ED Accreditation Update: Tours help prepare ED for the real thing

Having managers or directors perform tours of your ED can help you and your staff prepare for unannounced surveys, say sources interviewed by ED Accreditation Update.

Department tours also help EDs prepare, managers suggest. At Paradise Valley Hospital in National City, CA, a form is used for weekly mock tours.

"That’s to keep us on our toes, to make sure we get things done on a weekly basis," says Stephanie J. Baker, RN, BSN, CEN, MBA/HCM, director of emergency services.

The form lists multiple areas including fire prevention, electrical safety, medical waste, and supplies and equipment. Providers who are conducting tours can check "yes" or "no" regarding compliance. Maintenance is contacted to address areas of noncompliance.

Two charts are reviewed as part of the mock tour, and managers review various areas, including the assessment to ensure it was complete. Staff members are questioned on various items, such as, "What would you do if there’s a fire?"

Once a month, members of the hospital’s leadership team tour an area for which they are not normally responsible and complete the mock tour form, Baker says. "It gave us a fresh set of eyes," she adds. The vice president of patient care also participates in those tours, which gives the managers accountability, Baker adds.

Mock surveys help the staff become more comfortable answering questions, according to Duane Schmuck, nurse manager at Department of Veterans Affairs (VA) Long Beach (CA) Healthcare System.

At a mock survey held several months before VA Long Beach’s recent unannounced survey, managers ensured that all credentialing, licenses, and certifications were up to date, he says.

At Norton Suburban Hospital in Louisville, KY, the patient safety officer and the director of quality tour the ED and talked with staff about why the survey is important, explains Heather Cote, RN,BSN, MBA, chief nursing officer and vice president for patient care.

"They said, when the surveyors are here, they want to know, and they want our patients to know, we’re providing good, safe patient care,’" she points out.