Building Your Professional Toolkit: The Hospital Quality Director Series
Preparing for Accreditation and Licensing Surveys, Part 3
Welcome to Beyond the Swiss Cheese’s “Hospital Quality Director Series”, aimed at equipping hospital quality directors across the U.S. with tools, resources, and information for professional success in a role that frequently comes without any training or support. In Part 3 we will dive into methods to prepare hospital staff for survey, take care of logistical items prior to surveyor arrival, and discuss during and after survey activities. Let’s get started!
Step 6: Train and Educate Staff
Comprehensive Education Strategy
General Awareness Training: Ensure all staff understand the importance of accreditation and their role in the process.
Role-Specific Training: Provide targeted education on standards relevant to specific roles and departments.
Survey Process Training: Prepare staff for what to expect during the survey, including potential surveyor questions and appropriate responses.
Engagement Methods
Regular Staff Meetings: Use department meetings to review standards and progress.
Town Halls: Hold organization-wide sessions to communicate importance and progress.
Unit-Based Champions: Identify and train unit-based accreditation champions to serve as resources.
Just-in-Time Resources: Create quick reference guides or job aids for high-priority standards.
Step 7: Conduct Mock Surveys
Plan and Execute Mock Surveys
Schedule: Conduct a comprehensive mock survey 4-6 months before the anticipated survey date.
Simulate Reality: Make the mock survey as realistic as possible, using the same methodology as your accrediting organization.
Use External Perspective: Consider bringing in external consultants who can provide an objective assessment.
Follow Actual Survey Protocols: Use the same activities and pathways that surveyors would use (e.g., tracers, document review, staff interviews).
Address Findings
After the mock survey:
Review findings with leadership and department teams
Update action plans based on results
Conduct focused follow-up reviews for high-risk areas
Consider conducting smaller, targeted mock surveys for problem areas
Step 8: Prepare for Survey Day
Logistical Preparation
Designate Survey Coordinators: Identify staff who will escort surveyors and coordinate activities.
Prepare Survey Command Center: Set up a dedicated space with computers, phones, and necessary resources.
Organize Documents: Have frequently requested documents readily available (licenses, certificates, committee minutes, etc.).
Communication Plan: Establish how you will communicate survey activities and needs throughout the organization.
Staff Preparation
Conduct Final Briefings: Hold sessions to remind staff of expectations.
Prepare Leadership: Ensure executives and department leaders are available and prepared.
Create "Show Me" Opportunities: Identify areas of excellence to highlight during the survey. This is one of the best pieces of advice for starting off a survey on the right path. Proudly share what your organizations has done to make care safe for patients and caregivers!
Step 9: Survey Day Management
Day-of-Survey Protocols
Opening Conference: Be prepared for the initial meeting with surveyors, having key staff and documents ready.
Daily Briefings: Hold morning and evening debriefs with your team to address any issues identified and prepare for the next day.
Document Control: Establish a process for tracking and fulfilling document requests.
Issue Resolution: Create a rapid response process for addressing any concerns raised during the survey.
Communication During Survey
Maintain open, honest communication with surveyors
Don't be defensive about identified issues
Demonstrate your commitment to improvement
Document surveyor comments and requests for follow-up
Step 10: Post-Survey Activities
Immediate Follow-Up
Address Immediate Concerns: Quickly correct any significant issues identified during the survey.
Document Review: Review preliminary findings with your team to ensure understanding.
Clarification Requests: If appropriate, prepare requests for clarification on findings you believe may be inaccurate.
Long-Term Improvement
Develop Corrective Action Plans: Create detailed plans to address all findings.
Share Results: Communicate survey outcomes to staff and leadership.
Integrate into Ongoing Quality Processes: Incorporate survey findings into your quality improvement program.
Sustain Compliance: Establish monitoring systems to ensure continued compliance between surveys.
Conclusion
Successful accreditation preparation is not just about passing a survey—it's about creating a culture of continuous quality improvement and patient safety. By following this step-by-step guide, hospital quality directors can not only prepare effectively for accreditation and licensing surveys but also strengthen their organization's overall quality management systems. It’s never as easy as it sounds on paper, and the more experience you get with surveys, the more comfortable you will become. Lean on colleagues by joining professional organizations, listservs, educational webinars, and asking questions. Everyone was a beginner at this at one point, and all of us in the quality and patient safety leadership field want to help!