Staying on Top of Accreditation & Regulatory Surveys

September 1, 2017 Missi Halvorsen

What’s worse than having low quality performance in healthcare? Top performing organizations that don’t meet the proper requirements for accreditation and regulatory surveys.

Because accreditation surveys from the Centers for Medicare & Medicaid Services (CMS) are public, they can make or break a healthcare organization’s reputation. It’s essential for providers to be ready at any time, as surveyors often come unannounced. However, many challenges can get in the way, including compliance expectations, staff and evaluator competencies, and leadership responsibilities.

Compliance Expectations

The Joint Commission recently changed its approach to accreditation through the launch of Project REFRESH. This new evolution includes, but is not limited to, a series of interrelated projects that increase the severity and number of findings on survey reports. High-risk standards, which are frequently cited, may result in a follow up survey by the Joint Commission within 45 days. In fact, since the implementation of Project REFRESH, approximately 60 percent of all those surveyed are undergoing follow up surveys. More severe citations like “Immediate Threat to Life” or “Immediate Jeopardy” will also result in a follow up survey by CMS.

Staff & Evaluator Competencies

In addition to standard compliance issues, accrediting bodies and CMS are looking closely at staff competencies. Perhaps the surveyor witnesses an emergency department nurse admixing a medication? The surveyor will more than likely ask for the nurse’s competency file to see if he/she has documented medication admixing training.

In addition, surveyors might ask a central sterile technician to demonstrate or verbalize how to clean surgical instruments. Surveyors will also review human resource and departmental competency files to see if training is documented. This includes ensuring that the staff who oversee performance, are also competent to be an evaluator. For example, the central sterile technician’s supervisor must also have training and competencies in the cleaning of surgical instruments to properly evaluate their staff.

Leadership Responsibilities

Leaders must ensure a safe environment for staff to properly care for patients and families. In doing so, they should provide adequate resources, as well as continuously hold their staff accountable for compliance with regulations and standards. Having the right people, in the right position with the right kind of competency and accountability is essential. Failure to be an effective leader in these areas not only poses risks in survey compliance, but more importantly, risks in patient care and treatment.

Though standards and regulations are minimal requirements, leading providers strive to excel beyond the minimum to successfully care for and treat their community’s patients and families.

In my experience working with organizations to survive and thrive through accreditation survey season, providers that follow the below readiness checklist are seeing success.

  • Provide resources such as an accreditation coordinator to manage rapid changes in survey processes
  • Sanction a regulatory/accreditation leadership committee to review survey changes and provide assessment results in compliance issues
  • Assign staff accountability for standard/regulatory compliance (chapter leaders)
  • Monitor progress toward goals
  • Prepare for the survey in advance and test readiness with mock surveys
  • Engage the medical staff leadership to alert them of compliance issues
  • Update all required documents and have them available at a moment’s notice
  • Schedule time for internal patient tracer activities and mock surveys
  • Budget for annual mock surveys, performed by external consultants

The result of a successful survey isn’t just passing it. A successful survey means that your organization effectively demonstrated to surveyors that you provide the best care possible, to every patient, every time.

Have questions or want to hear more about how to train your staff and leaders to get aligned around accreditation? Post a question below or reach out here.

Author information

Missi Halvorsen

Missi Halvorsen

I’m the Director of Patient Safety and Quality for Premier, based in Northeast Florida, and enjoy traveling across the nation, to assist healthcare organizations with accreditation and regulatory compliance. When I’m not working, you’ll find me riding horses, kayaking or snow skiing.


The post Staying on Top of Accreditation & Regulatory Surveys appeared first on Action For Better Healthcare.

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