In addition to conducting regular internal quality and safety inspections, hospitals, health systems and clinical laboratories need to maintain compliance with accreditation standards.
The cool winter air puts a chance of snow in the forecast just about every day. Draining the hose-bibs, locating the shovel, checking the tread on the car tires and generally just being prepared for what’s to come can give us a sense of satisfaction and security. And one less thing to worry about with the holidays fast approaching.
Simple steps toward preparedness can help you to be just as confident with your upcoming accreditation survey. Having the right tools and information gathered and organized can help to ensure that you not only weather the storm, but make a valuable learning experience of each site visit.
- Be certain you are using the correct version of the accreditation standards — it may seem like a no-brainer, but with everything else you are responsible for it is entirely possible that updates have been published without your knowledge. Stay current with most the recent accreditation standards handbook(s), state regulations and, if applicable, CMS conditions
- Keeping accreditation survey readiness top-of-mind, make sure you get your application for renewal of accreditation submitted on time.
- Make sure the survey date you choose is solid, with possible back-up plans or contingencies if key resources become indisposed for reasons out of your control. Changing the survey date after the survey has been scheduled can result in additional fees and possible delays depending on the policy of the accreditation organization.
- Hit the books — know what portions of the accreditation standards apply to your organization and read them thoroughly
- If the accreditation organization offers self-assessment tools, take full advantage of them as they are often the same or very similar to the tools surveyors will use onsite. Also, perform quarterly self-assessment audits of credential files, personnel files, and medical record files and keep credentials and peer review files current
- Keep meticulous records on inspection, testing, & maintenance (ITM) on all equipment and devices
- Conduct a mock survey annually
- Make accreditation readiness every staff member’s job (include in position description, orientation, annual performance review)
- Document at least 2 QI (Quality Improvement) studies and benchmarking activities each year
- Participate in continuing education programs offered by accreditation organizations and related entities; take advantage of opportunities to network with your peers regarding the material and don’t be afraid to ask for help
Knowing what to expect and where you stand beforehand are keys to not only a successful survey but in maintaining a culture of quality, patient safety and continual improvement. Being prepared also gives you back valuable time during a survey that can be spent learning from the surveyor’s experience.