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Accreditation Surveys: Working Together To Achieve Success

By Don Sadler

Accreditation surveys can be a stressful time for health care organizations. To help reduce the stress level at your organization, we asked several experts for their top tips when it comes to preparing for and passing accreditation surveys.

Go By the Book

The experts were unanimous in stressing the importance of studying your accreditation handbook.

“Know all the core chapters and any adjunct chapters that are relevant to your facility,” says Jan Davidson, MSN, RN, CNOR, CASC, the Director of the Ambulatory Surgery Division of the Association of periOperative Registered Nurses (AORN).

Davidson also encourages health care organizations to drill their staff on standards so they will be prepared if they are asked questions by the surveyor.

“If a standard says you need a policy, have the policy ready to show the surveyor,” she says.

“Stay current with the most recent accreditation standards handbook,” adds Raymond E. Grundman, MSN, MPA, FNP-BC, CASC, External Relations and Business Development, the Accreditation Association for Ambulatory Health Care (AAAHC).

Michael Kulczycki, the executive director for the Ambulatory Care Accreditation Program at The Joint Commission, says their surveyors are amazed to occasionally find initial applicant organizations with the standards manual still shrink-wrapped.

“To be successful you need to read and become familiar with the standards manual,” he says.

The electronic edition of the manual is provided complimentary as part of accreditation, says Kulczycki, while hard copies are available for purchase.

Grundman also emphasizes staying up to date on state regulations and licensing requirements, as well as CMS Conditions for Coverage.

“Also conduct a full mock survey annually,” he adds. “And perform quarterly self-assessment audits of credential files, personnel files and medical record files. Keep credentialing and peer review files current with date-sensitive documents.”

Kulczycki stresses the importance of teamwork when preparing for an accreditation survey.

“It takes an entire office team to successfully become accredited,” he says. “Accreditation success begins with leadership support, guidance and direction.”

“Don’t leave the entire implementation of the accreditation standards up to the assigned accreditation coordinator,” Kulczycki adds. “This work can be parsed out to team members and aligned with them according to their areas of expertise, from infection control to environment of care.”Davidson agrees.

“Preparation for your accreditation survey isn’t something you can do alone,” she says. “Ideally, you should start preparing three months before the survey. Preparation should be something you work on every day and keep updating as needed.”

Get Your Logbooks In Order

Doug Rabkin, the president of AccreditSoft! Inc., a Pasadena, California company that provides software that helps health care organizations pass accreditation surveys, stresses the importance of getting all of your daily logbooks in order.

“This means collecting three years worth of paper forms,” says Rabkin. “Surveyors look for compliance with these forms. More specifically, are the nurses filling them out on the days that surgeries are scheduled?”

According to Rabkin, logbook fraud is currently a hot-button issue with the accrediting organizations.

“It’s easy to tell if multiple days are filled out in one sitting, and surveyors are on the lookout for this,” he says.

For example, many nurses will use Friday afternoon to backfill the week’s logbooks, Rabkin says. Accreditsoft!’s software automates logbooks to prevent such backfilling and also provides a report of improper logbook entries.

Rabkin tells of a plastic surgeon who discovered that his techs had not filled out logs for three years.

“He hired a tech who tried to create three years of logs before his accreditation survey,” says Rabkin. “But the surveyor caught him and he lost his accreditation.”

Both Davidson and Grundman concur with Rabkin’s emphasis on maintaining accurate logbooks. Davidson points specifically to books logging preventive maintenance of your equipment, patient and staff radiation exposure, employee dosimetry badge readings, and sterilization.

“Keep meticulous records and logbooks on Inspection, Testing and Maintenance (ITM) on all equipment and devices following the manufacturer’s Directions For Use (DFU),” Grundman adds.

Grundman also recommends documenting ongoing surveillance of infection prevention/control practices including hand hygiene, instrument/equipment processing and staff education and training.

“Also focus on safe medication practices,” he says.

Safe medication practices include:

  • Medication reconciliation at each visit,
  • Lookalike and soundalike medications,
  • CDC guidelines for safe injection practices,
  • Proper use of multi-dose vials,
  • Proper disposal of unused/outdated meds, and
  • Prevention of drug diversion.

“And don’t neglect to participate in continuing education programs from your accreditation organization and state and national professional associations,” Grundman adds. “Network with your peers and ask them for help, too.”

Involve Your Key Stakeholders

Davidson recommends starting the survey process with a power point presentation of your facility.

“Make sure your key stakeholders are present at the introductory meeting,” she says. This includes your medical director, administrator, nursing director and the person who oversees your infection prevention program.

This meeting is a great opportunity to showcase what you do best every day, says Davidson.

“Be proud of your facility, your work, your staff and your patient outcomes,” she says.

“And remember: Nothing frustrates a surveyor more than having to ask for everything,” Davidson adds. “Provide the surveyor with a private work area and have all the material available that will be needed to review. Be available if the surveyor needs anything, but otherwise give the surveyor the time and space needed to do the work.”

“Remember that surveyors are evaluating processes, not people,” says Kulczycki. “So it’s OK for a staff member to not know the answer to a surveyor query as long as he or she knows which colleague does. Therefore, make sure you know who the experts are within your organization.”

In preparation for your survey, Davidson also recommends reviewing your past survey report with the key stakeholders in your facility – such as the medical director, chairperson of the quality improvement committee, and persons who oversee infection prevention.

“Identify any gaps since the last survey,” Davidson says. “Are there any new standards or changes to existing standards since your last survey? If so, how do they impact your facility?”

The Magnet Recognition Program

While much attention is paid to accreditation surveys performed by The Joint Commission and the AAAHC, the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program is also important to many health care organizations.

“The Magnet Recognition Program is a nursing designation of excellence for achievement of exemplary outcomes while working with inter-professional teams,” says Julia Aucoin, DNS, RN-BC, CNE, who has worked as an American Nurses Association nursing knowledge center consultant in Silver Spring, Maryland.

“Attaining and sustaining a Magnet environment requires constant attention to opportunities for improvement while engaging colleagues in generating new ideas and applying evidence to nursing practice,” says Aucoin.

She recommends creating a four-year calendar to alert everyone to the milestones and flow of information necessary for ongoing documentation to the Magnet Program office.

“Introducing the Magnet concepts to new staff and reminding existing staff that stakes are higher with every designation will help keep the teams engaged in the process,” says Aucoin.

A Learning Opportunity

Davidson also stresses the importance of using the survey accreditation process as an opportunity to learn.

“If the surveyor is critical of something at your facility, ask him or her to help you understand how to do things differently,” Davidson says.

“Surveyors want you to succeed and they love to teach,” she adds. “Contrary to what you may believe, they are not there to find fault or be critical of your facility. They are there to make sure you have a facility and staff that will keep your patients safe and well cared for.”



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