Be prepared: Healthcare facility readiness for public surveys
In May 2016, the Centers for Medicare & Medicaid Services (CMS) announced it would be making all survey results from accrediting organizations, such as The Joint Commission (TJC), public. This unprecedented decision redefined the healthcare landscape – empowering healthcare consumers to make a more informed decision on where to receive care.
As a result, healthcare providers were highly motivated to improve the quality of care and services they provide at their facilities.
The on-site survey process focuses on patient safety and quality by evaluating the actual care processes and technology used in a facility with real-time data analytics. Surveys can be planned or unannounced, meaning healthcare facilities must always be prepared. According to TJC, after the survey, an organization’s report of findings is posted to its Joint Commission Connect® extranet, with the organization’s official accreditation decision publicly posted to TJC’s Quality Check® website within one business day of the published survey.
Whether a public survey makes your facilities team think “Oh no, this is going to make our hospital look horrible!” or “No big deal, our hospital is in great shape and has nothing to hide,” surveys can be daunting for all involved. After all, surveys that are available to the public bring yet another layer of accountability to healthcare organizations.
No matter when your next survey occurs, here’s how YOU (and your team) can prepare:
Centralize & standardize your facilities’ documentation.
When surveyors see reports that are disparate and uncoordinated, they will interpret that as a sign of dysfunction. Not only do disparate reports and processes make it difficult for you to get a clear picture of your physical environment, they also make it hard to pinpoint what’s falling through the cracks.
To counter those problems, direct your facilities team to use simple matrixes to track progress in alignment with regulatory requirements. Ensure the team reviews vendor reports who inspect, maintain and test on a consistent and timely manner. Often, vendor reports are missing signatures, codes or vital information that could jeopardize a regulatory survey. Other times vendor reports can identify a life safety issue that goes unread and ends up falling behind the remediation timeline. Our VP, Program Development, Support and FM Compliance, Larry Lacombe, has also previously covered the ways healthcare facilities can maintain compliance with third-party vendors in BOSS Magazine.
Watch for industry survey trends.
Identifying industry survey trends – common deficiencies and the focus areas for TJC – is a relatively simple way to avoid the same high-potential hits when a surveyor steps into your facility. It’s wise to leverage that intel to preemptively address common hits before surveyors show up.
Additionally, public surveys make it easier to examine other healthcare facilities in your area, allowing you to pinpoint any trends or areas of focus from the surveyors. But keep in mind, your information will also be examined by your hospital peers, making it even more crucial to ensure your facility is survey-ready. While looking at industry trends and public data can provide a good indication of your survey success, it should not be used as a replacement for a thorough compliance review within your facility prior to any survey.
Know the health of your physical environment.
“How healthy is my facility’s physical environment?” you may wonder. Conducting a complete compliance review on a regular basis can help healthcare providers answer this question. This can enlighten you on potential problem areas that should be addressed prior to a surveyor walking through your doors. The exercise of evaluating the current state of compliance will allow you to gain a better understanding of what it will take on an ongoing basis to always be survey-ready.
Spread – don’t defer maintenance.
Historically, hospitals have nurtured a habit of waiting to address facilities’ deficiencies until 12–18 months before a survey. At that point, they’d throw money at problems in a mad dash against time to get everything ready for surveyors. Even if surveyors identified an issue, facilities still had a generous grace period to fix it.
Now, with the shrunken remediation timeline, you’d have to throw a lot more money to fix problems within the required 60-day grace period. Facilities have roughly three years between surveys. Use them! Spread out investments and improvement plans over that time and avoid paying far more in violations and rush service fees down the road.
Stage mock-surveys at your facility.
Conducting random mock-surveys will ensure that your organization will be prepared for a survey by an accreditation organization, even if it’s unannounced. Through this process, facilities can identify items a surveyor might find, giving your team enough time to correct them before the surveyor even walks through the door. The mock-survey will allow for a smoother survey process in the future, and it will minimize, if not eliminate, any surprises that may have shown up otherwise.
A compliant healthcare facility translates into a safe healing environment for all patients, staff and visitors. With patient safety already top-of-mind amongst healthcare leaders, following these steps will ensure your organization is survey-ready, even if you’re unsure of when your next survey will be.
Interested in learning more about setting your facility up for 24/7 Joint Commission readiness? Download our white paper on ensuring daily compliance or contact us to see how Medxcel can help your healthcare facility today.
Medxcel Facilities Management enables healthcare providers to optimize their facility assets, systems and in-house capabilities, while reducing expenses. Built by and for healthcare, Medxcel Facilities Management’s solutions are being implemented in Ascension Health facilities nationwide.