Get off to a good start: Set survey ground rules

Two pros advise you two be assertive

"You have to be aware of the intent of the Joint Commission’s standards, you have to be knowledgeable about your own institution, and you can’t let surveyors get away with inappropriate actions," says Steven A. Muller, MD, senior vice president for medical affairs at Covenant Health System in Waterloo, IA. He advises that people working with surveyors from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations set out ground rules on day one. For example, make sure there are governing body members in the opening conference. That clearly establishes a premise that the board of directors is interested in what’s going on and not just paying lip service to administration. That takes care of all kinds of questions for the rest of the survey.

Muller says the logistics of the opening of the survey are important. Make sure you know where surveyors are going to park and what entrance they’ll use. Have someone meet them, and make sure the room allocated for their use is adequate.

"This may seem like nickel-and-dime stuff," he says, "but it is important in setting the tone for the rest of the survey." If the surveyors come in and see a disorganized atmosphere from the start, they’re going to develop a confrontational attitude. Muller advises that you ensure that any surveyor with a physical disability — inability to handle stairs, for example — has access to alternative arrangements such as an elevator. "Providing those amenities up front makes all the difference in the world."

Be totally familiar with the standards so you’re on an equal footing with the surveyors, he advises. Ask surveyors to clarify or interpret a standard if you need to. In turn, if they can’t, they should be willing to make a call to the Joint Commission to clarify.

Mary Jo Zallar, RN, BSN, CPHQ, at North west Texas Healthcare System in Amarillo, has been working in the quality field for 13 years. She says while her facility had some problems with surveyors in the past, recently there has been no difficulty. "When it comes to Type 1 findings, we’ve found it helps to be assertive in presenting what you have done," she says. "If the Joint Commission identifies something that you feel should not be classified as a Type 1 — it may be an isolated incident or one that you’re already addressing — tell them. We’ve found surveyors to be reasonable people."

If you have lots of problems, it may be more difficult to talk them out of a Type 1, she adds, but if your facility’s overall systems and functions are in place, the surveyors are often impressed by that. "Any surveyor will find something," Zallar says. "It’s a matter of an item’s significance and whether you have a fix in place."