by Sandy Berreth RN, MS, CASC
So your organization has finally decided to “go for it” and attain accreditation. Or perhaps you’re already accredited, but it’s been three years since you went through a survey and you’ve added several staff members new to the process. How do you make a good impression right off the bat and set the tone for a smooth and successful survey?
I have been surveying for 5 years; I’m not an “old” pro, but I have practical knowledge since I’m an administrator in an AAAHC-accredited organization so I know what it’s like to be on your side of the table.
First Impressions count
The importance of first impressions cannot be understated. You know what they say: You never get a second chance to make a first impression. So when the accreditation surveyor arrives, you — as your organization’s representative — must present an attitude of calm preparedness. In fact, your first impression starts even earlier: from the moment you submitted your application documents.
The surveyor has already conducted a “mini” survey of your organization from the information your organization sent — in my case, to AAAHC, but probably this applies to any accrediting organization. It’s worth noting here that the application process is not a futile activity. Each piece of information sent as part of that process has been reviewed before a surveyor is at your door. Make sure the information is correct, clear, and complete. It’s part of your first impression.
Once on-site, it is the responsibility of the surveyor to distinguish quality vs. quantity. Each surveyor has their own style, but each observes and reviews with similar core knowledge. Records, documents, practice and procedures are the one-sided mirror into your organization. The AAAHC surveyor wants to find gems rather than flaws. Together, you can collaborate to achieve success.
The basics to a successful survey
The basics to having a successful survey are preparation, preparation, and preparation. I’ve heard that having an accreditation survey is like having an open book test. That book, of course, is the handbook of accreditation standards. So first and foremost, your organization must have the book, and your organization must read the book – preferably several times. In fact, you should have gone through the handbook with other members of your staff and conducted a self-evaluation to see how close you already are to complying with the standards. If you see problems, that’s the time to correct them – before the surveyor(s) arrive.
Be ready for every contingency
Each surveyor comes prepared with a “to-do” list to make the review a structured process. It’s like doing a surgical procedure; you generally have to start with a prepped and draped patient and an incision. With the survey, you have to be equally prepared; try to have your information at hand. If the surveyor asks a question that you don’t have the answer for, don’t panic. Tell him or her that you don’t know but you will get it. Then get it. An accreditation survey is an introduction to the world of collaboration and alliances with AAAHC. The surveyor is not there to “tell” you how to do things; the surveyor is there to see if you have recognized and covered a “solution/process” to achieve success as dictated by AAAHC Standards. How you work together is your opportunity to reflect your organization’s style, qualities and character.
Demonstrate your commitment to quality
The primary distinction of quality is patient care; and that care starts the minute the patient is received at the reception desk. Is immediate eye contact made, and is the staff respectful? When the patient is met by the patient care provider, is the he or she greeted with sincere professionalism?
I was once extremely impressed during a “tour” when the organization’s representative “foamed” her hands before entering the patient care area, and further explained that every patient care provider must “foam” before entering a patient care area. That’s distinctive quality.
Demonstrating a commitment to quality and “Best Practices” is about an attitude. The surveyor will – through observing and interviewing – determine if the staff understands the steps to giving “great” patient care. Having surveyors around shouldn’t change their practice; as a nurse, myself, you can tell!
Little things count
When there is evidence of practiced excellence, a surveyor is immediately aware of the care given to the patients. That excellence is demonstrated during the tour of the organization. This is the best time for you or your organization’s representative to convey a lasting impression of care given to patients and visitors. Organizations should keep in mind that surveyors are observant of the little things; for instance, we look at posted notes and signs; we notice locked and unlocked cupboards; we notice floors and tops of monitors — those are just the basics. Surveyors want to observe patient care looking unrehearsed and genuinely considerate; we observe when patient curtains are drawn for privacy and the bathrooms are cleaned. The smallest of tasks are noticed.
More than just policies and procedures
Generally, the staff knows how to deliver care, the policies and procedures are in place, and the processes are well-documented. But being an accredited organization goes further. Being accredited is also about care given – not just to patients but to visitors, to the physicians, to each other. If you can convey that, and make sure your organization is well-prepared, the surveyor will be able to conduct a smooth survey. The surveyor will be enormously appreciative. And you will have made a favorable impression.
About the Author
Sandy Berreth is the Administrator at Brainerd Lakes Surgery Center, Minnesota. She has been involved in health care for over 35 years, first practicing in the acute care setting as an OR nurse and coordinator. Over 15 years ago, she made the transition into ambulatory care, and since then has been instrumental in the development and successful management of two surgery centers. Along with her current administrative position, she also is a surveyor for AAAHC and has undergone the surveying training program just like everyone else. Which makes her a knowledgeable and understanding surveyor.