Accreditors don't call before they visit: Best practices for regulatory readiness at all times

Regulatory readiness is a top priority for healthcare leaders, but it truly is a "team sport." Employees must understand the processes and workflows in their areas that promote patient safety and they must feel comfortable discussing them.

Becker's Hospital Review recently spoke with Betty Casey, MSN, RN, Senior Vice President of Operations at Surgical Solutions, about how healthcare systems can better prepare for visits from accreditation agencies and other regulatory organizations. 

Question: Can you talk about the surgical accreditation landscape — what are the different accreditation bodies and how do their surveys vary?

Betty Casey: “The survey process varies based on whether you are a freestanding facility or whether you are tied to a hospital. It also depends on who your licensures are affiliated with; that is, whether you are under one hospital licensure or you have your own licensure. 

Typical accreditation bodies in surgical services and hospitals are The Joint Commission (TJC), DNV and the Accreditation Association for Ambulatory Health Care (AAAHC). The state health department may also come in wearing the hat of CMS.

Most of the time when I think about regulatory readiness, I consider any visitor who could come in for any number of reasons. It could be for an annual or tri-annual certification or it could be in response to a complaint. Since most visits are unplanned, organizations must be regulatory ready at every given moment.”

Q: How can facilities best prepare for these surveys? What tools, exercises or other resources are most valuable?

BC.: “A good first step is to understand the different bodies that regulate your organization. Determine what your state-specific health department requirements are for running a healthcare organization. Every state is different. 

Second, take the time to visit The Joint Commission and CMS websites and sign up for their alerts. These will give you insight into their current priorities. It's also helpful to look at the FAQs on these websites — see what people are asking and how TJC and CMS are responding. 

When you are rounding with employees, ask them questions that a surveyor would ask. Cheat sheets and ’badge buddies‘ can be useful reference tools for things like codes and patient safety best practices. It can also be fun to engage staff members with a ’survey question of the day‘ on the team bulletin board. When an employee answers the question correctly, give them a Starbucks gift card.” 

Q: Can you walk readers through the execution of a mock survey? How can leaders ensure that these exercises are effective?

BC: “Mock surveys are a great tool and they can be done by anyone, anywhere. You don't have to pay thousands of dollars to a consultant to come in. You can start by creating a checklist of the processes in your area that an accreditor will observe. One idea is to use your staff meetings to engage employees in developing checklists and mock survey questions.

It can also be helpful to work with a peer in another department — share your checklists and then conduct a mock survey in their area. Nothing is better than when you have an operating room and emergency room sharing information and observing different workflows. That leads to process improvements and it helps teams be more prepared for regulatory visits.

During a survey, regulatory agencies ask the employees questions, not the leaders. You don't want your team members to feel intimidated when that happens. Mock surveys help employees understand that regulatory visits are part of the everyday work environment and they will feel more comfortable showcasing the great work they are doing. 

Mock surveys are a win-win for everyone. They cost nothing, but they build relationships and help your teams understand the importance of working together.” 

Q: How can facility leaders best respond to any citations or concerns identified during a survey?

BC: “Take a deep breath, step back and listen to the concerns before responding. We all have a desire to ’fix‘ things but reacting quickly isn't the best solution. Sometimes, you need to collect additional data and that can take time. Remind employees that if they don't know the answer to a question, tell the surveyor that they know where to get the information. 

Above all, keep in mind that regulatory visits are conducted for a good reason. We want healthcare organizations to protect and provide the very best care to patients. If the person in the hospital bed were your family member, you wouldn't want anything less.” 

Q: How can Surgical Solutions help healthcare organizations maintain regulatory readiness?

BC: “Being regulatory-ready is a mindset that must be in place every day, especially in healthcare. Areas where procedures are taking place can add additional complexity, especially given recent regulatory changes. Organizations must be vigilant about procedural areas like operating rooms, Cath labs, endoscopy units, sterile processing and more.

The pressure to be regulatory-ready around the clock, every single day, adds stress to an already taxing work environment. Labor shortages and mobile staffing in many procedural areas have also heightened readiness concerns. Many hospitals and health systems now feel a greater urgency to partner with a company like Surgical Solutions, which can provide the expertise needed to prepare for a regulatory visit or implement an integrated solution to ensure that standards are ’lived‘ every day. 

Our company provides the knowledge and helps ensure that regulatory mandates are part of the work. Anyone can tell you what to do but few can stand beside you and your team and lead the way. Success requires expertise from those who have walked in your shoes as clinical leaders. It also requires a partner that can provide the clinical workforce who can work alongside your team and ensure that every patient has best-in-class care.”

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