Mock surveys help when JCAHO comes knocking
The day surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) stroll through your facility is always a tense one, with the staff dreading the moment when they’re put on the spot. But much of the anxiety can be reduced by using "mock surveys" in which you or a consultant play the role of a surveyor, giving the staff some experience that will ease their fears while also ferreting out the weaknesses in your accreditation program.
Mock surveys can be used as a way to test your program, and in fact, the more you use them, the more comfortable your staff will be with the idea of having a surveyor look over their shoulders and quiz them on various policies and procedures. Some experts on Joint Commission accreditation recommend incorporating a series of mock surveys, sometimes culminating with a final dress rehearsal just before the real survey. A mock survey can be enormously helpful, says Susan Mellott, PhD, RN, CPHQ, FNAHQ, a consultant in Houston.
The surveys can be done in different ways, but the idea is to pretend that your facility is actually being surveyed. How seriously you get into the role-playing will vary, but all mock surveys should serve two purposes, Mellott says.
"You’re using the survey process to gather information, to see what’s actually going on in the facility and how people respond to questions," she says. "But you’re also allowing the staff to do a dry run and see what the survey process is. They’ve probably heard a lot about how important this is for the organization, and they’re nervous about trying to do the right thing. People can get very anxious when they hear the surveyor is coming down the hall."
The mock survey itself is only one part of an overall plan to prepare for the survey, but experts say some form of the role-playing should always be included. You can do it all internally if you have the resources, but any accreditation consultant will be able to help with mock surveys. The surveys can be all-encompassing, in the manner of a real Joint Commission survey, or they can concentrate only on the areas where you know your program is weak.
"If you’ve never done this before, one way to start is to look at the standards and all the areas where you received Type 1s before, plus the new standards you’ll be surveyed on, and the list of the Joint Commission’s top 10 Type 1s," Mellott says. "Those things can tell you what areas to focus on, the major spots where your Type 1s are likely to come from."
Plan early and work to the last minute
Planning for a Joint Commission survey should start at least 18 months before the anticipated survey date, Mellott says. Some organizations will make survey planning a year-round function for the quality leaders, but smaller organizations might find that impractical. The overall survey planning can entail a wide range of activities, but mock surveys can be seen as the tests — periodic tests while you work on the project and then a final exam.
The survey planning team should schedule several mock surveys throughout the planning period, and one consultant in Portland, OR, says you should finish with a dress rehearsal at the last minute. Michelle Pelling, MBA, RN, recommends doing the first mock survey about a year before the real one, then about six months before, and a final one anywhere from 30 days to one week prior to the actual survey.
The first one is a comprehensive survey that spots problems of a general nature, and the second one is more of a fine-tuning opportunity. The final dress rehearsal occurs when it’s too late to really change much about the hospital’s policies and procedures, but it can highlight problems with how that information is related by the staff and how easily documentation is provided to the surveyor.
After each mock survey, Mellott and Pelling recommend holding a review session with the team leaders to review the findings. That meeting should include devising an action plan for the team to address any shortcomings revealed by the mock survey and a time line for when the tasks should be completed.
Both consultants emphasize that you can get carried away with the mock surveys and start to think they are a panacea for your accreditation program. Bad mistake, they say. "Don’t think the mock survey is the whole ball game," Mellott says. "It’s just the data-gathering part. There’s plenty more work to do."
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