Building Your Professional Toolkit: The Hospital Quality Director Series

Preparing for Accreditation and Licensing Surveys, Part 2

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. Let’s dive into Part 2 of preparing for accreditation and licensing surveys.

Step 3: Conduct a Comprehensive Gap Analysis

Systematic Assessment

1. Create Assessment Tools: Develop checklists based on current standards to systematically evaluate compliance.

2. Department-by-Department Review: Have each department leader conduct a thorough assessment of their area's compliance with relevant standards.

3. Document Review: Examine policies, procedures, and protocols to ensure they align with current requirements.

4. Direct Observation: Observe actual care practices to determine if they match documented procedures.

5. Staff Interviews: Talk to staff at all levels to assess their understanding of requirements and procedures.

Prioritize Findings

After completing your gap analysis, the survey readiness team should:

• Categorize findings by severity (high, medium, low risk)

• Identify systemic issues versus isolated occurrences

• Prioritize gaps that impact patient safety or require significant time to address

Step 4: Develop and Implement Action Plans

Create Structured Action Plans

For each identified gap:

1. Define the Issue: Clearly describe the compliance gap.

2. Establish Goals: Set specific, measurable objectives to achieve compliance.

3. Outline Actions: Detail step-by-step tasks needed to close the gap.

4. Assign Responsibility: Designate individuals accountable for each action.

5. Set Deadlines: Create realistic timeframes for completion.

6. Identify Resources: Determine what resources (budget, staff, technology) are needed.

Implementation Strategies

• Policy Development/Revision: Update policies and procedures to align with current standards.

• Staff Education: Develop and deliver targeted education on new or revised procedures.

• System Improvements: Implement technology or process changes to support compliance.

• Monitoring Mechanisms: Establish ongoing monitoring to ensure sustained compliance.

Step 5: Develop Robust Documentation Systems

Organize Documentation

1. Centralize Key Documents: Create a central repository for policies, procedures, licenses, certificates, and other essential documentation.

2. Ensure Accessibility: Make sure documentation is readily accessible during surveys, whether in electronic or paper format.

3. Update Regularly: Establish a schedule for regular review and updating of all policies and procedures.

Focus on Critical Documentation Areas

Pay special attention to documentation related to:

• Patient assessments and reassessments

• Care planning

• Medication administration

• Informed consent

• Staff competencies and credentials

• Quality improvement activities

• Safety event reporting and follow-up

Now that your team has prepared the information needed for survey readiness, it is time to get the entire organization involved in the continued preparation. Come back for Part 3 where we will dive into methods to train and educate staff members about the survey process, practice with mock surveys, and take care of logistical details that will need to be in place when surveyors arrive.