Should your hospital spring for a mock survey?
Pre-emptive strikes, though pricey, can lift accreditation status
If there’s one thing you don’t want during your survey by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, it’s to be sandbagged. A Joint Commission bombshell can be expensive and nerve-racking but not entirely unavoidable.
You only have to anticipate a bit by arranging for a consultant to put your facility through your paces a few months in advance of your real survey. Or you can orchestrate a do-it-yourself mock survey to prepare for the real thing. Some Joint Commission standards have changed in recent years; a mock survey could help make sure you are up to speed on those modifications.
Whether your facility should enlist a consulting company to perform a mock survey depends on several factors, among them your performance last go-round. Your ability to pay or your willingness and ability to do the work yourself enter into your decision too. Self-assessment takes time and staffing you simply may not have.
The presurvey assessment evaluates a facility’s readiness for its scheduled survey by the the Joint Commission. Elice Branch, RN, director of quality management at Martin Luther Hospital, a 200- bed facility in Anaheim, CA, says her facility’s "reassessment" they prefer that term to mock survey provided guidance they would not have been able to get on their own. "The consultants not only heightened our awareness of what needed to get done; they facilitated its getting done. They told us what to do and how to do it," she says.
When Martin Luther had its Joint Commission survey three years ago, it scored in the high 80s with a few type 1 recommendations. The decision to enlist the help of consultants this time was made by the facility’s quality council, which includes senior management and medical staff.
"These surveys are stressful for everyone," says Branch. Consultants can ease that stress. They bring an objective point of view to the process. Consultants go through several surveys a year and can, without breaching the confidentiality of another organization, provide the benefit of their experience.
"Resorting to the use of consultants does not in any way take away from the strength of a hospital’s leadership," Branch says. "What you’re doing is combining the experience of the consultants with the commitment of your organization’s leadership and staff. It can make a huge difference." (See related article on what to expect from your mock survey, p. 128.)
Martin Luther chose BDO Seidman, a national accounting and consulting firm, for their reassessment or mock survey. They had been working with the company’s Costa Mesa, CA, office for a few months. "BDO’s reassessment began with an overview of what we’d accomplished over the past few months," says Branch. She says the main thing the firm did for the hospital was to help them establish priorities. "For example, they helped us establish a structure to facilitate the flow of our performance improvement information," she says. "Information had been flowing, but not always in a consistent manner. We re-engineered our medical staff departments and committees." Pharmacy, therapeutics, infection control, and medical records had been stand-alone committees. After the reassessment, they became a function of the quality management committee so there would be consistent reporting of performance improvement information to those with a need to know.
Two consultants came to Martin Luther for two days. One visited the ancillary clinical areas and made assessments based on the Joint Commis sion’s standards such as patient rights, the continuum of care, how patients moved through the system, and patient and family education. "We used the daily format of the Joint Commission survey," says Branch, "including interviews and unit department visits."
"It’s no longer possible to do a SWAT team’ approach to survey preparation," says Opal Reinbold, senior associate with BDO Seidman in Costa Mesa, CA. "Early preparation is the key to high marks. An institution needs to get a feel for what the real survey will be like and how the Joint Commission’s requirements have changed since its last survey." Reinbold recommends that a facility begin 12 to 18 months before its scheduled survey. "Most good companies are booked six to eight weeks or more in advance."
You can bone up yourself . . . but then we all receive instructions on how to fill out our income tax returns from the Internal Revenue Service each year, don’t we? Yet CPAs still earn their keep.
Carole H. Patterson, deputy director of the department of standards at the Joint Commission, says the Joint Commission doesn’t require or recommend mock surveys, but doesn’t recommend against getting them either. (See related article on JCAHO subsidiary consulting firm, at right.) "We do suggest self-assessments against our standards," says Patterson, "and hospitals can set up their own. Since we started publishing the survey process guides, anyone can walk through the process." She says reading the Comprehensive Accreditation Manual for Hospitals: The Official Handbook is really all that’s necessary.
A new software program from the Joint Commission, called Score 100 (order code SC96W), is designed to help facilities assess their performance, track compliance efforts, and generate a preliminary report. It costs $1,295.
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