The Importance of a Preparatory Survey

Kurt Patton, MS, RPh, President Emeritus at Patton Healthcare Consulting, recently shared his insights on the importance of a preparatory survey. Read his answers below.

1) Are there any topics or standards that CMS and AO surveyors have been focusing on recently? Standards or building areas that are getting a lot of citations?  

For many years now TJC has had a very intense focus on the life safety code/environment of care, and infection prevention issues. Relative to infection prevention, TJC has focused, in particular, on sterilization and high level disinfection issues. These are multistep, complex processes that often involve many different staff in precleaning, transportation and ultimately sterilization or high level disinfection. These complex processes rely on detailed instructions from device manufacturers, and/or clinical practice guidelines such as AAMI or AORN, selected by the organization. Each of the multiple staff involved in the multistep process have to perform their tasks in exact accordance with the aforementioned guidance and the opportunity for someone to be less than 100% perfect is significant. 

Knowledge deficits is one part of the problem, meaning the competency assessment process is deficient, but staff taking short cuts due to staffing constraints is a second risk point. 

Regarding life safety code and environment of care there is also a common problem with knowledge deficits, in particular staff evaluating the environment or writing policies not being familiar with the detailed NFPA references that are used to construct the TJC elements of performance. There are important details in the NFPA references that have to be designed into the process. A second environmental/life safety code problem is often insufficient resources and time to fix problems once they are identified. 

2) In the email you proposed calling them preparatory surveys or consultation surveys instead of mock surveys. Could you explain your reasoning for this? 

The term “mock survey” demeans the importance of the evaluation because it sounds like the organization is pretending something. A preparatory survey better describes what is taking place. It is a thorough CMS/accreditor type evaluation that will help the organization be better prepared for the actual survey when it occurs. The techniques used, the questions asked are all similar to what CMS or an accreditor’s surveyor might ask. Going through this preparatory survey allows staff to become familiar with questions they might be asked, and helps to uncover vulnerabilities that can be improved upon prior to your actual survey. Every organization has quality staff to help them prepare, but those quality staff may have been through a handful of surveys, whereas consultants have been through hundreds, often on behalf of an accreditor or governmental agency. The consultants can zero in on weaknesses that might be missed internally. 

3) In your opinion, how frequently should a healthcare organization run a preparatory survey? Annually, quarterly, or some other set time frame? 

The cost of a consultant-run preparatory survey can be significant, particularly for larger organizations. If budgets permit, doing a preparatory survey once a year is a good way to prepare. We have also used a different technique for some organizations that we call our continuous accreditation survey (CAS) , where we break up a full survey into component portions, life safety, infection prevention, medication management, medical staff credentialing and privileging, etc. and send one surveyor at a time to conduct those detailed reviews every few months throughout the accreditation cycle. This reduces the footprint and potential disruption that a full preparatory survey team might cause and also allows the organization to focus better on recommendations when supplied in smaller increments. Getting a full survey report with 50-100 recommendations can be overwhelming and slow down the corrective action phase. 

4) What materials do you need to do a preparatory survey? Training, documents, other supplies or materials? 

The Joint Commission publishes a survey activity guide that describes what documents to have ready, in the event they show up for an unannounced survey. This compilation of documents should be refreshed each time a policy is updated and be ready to roll in upon request. There should also be a room assigned for the surveyors to use as a work base and a process established to clear conference room schedules for leadership meetings with the consultant surveyors. There should also be identified escorts and/or scribes identified to help lead the accreditor’s surveyors to specific destinations within the organization. CMS surveyors often want less guidance, but may still need help to navigate to locations and or within the electronic medical record. The process of getting things ready and moving for the consultant surveyors should be no different than you already have in place for your accreditor or CMS. Should surveyors request a specific policy, you want to be able to quickly find that policy and deliver it to the appropriate surveyor. 

5) What groups or people need to be involved in running the preparatory survey? How big does your prep survey team have to be? 

Again, the size of the organization plays a role here, but at least one staff person should staff the home base, and at least one staff person should be prepared to accompany each surveyor. I have also seen some health systems sending their system leader, or service line leader to accompany a surveyor because the system leader is often in the best position to rapidly redesign, educate or modify an existing process should  a defect be noted. 

6) Since CMS and AO surveys are meant to be surprises, should you try to make your preparatory survey a surprise as much as possible? Is there a benefit to this? 

Some organizations like to use an unannounced preparatory survey because it is similar to what they will experience with either CMS or an accreditor. We generally recommend not using an unannounced preparatory survey because we want staff and managers to know we are going to be there and to use their time with us to ask questions, to show us things they are concerned about and problem solve. I have found some of the best questions and issues come forward from staff we have visited with many times and who have developed a sense of comfort. If staff resolve concerns with us, we can help alleviate that concern or modify a process to alleviate that concern Consultants don’t want to scare the staff, they want to interact with the staff and help them to be better prepared for the actual accreditation or CMS survey. 

8) What are some common mistakes, assumptions, or misconceptions people have when doing a preparatory survey? Errors that could lead to trouble when the real surveyors come?

The most common mistake is when staff are coached to “just answer the questions asked, don’t volunteer anything”. This approach may be best for a police interrogation, but not a consultative evaluation where you want to uncover the problems so they can be corrected before the accreditor or CMS arrives. 

