SDS Accreditation Update

Survey over? Time to start preparing again

Non-survey years are more important

Aaaahhhh. The survey is over. "I don' t have to worry about this for another two and one-half years," you might think.

But you' d be wrong, says Jennifer Cowel, RN, MHSA, vice president at Glendale, AZ-based Patton Healthcare Consulting, which offers regulatory compliance and accreditation readiness consulting, and a former hospital surveyor and director of service operations in accreditation in the central office for The Joint Commission. Cowel gave a presentation earlier this year for AHC Media, publisher of Same-Day Surgery, on "The Surveyors are Here, Now What? Successful Strategies for Your Next TJC Survey." (For ordering information, see Resource, below.) .

Your survey success depends on several items, Cowel says. "One is what happens when they show up at the door, but more importantly is managing the non-survey years," she says. If you start preparing far ahead of time, "you' re going to be able to present your best face, and your best quality to that survey team," Cowel says.

After the survey, keep the momentum going. Realize you might not have your next survey in the year it' s due. The Joint Commission reserve the right to conduct random validation surveys, and they do those surveys in about 5% of hospitals and surgery centers in any given survey year, Cowel says. "So you want to have your ducks in a row even if you don' t think The Joint Commission is going to be there for another year or two," she says.

Facing the challenges

Several areas present challenges in the non-survey years, Cowel says. One is your plan for improvement (PFI).

On your Joint Commission Extranet site, see the section titled PFA Part 4, Cowel says. "It is a list of things that you have self-disclosed to The Joint Commission that are in your environment, that are not working, that need to be fixed, that impact Life Safety," she says.

That section includes a timeframe for addressing compliance problems, Cowel says. If you have leadership changes, this timeframe can fall off the radar, "and you will have had a Life Safety violation that you said you were going to fix six months ago," she warns.

Consider these other suggestions:

• Keep your policies simple.

One facility Cowel visited had a policy for verbal order authentication that was so detailed that it dictated what color ink a nurse had to use (green) and what acronym had to be used (VORB).

"The Joint Commission will look at your policies, and you can be scored out either at the standards or your own policies," she says.

Keep you policies simple so they are flexible enough to adapt to different areas, such as outpatient and inpatient, Cowel says. "And don' t get yourself in a situation where your good intention on a very detailed policy trips you up during your survey because it' s just not implementable at the level of detail that someone envisioned it," she says.

• Implement standards and National Patient Safety Goals (NPSGs) as soon as they are published.

The Joint Commission, for example, implements new standards and updated elements of performance (EPs) twice a year: Jan. 1 and July 1, Cowel says. The Accreditation Association for Ambulatory Health Care (AAAHC) updates their standards around March 1 annually.

"This is the time that you want to send them out in your department meeting minutes," she says. "Send them out as assignments. Follow up to make sure that they are implemented in your organization."

Joint Commission surveyors go through training on new standards and EPs every year in January, just after the holidays, Cowel says. "And oftentimes what we see in the January and February surveys: Everything that' s new is now a focus area," she says.

• Focus on the top 10 scored standards and NPSGs.

The top 25 or 30 standards with the highest noncompliance rates are scored in about 90% or more of the findings that are scored throughout the country, throughout the year, Cowel says.

While you do have to be compliance with all of the standards, your risk are in the top scored 25 standards or NPSGs, she says, "so keep your eyes on those."

If you focus your limited resources and funds on those standards, "that will get you very far in getting yourself a very smooth survey processes and a good survey outcome," Cowel says. (To access the most recent list of highest non-compliance among standards and NPSGs for hospitals, ambulatory organizations, and office-based organizations, go to

• Use your staff to perform mock surveys.

Use unit managers and infection control staff to perform mock surveys, Cowel advises.

"You are going to get incredible valuable information about your own internal compliance, and you' ll also be able to do mid-term corrections along the way in those areas that you are struggling with," she says.

For example, you might find during mock surveys that anesthesia staff aren' t complying with checking the box that says "I did an immediate pre-induction assessment prior to anesthesia." Look at your flow to see if that checkbox is out of order, Cowel suggests. If needed, change the flow or change the forms, she says. Change something "so that your staff can do good work but the forms, the flow, the policies are not an impediment to taking credit for the good work you do," Cowel says.