What should your mock survey include?
Eight items you shouldn’t forget
When Barbara January, RN, clinical services specialist for the Minnetonka, MN-based In Home Health, developed an in-house mock survey program for the agency’s 29 offices, she wanted to be sure she covered all bases. Over time, a typical practice survey developed to include these eight items:
1. Agenda review. January starts by holding an opening conference to introduce the corporate representative who will conduct the survey to the branch staff and to review the survey agenda.
2. Home visits. A sampling of visits from the day the survey starts is chosen. January says she likes to make sure certain kinds of visits are included. "Infusion and wound cases are my top choices. That ensures I see some complex cases that deal with infection control issues."
3. Staff interviews. January likes to interview staff members in groups, bringing in a few aides or nurses at one time. "I don’t want just one person to get all the benefit," she says. These group sessions usually last about 30 minutes each. She supplements that information with one-on-one interviews with nurses while she’s in the car going on home visits, or with people she sees in the hallways during the three-day survey. Along with answering typical survey questions — such as what would an aide do if they suspect a patient was being abused — these meetings also give staff a chance to bring up other issues. "However, staff members know that this isn’t time to bring up personnel issues. They know they can talk about policies, processes, and procedures."
4. Document reviews. This includes a review of policy and procedure manuals, training and continuing education materials, administrative and professional advisory board meeting minutes, pharmacy dispensing records, client education materials, and equipment maintenance records.
5. Random chart reviews. January says she selects clinical records of both current and discharged clients from all divisions.
6. Review of contracted services. January looks at the services to make sure they are in compliance with JCAHO and agency policies and other regulatory requirements.
7. Employee personnel/medical file review. A random sampling of these records are chosen for review.
8. Exit conference. This last step includes reviewing the findings of the mock surveys with staff and management and making recommendations for improvement.
"The process closely mirrors the Joint Commission survey," says January. "We have found that this gives branches the best experience for what a real survey will be like."