Survey Process - QHR Quality Knowledge Base

Survey Readiness Overview:
Failing to Prepare is Preparing
to Fail
Donna Wood, RN, Practice Leader,
Clinical Operations
Chris Martorella, RN, Manager,
Clinical Operations
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Donna Wood, RN, BSN, MHA, MRM
Practice Leader, Clinical Operations
As leader of QHR’s Clinical Operations consulting practice, Donna Wood
oversees the development and execution of strategies for hospitals and
health systems that guide improvement initiatives in Clinical Operations,
Care Coordination, Patient Safety, Nursing Excellence, Performance
Improvement, and Regulatory Compliance.
With more than 30 years of healthcare experience, Donna effectively delivers quality
turnaround engagements and clinical transformation strategies to her clients. Prior to
joining QHR, she served in various leadership and hospital consulting roles, including:
clinical experience in Critical Care at Brigham & Women’s Hospital in Boston, from staff
nurse to VP of Critical Care Services and director in Deloitte Consulting’s Healthcare
Practice, with a focus on Performance Improvement.
A pioneer in Patient Safety, Donna has participated on several Institute for Healthcare
Improvement (IHI) teams, including serving as faculty for IHI courses. She was also an
early participant in the AHA Patient Safety Fellowship program.
Christopher Martorella, MSN, RN, NEA-BC, CENP
Manager, Clinical Operations
Christopher Martorella firmly believes that success in Patient Services
is founded on educated and mutually supportive nursing/medical
teams, and an ongoing commitment to identifying and resolving root
causes of patient dissatisfaction. To this end, much of his work focuses
on creating, implementing and evaluating programs that increase
competencies and drive quality measures; patient, physician and employee satisfaction; and
Chris brings more than 25 years of healthcare management experience to QHR and its
hospital clients. development. With a background in Critical Care Nursing, he has worked in
community hospital and academic medical centers and has served as staff nurse through
Vice President and Chief Nursing Officer.
Double boarded in nursing administration, Chris received his BSN from Florida State
University, an MSN from the University of Florida and is currently enrolled in the DNP
program at the University of Central Florida.
Greetings and
Get Familiar with the Survey Process
 Obtain a sample of a typical survey
agenda (available on your TJC
extranet site)
 Review the various activities
Patient care tracers, system tracers, document
review, daily briefings and surveyor planning
Familiarize yourself with the standards that will be
covered during the focused sessions and tracers as
well as the duration of each session
Use your resources (account execs, hospital
Staying Educated
 Subscribe to regulatory newsletters and bulletins
from the Joint Commission
The Source
EC News
 Share information with leaders and staff that are
 Participate in webinars and conferences aimed at
keeping facilities updated on standards
Making Regulatory Fun!
 Develop an annual Joint Commission fair
Encourage participation with prizes
Develop fun educational activities
o Create a “patient room of horrors” with multiple safety
issues and see how many issues staff can identify
o Crossword puzzles, word finds
and quizzes designed to impart
regulatory information
o Various booths with critical
standard manned by leadership
 Plan fun activities for Patient
Safety Week as well (another
venue to reinforce regulations)
Keep Policy Manuals Up To Date
 Update policies as regulatory
standards change
 Build policies that are multidisciplinary in nature
with teams from each area impacted
Example: Plan for the provision of care
 Keep rosters of staff attendance
 Assure that appropriate staff
are educated to the changes
in policy
Making It Easier on Survey Day
 Maintain Joint Commission readiness manuals
Key policies that the survey team will want to review
prior to starting tracer activities
Supportive documentation should also be contained
in these manuals
Remember this information will serve as the “first
impression” that the survey team develops about
your organization
Maintaining PI Teams
 Assure that Performance
Improvement teams are making
 Use the facility’s overall quality monitoring
committee to charter and monitor the progress of
teams aimed at improving regulatory compliance
 Consider dividing up chapters with different leaders
across the organization
Allow them to choose team members
Include front line staff
Keep Readiness Activities Robust
 Environment of Care rounds
Not just for Plant Ops and Housekeeping staff
This is a great multidisciplinary vehicle for assessing
multiple standards
o Life Safety
o Infection Control and
o Clinical standards
Include Infection Control, departmental leaders of
the areas being surveyed and include staff!
