Planning more important for unannounced surveys

Plan activities throughout calendar year

Careful yearly planning always has been the key to effective survey preparation, and much of what you should do is independent of how soon you will be surveyed. The move to unannounced surveys will make it even more important to plan compliance activities throughout the calendar year, says one consultant who helps hospitals prepare for surveys by the Joint Commission on Accreditation of Healthcare Organizations.

You should create a yearly calendar that shows when certain tasks should be started and completed and that prompts you to review specific goals throughout the year, says Susan Mellott, PhD, RN, CPHQ, FNAHQ, in Houston.

"That kind of system will still work, and it becomes even more important in 2006," she says. "Scheduling things and making sure you have an ongoing effort throughout the year will become more important now than ever before."

In the first quarter, for instance, your calendar should remind you to have all your improvement plans evaluated and any new plans started in the committee process. Ensure that in the first quarter the human resources report is delivered to the board of directors and that the board has done its self-evaluation.

In July, the Joint Commission’s patient safety goals will be released. Mark your calendar to check on the release of the new goals and then establish a plan for selecting the goals you will address by the January deadline. Make a schedule to achieve those goals.

"All those are annual things that should be on your calendar every year," Mellott says. "It’s not dependent on when your survey is scheduled. That’s a very big portion of what you need to do to get ready every year."

All of this planning can be put on a calendar-year or fiscal-year schedule, though Mellott prefers the calendar year just because people tend to think in those terms. She suggests that halfway through the year you look at your program goals and assess how you are doing so far.

"You can say we slacked off on this one in the first half of the year, so we need to work harder on it now,’" she says. "Your evaluations need to be ongoing. That can take care of a big part of your survey preparation because when the survey time nears, you don’t have to ask whether you’ve taken care of this or that. You know because you’ve been checking on it regularly."

Your systems should encourage documentation and force you throughout the year to accomplish the many tasks necessary for Joint Commission compliance. One example is a matrix that ensures you have completed all the necessary fire drills throughout the year, Mellott says. The same type of matrix can be used to accomplish many tasks, and it serves as a way to document that they were done.

"You have to do one fire drill per shift per quarter, so you would make a matrix that has four quarters and three blocks in each quarter. When you do the fire drill, you write in the date, hour, where it was, all the other data you need to document it as you do it," she says. "The same thing can be used for disaster drills, baby abduction drills, anything else you have to get done through the year. We’re going to have to use more systems like that."

A matrix of similar tools will be valuable when surveyors drop by and you need to show them where you stand in terms of complying with certain requirements. When you had time to prepare for the surveyors on a specific date, you could prepare reports and presentations to show your compliance. With unannounced surveys, you will need working documents such as the fire drill matrix to show what you have done and what you have planned for the rest of the year, Mellott says.

Process will need to evolve over the years

Switching to such systems will take time, so Mellott advises starting soon. But there is no need to abandon your current triennial survey-based approach if you have one coming up soon. If you know when your next survey is coming, you still can use your upcoming survey date as a target, and as the survey date approaches, you can step up your planning with survey-specific preparations. Months before the scheduled survey — or as part of your readiness planning for unannounced surveys — you should consider having an internal or external mock survey. If you decide to do it internally, don’t have managers survey their own departments. Instead, have them trade off and survey each other’s areas.

"They know what’s supposed to be in their area, so they’re going to see it whether it’s really there or not," she says.

Better yet, if your facility has affiliated health care facilities in the area, have the staff trade mock surveys. Your staff will survey their facility and their staff will survey yours, to add more realism with strangers walking around and asking questions. Some providers opt to use outside consultants for the mock survey for the same reason.

There still is some uncertainty about what form the self-assessments will take under the new process, so Mellott says health care providers will have to reassess their plans when that information is available. It is very likely that you will be able to use the mock survey as a means of conducting your self-assessment, she says. The timing is right, and the mock survey would be a good way to gather the right information while also preparing your staff for actually having Joint Commission surveyors on site.

Weak areas in employee education should be identified in the mock survey or self-assessment. At this time, you also can focus on the areas in which you know the Joint Commission will show particular interest.

"This year it’s the patient safety goals," she says. "They want people at the staff level to know what those are and what that means for the care of patients at their level. For patient identification, for instance, they will ask the staff how you properly identify the patient, exactly what steps do you take."

Many standard techniques still will work

As the survey window approaches, you can step up activities that keep your staff focused on important accreditation issues and help them become comfortable with discussing them. For instance, Mellott says there still will be a need for employee education activities such as a "JCAHO Fair" that provides a fun event in which participants are rewarded with small prizes for going from booth to booth and answering questions about issues important to the survey.

Those techniques have been used in the past when you could target a specific survey date, and Mellott says they will remain useful even though you can’t plan them around a known survey schedule. Instead, she says, you may want to make them an annual or semiannual event. That advice will apply to many techniques that have worked in the past, she says. They’ll still work, but you’ll have to use them more regularly instead of only in the ramp up to the triennial survey.

To change the way you think about survey preparation, you may have to look for educational opportunities that are calendar-based rather than oriented to a survey date. One technique Mellott suggests is using holidays throughout the year to promote survey preparation.

"Lots of providers seize on themes like July 4th or Valentine’s Day to educate staff with newsletters or inserts in paychecks, or posters in the facility," she says. "It just gives you an opportunity to get a message out in a creative way, and creativity never hurts when you’re trying to get someone’s attention."