Swimming in the Abyss: Preparing for Unannounced Accreditation, CMS, or State Surveys

Regulatory oversight by CMS, OSHA, and other agencies continues to accelerate. Patients and families are more astute about reporting and using language to suggest immediate jeopardy. Organizations must be continuously ready for unannounced surveys using a multi-faceted approach to achieve high reliability. A culture of continuous readiness starts with leadership oversight. Engagement also includes intensive staff and leadership education and training. Best practices regarding internal audits, tracers, and coaching sessions will be shared. Prepping for actual surveys includes standard work job aids as well as redundancy roles. The ability to be flexible during an actual survey is critical for achieving successful outcomes.

Tool: Standard Work and Departmental Tracer tools

Problem: Our first objective is to ensure that staff are knowledgeable about key aspects of accreditation readiness and can apply these principles in their work. The second objective is to ensure that any Quality Improvement employee can prepare for an impending survey.

Tool Selection: We have developed these tools in order to be successful. The standard work tool allows us to ensure that any Quality Improvement staff member can prepare for a survey. The audit tool for staff is a standard work tool that can be modified to address the priorities of the organization.

Usage: The audit tool for staff is distributed to all applicable departments electronically. The audits are completed weekly over the course of a month to ensure that all staff are reached. The topics for the tool are changed monthly and rotated annually to ensure ongoing knowledge and data trends are monitored.

Results: We have used these audit tools for many years. The topics are changed based on priorities for the organization and in recognition of regulatory changes. Every month we see improvement in the data as it relates to staff knowledge and process compliance. Ongoing staff turnover prevents an ongoing challenge.

Director of Accreditation and Patient Safety at Northside Hospital
Director of Accreditation and Patient Safety – Northside Hospital

Speaker Type: 60 Minute Session On-Demand, Poster Presentations On-Demand

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