Patient Level Readiness
 Nursing, case management and the other clinical
disciplines should be meeting to review patients for
length of stay (LOS) and discharge planning
Consider adding utilization functions
Include pharmacy, dietary,
therapy, respiratory and
Frequency of meetings should
be based on average LOS
Document meeting results and
changes in care plan in the medical record
Hourly Rounding
 Nursing should be conducting
hourly rounding
Evaluate for 4 Ps
Associated with decreases in
o Falls and pressure ulcers (hospital
acquired conditions)
o Call lights for bathroom and pain (increases patient
Patient Rounding
 At the minimum by nursing leadership but senior
leadership involvement is preferred
Learn about issues that are of concern to your
customers (patients)
Monitor for regulatory issues
Opportunity for recognizing staff
Mock Tracer Activities
 Multidisciplinary
 Cover as many standards as possible
 Use checklists to follow up on
 All shifts
 All departments
 On a monthly basis
 Involve staff by asking key
 Remember: second generation tracers!
Don’t Forget Patient Safety!
 Patient safety goals should also be included in the
mock tracer activities
 “Hanging out” in the nursing
station is a great way to
evaluate hand-offs between
disciplines and communication
between caregivers
 What is your process for
critical lab value communication?
 Monitor medication passes for patient identification
and hand washing
More on Patient Safety
 Pay careful attention to non-surgical
settings (Radiology, Special Procedures,
med/surg) for compliance to:
Labeling of medications and syringes during
Completion and documentation of time out
 Must demonstrate similar standards of care
throughout the organization
 Go to the pharmacy and ask nursing to open the
medication cabinets. How are LASA and high risk
medications handled? Policy posted?
Conditions of Participation
 Don’t forget about monitoring to make sure you are
meeting the A-B-Cs of COPs
 Have you notified TJC of any new
 Have you added any off site
departments that should be included
in the survey process?
 Has there been a change in the CEO?
Annual Review
 Perform a review of all standards and how the
hospital meets or exceeds the
 Remember to include each
element of performance
Keep Information in Front of Staff
 Post survey readiness information
Posters in patient care areas
Bulletin boards
Streaming television
Electronic bulletin boards
Pay check stuffers
Laminated cards to
attach to ID badges
Cafeteria table tents
 Information about compliance rates and
performance improvement
 Wave of the future
 Foster a spirit of competition which may
positively impact compliance
 Assists staff in being able to speak to
quality and performance improvement
when questioned by surveyors
Consider Survey Complexity
 If complex, your facility may surveyed under
multiple accreditation programs and standards
 Examples: Acute Care, Homecare, Long Term
Care, Behavioral Health
 Prepare a document that cross references each set
of accreditation programs
Include the name of main contact and phone number
for each of the programs
Note: The regulatory leader cannot be everywhere
at once
Prepare Staff for Survey Complexity
 Staff and leaders should have access to the current
standards in their accreditation manuals
 Some support departments (i.e. Therapy Services
and Pharmacy) will participate across one or more
accreditation standards
Watching and Waiting…
 With rare exceptions, surveys will be unannounced
 Stay in touch with local colleagues to gain insight
into surveyor patterns (i.e. State surveyors)
 Designate a staff member to check the TJC website
 CONSTANT survey
readiness is key
Plan for the Arrival Process
 Develop a procedure that outlines what should be
done and by whom when surveyors arrive
 Staff at hospital entry points should be fully
competent on this process
Who do they contact first, second, third?
Provide office extensions and cell phone numbers
(with second and third back-ups)
Assure that surveyors are positively identified
(picture IDs)
Notification of the rest of the hospital
 Drill this process
Readiness Guide
Surveyor Arrival
Responsible Staff
Greet surveyor(s)
Verify identity
Look at picture ID to
ensure they are
from the accrediting
Ask them to wait
Validate authenticity of
survey (if you have this
(staff contact who has
this ability/authority)
Survey Activity Guide for Health Care Organizations
(2012). The Joint Commission. Accessed from the
web on March 15, 2012:
IT Workflow: Getting Nurses Back to Patients
April 24, 2012 2:00 p.m. CST
CSR webinar: Emergency Preparedness – Contingency Planning for Whatever Happens
May 16, 2012 11:00 a.m. CST
CSR webinar: New Joint Commission Standards (Clinical and Environment of Care)
July 18, 2012 11:00 a.m. CST
CSR webinar: Be Prepared to Meeting National Patient Safety Goals
September 19, 2012 11:00 a.m. CST
CSR webinar: Environment of Care – Issues You Should Plan to Avoid
November 14, 2012 11:00 a.m. CST
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 To receive credit for this program, please complete the
evaluation form as instructed in the email. You have ten
days after receipt to complete the online evaluation.
 If you are unable to complete the evaluation within the tenday deadline, your certificate will be delayed. Please
contact [email protected] for assistance.
For More Information
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Intended for internal guidance only, and not as
recommendations for specific situations. Readers should
consult a qualified attorney for specific legal guidance.

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