facilities and possibly see things they do not.
“You might pass an item in the hallway that really shouldn’t be there, but you don’t notice it because it’s been there for such a long time,” Brandon offers. “But someone coming in from the outside can question what that is in the hallway.”
That is why mock surveys should be conducted by someone outside the facility whenever possible. If the mock survey is not conducted by an accrediting body or by the health system, Brandon suggests asking a team from another hospital in the community to assist.
Allowing an in-house team to conduct mock surveys should be a last resort, according to Brandon. The mock survey often is not taken as seriously when the surveyors are familiar faces. An outside “expert” visiting the hospital often is more influential when explaining standards and how to comply.
Later, the hospital can reciprocate, thereby giving both facilities a fresh set of eyes to look at operations.
Regular Schedule Optimal
CHC tries to conduct mock surveys at each facility every 12 to 18 months, but Brandon notes other facilities may not have the resources to conduct mock surveys that often. In addition to partnering with local facilities, a hospital can hire outside vendors to conduct the mock survey.
“It should be an ongoing quality initiative in every organization, to not only drive compliance to the standards but also to facilitate the creation of safe and highly reliable organizations. For them to do that, they have to mirror how an actual survey would be conducted,” Brandon says. “Since every organization is unique in how it meets the standards, we begin with looking at their policies, procedures, plans, documentation to ensure they are compliant from a documentation perspective. Then, we spend time validating that by going around through the organization ... to validate what they say they are doing in their plans, policies, processes, bylaws.”
It is important to conduct the mock survey as realistically as possible. Staff should take it seriously and not see it as just friendly banter about compliance standards. CHC mock surveyors make it known they are conducting a mock survey, but conduct themselves as a real surveyor would. “We ask [staff] a lot of questions and try to look at every standard we possibly can. At the same time, we do let them know we are there to help them,” Brandon says. “If they have a concern about something that is not meeting standards, we encourage them to bring it up so we can help them find a way to address it. It’s serious, but we want to be helpful.”
Follow-through is an important component of a mock survey. Because most standards are not prescriptive about how to comply, mock surveyors want to confirm that whatever method or pathway has been chosen is carried out.
“If [staff are] not doing what they say they are doing, it doesn’t necessarily mean they are out of compliance with the standard. They may be doing something just as effective, or even more so, than the process they documented,” Brandon says. “But if that is the case, they need to go back and document the way they are actually doing it. We’re looking for consistency, in addition to whether they are meeting the standard.”
Most hospitals will conduct mock surveys relevant to their deeming authority. DNV-GL and TJC have embedded within them the CMS Conditions of Participation. Typically, CMS standards are covered in mock surveys for other accreditors.
CMS does not conduct mock surveys. However, for questions about the accreditation process and the potential benefit of mock surveys, a spokesman suggested some resources might be helpful (found in the resource list at this end of this article).
For laboratories, CHC performs a general review, but not a specific audit because they use a separate set of standards apart from the rest of the hospital. Usually, laboratory directors oversee those standards and may organize their own internal audits or mock surveys.
Use the Information
What leaders do with the information gleaned from a mock survey is crucial to making the experience worthwhile. Administrators should use the survey data to identify areas of need, action plans, and ways to monitor progress.
It is important to communicate the findings to those who were involved. Staff often want to know how they compared to others and how compliant they are overall.
“A lot of times, that information makes its way into a report in a binder, and then it’s never seen again,” Horine says. “Communicating that information widely is very beneficial. Use that information the way it was intended, to shore up any loose ends or areas where you’re more apt to get findings.”
During the survey, JCR consultants are accompanied by scribes from the facility who take their own notes. Later, mock surveyors discuss those notes with scribes to ensure they understand the significance of some comments recorded.
JCR provides initial findings to facility leadership on each day of the mock survey. That is followed by a full written report in the form of an action plan and a PowerPoint presentation that uses the SAFER Matrix. Sometimes, the facility asks that at least one consultant return to review progress on addressing the issues uncovered.
CHC provides a report to the surveyed hospital within two weeks. But like JCR, they also work with scribes who follow the mock surveyors and can collect notes for immediate daily review. CHC also helps the hospital develop an action plan and follows up later to check progress.
Brandon says it is important to see the mock survey results as an opportunity to improve before the real survey, rather than seeing it as criticism. In some cases, hospitals are reluctant to pass on the results of the survey to departments and staff members because they do not want to seem critical or discouraging.
“That is worst thing that can happen,” Brandon says. “The greatest pitfall is to get the information and do nothing with those findings.”
- Centers for Medicare & Medicaid Services. CMS-approved accrediting organizations contacts for prospective clients. Aug. 25, 2020.
- Centers for Medicare & Medicaid Services. Accreditation of Medicare certified providers & suppliers. Page last modified Aug. 25, 2020.
- Paula Brandon, RN, Vice President, Quality and Clinical Support, Community Hospital Corporation, Plano, TX. Phone: (972) 943-6400.
- Patrick Horine, Chief Executive Officer, DNV GL Healthcare, Milford, OH. Phone: (866) 523-6842.
- Rosanne Passeri Farrell, MPA, BSc, RN, CJCP, FACHE, Principal Consultant, Joint Commission Resources, Oak Brook, IL. Phone: (630) 268-7400.