9) With your background in accreditation and surveying, is there any advice you’d give on running a successful preparatory survey? Something you’ve seen that works really well or showed the organization being surveyed had put in the effort? 

I mentioned earlier the potential of involving health system leaders, service line leaders, or subject matter experts in the survey and I have seen some of the best problem resolution when they are involved. This contrasts with  some health systems, where even consultative surveys are confidential among and between hospitals. We can identify an issue at hospital A and talk with them on how to resolve it, but then we see the same problem at hospital B, C and D because they are not aware of the vulnerability. When the health system leads are involved, those problems are resolved before you go to hospitals B, C and D. 

10) How closely do you want your prep survey to mirror a real one? Or in other words, do you recommend making your preparatory survey be as in-depth and take as long  as a real one? Why or why not? 

We would recommend mirroring the duration similar to, if not identical to the anticipated accreditors survey compliment and duration. In some instances, this may be cost prohibitive, but the consultant firm can work with the healthcare organization to prioritize the highest risk areas. For example, you would never want to skip the operating rooms, intensive care settings, psychiatry or central sterile supply, however skipping several remote ambulatory care clinics is comparatively low risk of significant findings, providing they are not performing any invasive procedures. 

11) How would you recommend deciding what areas to look at or prioritize during a preparatory survey? After all, the point of surveys is that you don’t know what or where the problems are. 

Experienced consultants know where the highest risks are because of the frequency with which they write significant findings in those high risk settings. Their observations of noncompliance are usually consistent with the accreditors publications of the most frequently scored standards. Issues such as sterilization processes, high level disinfection, medication titrations in an ICU setting, suicide prevention in behavioral health and the ever problematic life safety code issues are mostly all concentrated in the inpatient setting and within a limited number of unit types. Organization quality staff also know where they have weaknesses identified through internal monitoring. Discussing potential sites or units to visit with quality leaders can help to identify a good sample of units with risk, while not visiting every location and unit. That’s not to say you won’t find some noncompliance in a general medical-surgical unit or an ambulatory care clinic, but the chance of finding multiple high risk findings in those more general areas is less. 

12) When your preparatory survey uncovers an issue, what needs to happen next? 

The organization will want to fix those items and consultants usually have references, advice on how to fix it, and will sometimes even have anonymous policies and procedures or audit suggestions to help the organization resolve the problem. Fortunately, consultants are not constrained by any deeming arrangements or concerns about teaching/consulting that an accreditor has. 

13) What makes a preparatory survey successful or unsuccessful  in your opinion? 

Open and honest communication from leadership and staff make the preparatory survey most effective. Leadership has already conducted monitoring, tracked incidents and knows where some vulnerabilities may reside. Leaders saying, we may need your help in correcting a problem we are having in our (unit), or (department) helps to quickly bring issues to the surface for resolution. Similarly, area managers and staff who are comfortable with the consultant can bring very important questions or issues to the forefront for the consultant to weigh in on problem resolution or help guide them that what is seen is not really going to be an issue. 

14) When real surveyors from CMS or AOs come, can they ask to see the results of your preparatory survey? 

Consultant reports are part of an organization’s performance improvement work and performance improvement data is generally not used by either accreditors or CMS to write findings. Perhaps more importantly accreditors and CMS want to identify their own findings from direct observations or medical record reviews so they have little use for consultant reports. 

15) In your own words, can you explain why preparatory surveys matter? What do you say to staff members who might be busy and not see the value in this activity?  

The importance or value of a preparatory survey is that the consultants can identify issues of importance and the organization can resolve those problems before the accreditor or CMS identify that same issue. Consultants do need to be aware of genuine workload issues that may be creating time pressures for staff. For example, when visiting the emergency room, go early in the morning before patient visits start to climb so staff can spend time with you. When arriving in a unit you need to pick up signals of staff workload pressure, such as when staff say “we just got 3 new admissions” or “3 patients returned from the OR. A consultant can come back at a different time and staff will appreciate that consideration and when you do return the visit will be more productive. However, sometimes a consultant may experience a staff member who is not on board with the survey event because they perceive their area as near perfect. Here the consultant just has to proceed and when issues are identified, discuss what happens on an accreditor or CMS survey that could have adverse implications for the organization. Sometimes these area staff come around to recognizing the value and sometimes they don’t. 

16) Anything else you’d like to add? Questions I could have asked? 

We like to help coach staff and organization leaders on how to work with surveyors and how to respond to potential survey findings, and how to read the signals they surveyors may be hinting at. For example, the morning briefing is particularly informative and if significant issues or the same issue is coming up in multiple locations the organization will want to determine why that is occurring and what did we do to develop that process such as policy development, training and monitoring. Surveyors may be thinking this is a prevalent, high risk issue that could lead to an adverse decision or CMS immediate jeopardy situation. There may be information that can be shared with the surveyors in policy, training materials, references, etc. that can dissuade them from escalating this from just a single finding. 

Another coaching tip is for the escorts and hospital leaders that accompany the surveyors to not plead guilty to every issue identified. We see a uniform approach in TJC survey findings that says something to the effect: “this was discussed with the unit director/medical director/nursing director or administrator who confirmed the inadequacy of the organization’s process”. When organization leaders have plead guilty on the spot, it makes any attempt at clarification almost impossible. A better approach when a surveyor identifies a potential finding is to say: “I’m surprised to hear this, I had been informed that we were on top of this issue through our internal monitoring, but thank you, we will certainly look into this”.