SDS Accreditation Update

What do surveyors look at? Your peers fill you in

Make sure firewalls and staff answers are solid

While surveyors continue to focus upon National Patient Safety Goals and use the tracer methodology as they conduct surveys for the Joint Commission, not all surveyors trace a single patient throughout the process.

"Our surveyor did observe our staff admitting a patient, and he did talk with a patient and parent in pre-op as well as recovery, but he didn’t always follow the same patient throughout the process," says Pam Courter, RN, manager of quality assurance for Children’s Surgery Center in Columbus, OH.

The surveyor also did not go into an operating room during a procedure, but he talked with a nurse to find out how staff verified the patient’s identity, surgical site, and procedure. "He told us that he did not want to get in the way’ during our procedures," she says.

At Advanced Surgery Center of Georgia in Canton, the surveyor did pick one patient who was followed throughout the day, says Sybil Gaytan, RN, clinical director. "He didn’t stay with the patient the entire time, but he talked with the patient in admitting, pre-op, and recovery and was there to listen to staff members explaining everything to the patient and answering questions," she says.

In addition to following a patient on the day of surgery, Gaytan’s surveyor also pulled charts of recent patients and traced those patients’ experience by talking with staff members who provided their care, she says. "As staff members answered the surveyor’s questions, it was important that everyone answered concisely and consistently."

For example, when the surveyor asked when a patient’s identification is verified, it was important that everyone stated that it is verified upon admission, in pre-op, and in the operating room rather than just mentioning one place, she says.

As her same-day surgery program prepared for the survey, Gaytan emphasized that staff members should just do what they do every day.

"It is not a good idea to start changing the way you do things just before a surveyor arrives," she says. Not only do staff members get confused and flustered, but you can’t be sure that part-time or vacationing staff members get the same information about changes, she adds. If you do see ways to improve your processes as you get close to your survey, make plans to do so after the survey, she suggests.

The thoroughness of the survey impressed Margaret G. Acker, RN, MSN, chief executive officer of Blake Woods Medical Park Surgery Center in Jackson, MI. "Our surveyors left no rock unturned, but they were fair and approached their role as teachers," she says.

There was one surprise in the survey, she says. The center had added some computers, and a wall was drilled through to pull the wires, Acker notes. One of the surveyors noted that the wall through which the wires were pulled was a firewall.

Firewalls cannot have any penetrations unless they are sealed with a fire stop (a sealant or an approved device that is double-walled). The center’s maintenance staff sealed the wall so that it still has a firewall rating, she adds. "When we chose the location for the computers, it never occurred to us that we had to drill through a firewall," Acker says. "We’ll be more careful next time."

While being a pediatric same-day surgery center didn’t affect the way that Courter and her co-workers approached preparation for the survey, the pediatric patient population did throw off the surveyor a little bit, she says. "The surveyor wasn’t accustomed to talking with children, but he adjusted and talked with the children and the parents as he traced patients," Courter adds. "You have to adjust because you can’t ask a child questions in the same manner you ask adults."

Also, the staff had to explain that they do look at prevention of falls and take steps to reduce the risk of falls, but falls are defined differently in a pediatric program, she says "After all, it’s normal for a 2-year-old to fall when walking across a room, so we can’t prevent that," Courter adds.

A pediatric facility can reduce risk of further injury by taking steps such as eliminating furniture with sharp corners in patient areas, she says.

If your same-day surgery program serves pediatric patients exclusively, you also may have more of a challenge in your performance improvement program when surveyed, Courter suggests.

"We do gather benchmark information from other sources, but it is hard to find pediatric outpatient surgery information," she explains. "We can compare some of our information to hospital-based pediatric information, but not when it comes to things like infection rates."

Because Courter’s patients stay a short time, they are less likely to be exposed to the same types of post-surgical infections as hospital surgical patients, she says.

Be prepared to show that you’ve used all available resources for benchmarking and explain why some data can’t be used, Courter adds.

Gaytan found the survey to be a great learning experience. In addition to being found in full compliance with all standards, "the surveyor told me that he would be proud for him or any of his family members to undergo surgery in our facility," she says.


For more tips from surveyed organizations, contact:

  • Pam Courter, RN, BSN, Manager of Quality Assurance, Children’s Surgery Center, 660 Children’s Drive, Columbus, OH 43205. Phone: (614) 722-2920.
  • Sybil Gaytan, RN, Clinical Director, Advanced Surgery Center of Georgia, 220 Hospital Road, Canton, GA 30114. Phone: (770) 479-2202.