When surveyor seeks info that’s not in the standards
It’s one of the most popular questions among same-day surgery programs being accredited: What do you do when your surveyor asks for something that’s not required in the standards? Many managers worry that questioning the surveyor will have a negative impact on the survey results. At the same time, managers can be frustrated over some surveyors’ lack of flexibility. Here are some tips for dealing with this dilemma:
• Ask, "Where is that requirement in the standards?"
"When they say, I want to see X, Y, Z,’ you ask them Where is it in the manual?’" suggests Ann Kobs, MS, RN, former director of the department of standards and current sentinel event specialist for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. "They probably can’t find it, so they’re dead in the water right there."
Don’t be afraid to ask questions
Or, Kobs advises, ask whether the request is a personal preference of the surveyor. "Ask that question," she says. "You’re paying for it, for heaven’s sake."
• Provide information on your way of meeting the standard.
Most surveyors apply standards based on their own framework. But that doesn’t mean they are prejudiced against an alternative method, says Beth Derby, RN, MBA, a surveyor for the Accreditation Association of Ambulatory Health Care (AAAHC) in Skokie, IL, and executive vice president for Health Resources International (HRI) in West Hartford, CT.
If a surveyor asks for a written policy, for example, but you don’t have one, feel free to show how you meet the standard in question, Derby suggests.
"As long as [managers] can adequately make their case, I think most surveyors are able to step outside their box and appreciate that a facility is in compliance, regardless of whether the tools are somewhat different from the experience of the surveyors," she says.
AAAHC tries to have surveyors with backgrounds similar to the facility being surveyed, Derby says. However, if you work in a surgery center and your surveyors come from a traditional hospital background, they might need more information from the facility on how to meet a particular standard. As an example, on the issue of medical staff members attending medical staff meetings, a center may offer smaller subspecialty group meetings as an alternative, given that mandatory attendance several times a year may not be feasible.
• If all else fails, complain.
There is a team leader among Joint Commission surveyors, Kobs points out. "If you can’t settle it with the surveyor, go to the team leader," she suggests. "If the rambunctious one is the team leader, call us at Joint Commission."
Derby agrees that you should complain to the chairperson of the surveying group first and feel free to contact the accrediting organization directly if your concerns are not addressed. Another option is to defend your position when you receive the draft report from the accreditation home office, she suggests. You can respond with supporting documentation that supports your position.
Don’t avoid complaining because you’re concerned about a negative impact on the survey, Kobs emphasizes. "I’m here to tell you if we don’t hear about these surveyors, you get the same people back," she says. "It’s just like your place. Nobody says anything. Guess what? They’re still around, unfortunately."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content