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During a recent survey at Trident Health System in Charleston, SC, there were times it was obvious that a staff member didn’t understand what the surveyor was getting at, says Helena Feather, vice president of compliance and health information.
"So we asked the surveyors to restate or clarify what they were looking for," she says. "All they would have needed to do is say they didn’t want to hear from us, but that didn’t happen."
Surveyors made it clear they didn’t want an entourage, but there was always an administrative person alongside with the surveyor, says Feather.
"If something was uncomfortable or got out of hand, one of us would step in and say, This person may not know the details; can we get another bedside nurse who could better answer those questions?’" she adds.
Still, resist the temptation to breathe down the surveyor’s neck, advises Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting, based in Metamora, MI.
"If surveyors are feeling they are being put in a box or people are constantly asking where they will be next, they may become annoyed," she says.
"The more surveyors see that, they may be less inclined to share information in advance of where they will be heading next," Homa-Lowry adds.
The nature of patient tracers makes it impossible for even the surveyors to know their destination beforehand, she underscores.
"If surveyors are in a unit and notice a problem with infection control practices related to equipment, then they may stop what they’re doing and go to the source of those services," Homa-Lowry points out.
The bottom line is that during patient tracers, surveyors are more interested in hearing from staff and patients than you, she says.
"They already know that the leaders can tell them about the policy and procedures," says Homa-Lowry. "It doesn’t help to have quality people trying to answer the questions or speak for unit staff."
If you do try to speak for a staff member, surveyors may feel you have something to hide and begin asking to see personnel files, she notes.
"It can be more irritating than helpful to surveyors if the quality manager is trying to step over and explain," Homa-Lowry says. "They may ask for additional personnel files to see exactly what training and competencies staff have and begin looking for trends and patterns."
Surveyors are looking for a different kind of information from staff than they can get from you, she explains.
"You may be up on the units and know the policies and procedures, but it’s not necessarily the same as working with them every day," says Homa-Lowry.
Sometimes, actions speak louder than data
During a recent mock survey done by Homa-Lowry, a patient was in a great deal of pain after a Whipple procedure. The nursing notes indicated that the nurse had called the physician about getting a more effective pain medication.
"When I spoke to the patient, he said that he was much more comfortable," she notes. "In that situation, the quality person could have told me the number of assessments done and the timeliness of them, but the nurse clearly demonstrated that they understood pain management and what they could do for further intervention, so I had no other questions or concerns."