Mock survey can help prepare staff
Having a mock survey can decrease staff anxiety and illuminate problem areas. At Columbus Regional Hospital (IN), ED staff were given a list of potential questions before a mock survey was held. "We tried to focus on the topics that might be problematic," explains Judy Maupin, MSN, RN, CNAA, senior advisor of clinical services.
Staff received notices that the mock survey would take place during a specific 90-minute period in the ED. At the appointed time, Maupin, a quality review staff and risk manager, and facility director toured the ED and questioned staff.
The mock surveyors did a walk-through inspection, randomly pulled some charts for review, and checked for expired medications. Commonly asked survey questions were posed to the nurse manager, medical director, and other clinicians. "We tried to make it as close to the real thing as possible," says Thomas Sonderman, MD, FACEP, medical director of the ED.
Staffers were drilled on survey topics and given immediate feedback. "If we thought their answer wasn't clear, we pointed out what surveyors are looking for, and coached them," says Maupin. "We let them know whether they should expand, or if they should leave a certain part out, since it might lead you down a path you don't want to go."
Ideally, a mock survey should be held a month in advance of the actual survey. "That way, it gives the staff time to tune some things up if they need to, but you don't lose steam," says Sonderman. "Staff can anticipate some commonly asked questions, with the opportunity to think them through beforehand."
The mock survey also reveals areas in need of review. "It helps show deficiencies in a proactive way. You can then initiate strategies to improve patient care," says Sonderman. "Doing a dress rehearsal also reduced the anxiety level during the actual review."
The mock survey enabled staff to comprehend what surveyors were looking for. "It helped them to understand the rationale behind the questions, so they could formulate well thought out answers," says Maupin. "The staff thought it was extremely helpful and also said it was worse than the actual survey itself, which is as it should be."
Outside consultants can provide valuable input when developing a mock survey. "Some consultants have been surveyors themselves, and can go over your policies and procedures to help illuminate some deficiencies you may not realize you have," says Sonderman. "Another approach is to identify internal people at your facility who have a thorough knowledge of Joint Commission requirements, which is a tremendous help."
[Editor's Note: A variety of publications are available to assist hospitals in preparing for a JCAHO review, including The Complete Guide to the 1998 Hospital Survey Process ($55 plus shipping and handling charge) and The Medical Staff Handbook: A Guide to Joint Commission Standards ($50 plus shipping and handling). The Joint Commission Journal on Quality Improvement is a monthly periodical ($145 for 12 issues; single copies are available for $16.50). For more information, contact the Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Fax: (630) 792-5005. World Wide Web: http://www.jcaho.org.]
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