6 clinical leaders on hospital accreditation visit prep: Act now, don't react later 

Hospital clinical leaders know the value of accreditation, whether from The Joint Commission or another organization. They know a commitment to meeting standards and emphasizing a consistent approach to care is essential to achieving desired ratings and ultimate accreditation.

Prior proper planning — and not waiting until a visit is expected — is the key to achieving high marks from The Joint Commission, Det Norske Veritas and the Healthcare Facilities Accreditation Program. 

In other words, focus on the race, not just the finish line. 

Hospitals must put measurable programs and a system of checks and balances in place to encourage vigilance at every step of the healthcare continuum. Further, take time to review prior surveys to find opportunities for improvement.

Every member of every team should be focused on adhering to safety and quality practices always, not just when the accreditation surveyors are expected to arrive.

Becker's asked clinical leaders one question: What advice would you give to clinical hospital leaders as they prepare (and wait) for hospital accreditation visits?

Here are six responses:

Editor's note: Responses have been lightly edited for length and clarity.

Ruby Brewer, MSN, RN. Chief Nursing and Quality Officer of East Jefferson General Hospital (Metairie, La.) and Interim Chief Nursing Officer of UHS University Healthcare System (New Orleans): Our hospital system supports its leaders with continual readiness. Because the quality and patient safety standards of The Joint Commission are always top of mind, we've implemented practices to ensure we stay ready at all hospitals.

Our goal is to maintain a high level of reliability within our organization, so we are prepared for, and not just reacting to, TJC reviews. As an organization, we have developed our own internal readiness system to ensure we follow best practices to improve our processes and provide our leaders with a model for success. We remain prepared by consistently utilizing the readiness processes that are in place including mock surveys, internal audits, checks and balances practices, and ongoing learning regarding standards and practices. This approach ensures that we are not only prepared for TMJ, but more importantly, ensuring the safety of our patients and staff.

Leslie Jurecko, MD. Chief Safety, Quality and Experience Officer of Cleveland Clinic: Preparing for accreditation visits can be stressful for organizations, especially if there is a reactive mindset. At Cleveland Clinic, we work on being proactive so that our teams are in a state of readiness at all times. This leads to reassurance and psychological safety. Leaning into high reliability and a culture of safety as part of accreditation preparedness speaks volumes to all caregivers. We can then take any necessary actions after accreditation visits and celebrate our preparedness.

Richard Shannon, MD. Chief Quality Officer of Duke Health (Durham, N.C.): The best way to be ready for a regulatory site visit is to create daily management systems which are unit-based. They should each consist of a visual management board which documents, in real time, the state of preparation of the unit's status with respect to staffing, supplies, equipment and patient care materials. The visual management board documents patients who are at risk for falls, pressure injuries and those with catheters in place and documents the use of standard work to reduce risk. 

The visual management board has an area improvement section which focuses on work redesign underway. Every day, the team huddles around the board to create situational awareness. Issues that cannot be managed locally are escalated to upper management.  

Adhi Sharma, MD. President of Mount Sinai South Nassau. (Oceanside, N.Y.): One tool we have found extremely effective is the use of tracer rounds, which are mock survey rounds conducted by trained staff. It not only is useful for identifying undiscovered inconsistencies in practice, but it also helps prepare the teams for survey readiness by engaging them in discussions that surveyors would likely have with them.  

We have found that staff survey readiness is well received by surveyors. When staff can speak to the elements of the survey confidently and correctly, it bodes for a strong survey result.

Peter Silver, MD. Senior Vice President, Chief Quality Officer and Associate Chief Medical Officer of Northwell Health (New Hyde Park, N.Y.): I have two pieces of advice: First, don't prepare for an accreditation visit just prior to the survey by the accrediting body. Instead, you should prepare year-round. Also, don't prepare with the principal motivation being that your hospital is being surveyed, but let it be because it is in the best interest of the safety of your patients. 

Second, make the survey a celebration of your accomplishments — of new initiatives by your staff to improve patient safety, your incorporation of health inequities and social determinants of care into your quality fabric or what you've done to improve staff safety and well-being. Use the survey as your chance to have your staff show off some of the great things that have been done in your hospitals.

Ulises Torres, MD. Chief Quality Officer of the George Washington University Hospital (Washington, D.C.): Support your accreditation/quality and safety colleagues by providing them with the adequate protected time to investigate and address the fall-outs from prior regulatory visits and current issues that need to be addressed. Sometimes we need to take care of their other daily tasks so this can happen. As a C-suite member, we should support through a humanistic lens and get out of the way.

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