First Surveyor Impressions: Key Indicators You'll Likely Nail (Or Fail) Your Facility Regulatory Survey
Within minutes of walking into your facility and talking with your staff, experienced surveyors have a very good idea whether you’ll nail or fail your facility regulatory survey. Document disorganization is a window into a program’s dysfunction, it’s hard to hide and seasoned surveyors invariably grow attuned to signs of a problematic facilities program.
Early red flags
One dead giveaway of document disorganization is simply the inability to quickly find and show records when questioned and not even having an understanding of the list of documents to be reviewed. “If you are disorganized, you can spend a lot of time in the document review phase because you have no idea where you put things, you’re spending a lot of time searching for the correct documents or reports, and a surveyor will just sit back and watch the train wreck,” shared Larry Lacombe, Vice President of Programs Management and Facilities Compliance at Medxcel Facilities Management.
“By contrast,” he added, “when surveyors walk into an office that’s organized and are handed documents that are also very well organized, they grow confident in the facility.”
Hence the importance of well-organized, standardized facilities records. Sounds simple enough—common sense, even—but impossible to achieve without efficient processes and consistent diligence in the months and years between surveys.
How surveyors view documentation organization (or lack thereof)
Is the information thorough? Is it easy to find? Is leadership confident in pinpointing the information when asked? If yes, you’ll do well in building rapport and earning the surveyor’s trust. Fail to answer those basic questions quickly, however, and you’ve just opened the door to a dozen more questions and issues they’ll audit.
To be clear, imagine getting audited for your taxes. The auditor asks to see a receipt. If you have that receipt, the conversation ends there. If you don’t, they start asking about six other receipts and further details surrounding the event.
Instead, you can increase your chances of a thumbs-up by presenting documentation in a way that provides confidence, structure, and makes the surveyor’s job easier.
Increase ease and clarity by eliminating blind spots and disparate data
With that in mind, Medxcel Facilities Management has developed a program called FMOS (
or Facilities Management Operating System, as a way to standardize and centralize documentation so facilities are always survey-ready.
Too often, facilities are managed by separate departments or entities, resulting in disparate reports that can be worlds apart and fraught with blind spots. No one wants to get to a survey and have one department or vendor looking at each other, saying, “I thought you had this covered.”
Rather, we consolidate all information in one place, and ensure the whole team understands the documentation and processes that go into it—so much so that they can answer basic questions pertaining to someone else’s responsibilities.
Increasing your chances of a positive outcome, giving you that peace of mind
Feedback from surveyors indicate growing comfort and familiarity with our consolidated reports: “Oh, yes, I’ve been in a Medxcel FM facility before. I’m familiar with your binders. Go ahead and sit back while I look through it.” It’s worth noting that surveyors’ jobs have evolved, demanding they audit more items in less time and they want to spend more time in the physical environment. Helping them check off items quickly works to your benefit.
All things considered, documentation that’s thorough and easy to navigate shows you’re proficient in managing your facilities programs. It also shows you’ve been consistent in taking the appropriate steps over time, as opposed to throwing things together in the weeks or months preceding the survey.
Ultimately, it’s also vital for ensuring a safe environment which would then result in a successful survey and giving you that peace of mind knowing your CMS accreditation is secure. More importantly, you can rest easier knowing patients are safe, and no facilities or regulatory mishap will hinder their care.
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.