The state of continuous survey readiness: Is your facility ready for callers?
Survey assessment’s going to be almost like a QI tool’
Continuous survey readiness isn’t just the latest trendy term in accreditation circles — it’s become an imperative. Gearing up at the last minute for a survey by the Joint Commission on Accreditation of Healthcare Organizations was never a very good idea. With imminent changes coming in the survey process, it’s more important than ever for your facility to be in a state of constant compliance with Joint Commission standards.
Those changes likely will involve surveyors coming to your facility twice as often as before — every 18 months rather than every three years — as well as the use of so-called "data proxies," such as ORYX data, sentinel event data, and information from your survey application, to help surveyors get a better idea of where your organization stands before the survey even begins.
Currently, surveyors use a pre-survey assessment and questionnaire to help direct the survey process. Denise A. Dach, RHIA, BMA, director of quality management at McLaren Regional Medical Center in Flint, MI, says, "My guess is that they would take the data proxies and try to correlate them in some fashion to the outcomes of the entire Joint Commission survey. . . . This information is something that the surveyors would come armed with and use to focus in on various processes."
The Joint Commission may eventually require facilities to perform routine self-assessments in order to supply surveyors with more information before going into a survey, according to Joseph L. Cappiello, MA, BSN, a Joint Commission official who spoke on this topic recently at the National Association for Healthcare Quality conference in Dallas.
But whether the Joint Commission ends up requiring such assessments, it’s crucial for your facility to perform internal self-assessments that allow you to know where you stand and what you need to work on, says Kathryn Wharton Ross, MS, RN, CNAA, a health care consultant in Durango, CO.
"With the changes the Joint Commission has made just within the last year and some of the future changes it’s discussing, it really is going to put a strain on hospitals to always be survey-ready," she says. "We used to be able to do a survey assessment to see where we were and fix some of the problems right before a survey. [Now] survey assessment’s going to be almost like a QI tool, where it’s an ongoing process in hospitals to make sure that those systems we have in place are working for us so that we are compliant with the standards all the time."
Dach agrees that internal self-assessment tools are critical for success. "We’ve changed our focus here from just Joint Commission accreditation to complete accreditation readiness. We undergo a number of different surveys by various organizations, not just the Joint Commission, so we fold all of those pieces into our self-assessment."
One approach McLaren took was to establish teams based on each of the functional chapters in the Joint Commission’s standards manual, Dach says. "Each of the teams took a set of standards, went through them and, using the scoring guidelines, evaluated where they felt [our facility was] and where it needed to be. Then they identified various tasks and objectives. [Administrators] used that for the self-assessment tool, to identify where we needed to work, and then set up various tasks to ensure that polices and procedures were updated, re-educate staff, and change processes, to make sure that we were meeting the intent of the standards and achieving significant compliance."
McLaren also established regular measurements for several high-profile standards and provided feedback to various departments and units. One example is McLaren’s environment-of-care surveys. "We have a self-assessment tool covering all of the different environment-of-care areas and key questions for each of those areas," Dach says. "The tool is sent to a department director a week or two ahead of their designated rounding date. Once a month, we conduct our surveys and go around to each department on a schedule. Members of our environment-of-care committee will randomly ask questions of staff while doing their walk-around survey, and then they calculate scores. So it’s a measurement tool that helps us understand on a department level how well our staff understand."
It can also serve as a teaching tool in department meetings, she notes. In addition, it allows the environment-of-care committee to identify common issues across the organization. "[The committee] sends out housewide briefings, which help educate or remind staff throughout the organization about a particular standard or a particular procedure or process that needs to be followed."
At McLaren, functional assessment teams usually include a number of staff, as well as a general department director or manager — someone from outside the area in question who can provide a different perspective.
The functional assessment teams report to the accreditation readiness team, which is charged with facilitating organizationwide compliance. "Members of the oversight team should have a significant leadership role [in the organization], as well as knowledge of Joint Commission standards and hospital processes," Dach says. "And certainly they should have some facilitation and process improvement skills because they end up being the liaisons and cheerleaders, if you will, for some of the functional teams."
How functional assessment teams report to the accreditation readiness team largely depends on the organization and what the specific issues are. "Typically, we start off with quarterly reporting. As you get a little closer to survey accreditation time, that may need to intensify, unless you’re in really good shape," Dach says. Meetings usually become more frequent in the last six months before a survey in order to work out last-minute details, such as putting together all the required documentation.
Mock surveys continue to be a significant part of survey preparation, but before your facility hires an expensive consulting firm to perform one, it’s important to know what the options are. For example, should you even hire an outside consultant, or would you be better off performing a mock survey internally or in partnership with another hospital?
"With cost constraints, it’s becoming more important for hospitals to evaluate where they put their resources," Dach says. McLaren typically uses consultants, but Dach says other facilities might choose not to. "I believe hospitals will find themselves trying to develop those kinds of competencies within their own staff and doing more internal mock surveys or sharing with other organizations," she says. "It really depends on how much time, energy, and money you want to use in the process."
Mock surveys cost thousands
She notes that, depending on the consultant, costs can run from $10,000 for a two-day mock survey, to $30,000 to $40,000, depending on the size of the organization and what it wants the consultants to do.
"There are various components that increase the expense," she says. For example, how many consultants do you want to come? Do you want a physician, an administrative surveyor, and a nurse surveyor, or do you want just one person to examine key components? "That’s how you decide what your need is: How much do you have in resources to spend on it? What are you trying to get out of it? How much external information do you think you need?"
Dach says McLaren plans to perform internal self-assessments annually and do shared surveys with sister hospitals perhaps every other year. "We probably will also have an external review at about the 18-month mark. But it will probably be a single independent person who will look at key policies, procedures, and processes so that we can be sure that we’re doing what we need to do."
Dach points out that McLaren’s plans might change if and when the Joint Commission begins sending surveyors out midcycle. "At that point, we’ll probably need to reevaluate whether . . . there’s any benefit to continuing with a consultant, or if we should move that up earlier in the cycle period," she says.
However you choose to go about measuring your survey readiness, it’s important to make sure that what you have on paper matches what practitioners at your facility are actually doing, Ross stresses. "I find that people get so ingrained in trying to prepare for a survey that they think there are these magic right answers," she says. "Often, for example, I see a documented policy or procedure that deals with an ethics committee. And yet, when you go around and talk to people in the hospital, you find that in actual practice they have various systems to deal with those ethical dilemmas."
What’s important, Ross adds, is to build systems that assure you can maintain compliance with accreditation standards on an ongoing basis. "Survey readiness right now is going to have to be ongoing, and it has to make sense to clinicians. You’re always going to have to be prepared for a survey. If there is a magic answer, it’s that you have to figure out what systems you have in place, how they meet the standards, and let people talk about them."
Sources
Denise A. Dach, RHIA, MBA, Director of Quality Management, McLaren Regional Medical Center, Flint, MI. Telephone: (810) 342-2248.
Kathryn Wharton Ross, MS, RN, CNAA, Health Care Consultant, Durango, CO. Telephone: (970) 247-1130.
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