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How do you conduct an actual Joint Commission on Accreditation of Healthcare Organizations mock survey? There’s more to it than just walking around with a clipboard and asking questions. Here’s some advice from the experts:
• Take it seriously. Play the role of a Joint Commission surveyor. The whole point is to simulate the actual survey, so you should try to play the role instead of just asking questions as a coworker, says Michelle Pelling, MBA, RN, a consultant in Portland, OR. How much you get into the acting opportunity will depend on the individual, but Pelling encourages people to pour it on.
"I play the role of the surveyor and walk them through the exact process," she says. "Each surveyor has unique approaches, but they’re supposed to follow certain patterns and so there is a certain predictability. We sometimes try to be a little harder than the surveyor will be because we want people to be prepared, but we don’t get disrespectful or bully people at all. That’s not what you’d expect from the real surveyor either."
• Carefully select observers and participants. If you are using an outside consultant, he or she probably is the best person to play the role of the surveyor. Having a stranger from outside the organization ask the questions will make the mock survey seem more real. If you’re not using a consult- ant, the best person is probably the quality manager or someone in an equivalent position. But also be a little flexible if one person is more comfortable with the acting. It might be better to select a team member who is more willing to role-play, rather than someone who will be reticent about that.
The mock surveyor should be accompanied by observers from the organization, says Susan Mellott, PhD, RN, CPHQ, FNAHQ, a consultant in Houston. The peer-review or quality professional should be on hand to observe, possibly with other members of the accreditation survey team. Performance improvement professionals, nursing leaders, and someone involved with clinical records documentation also are good choices.
In addition, look for leaders within different departments who may provide valuable insight during the survey. "You might want a clinician doing the patient care questions but not the functional care issues, because of the judgment calls that need to be made," Mellott says.
But be open-minded about who might be useful. Pelling suggests including a facilities management representative, for instance.
"The surveyor might ask what to do in a fire, and sometimes the facilities management person can offer ways to improve the response, or answer questions that come up during the survey," Pelling says. "Sometimes the staff person will realize she doesn’t know the answer well enough and ask for clarification. If you have the department representatives there, it can act as an inservice right on the spot."
• Be willing to break out of the survey role for on-the-spot education. While it’s important to act out the surveyor role as much as possible, don’t forego opportunities to answer questions and offer suggestions. The only exception might be the final dress rehearsal, in which you’re trying to maximize the simulation. But even then, don’t get so carried away with the playacting that you forget the real goal is to improve the survey results. If you limit yourself to doing the survey exactly like a real Joint Commission survey, you’ll miss the opportunity to give valuable advice, such as suggesting a different way to answer a question.
Remember that your mock surveys will take considerably longer than a real Joint Commission survey. The real surveyors do this for a living and can be very efficient, and they don’t have any need to stop and educate staff along the way.
• Schedule staff members who are likely to be present for the real survey. The organization often knows when the surveyor will visit, or at least have a good idea, so Pelling recommends trying to schedule those staff members to be present for your last mock survey. This will give those staff more exposure to the process and more practice with responding to questions.
• Look for staff who just can’t handle the pressure. The mock surveys will help you see how individual staff respond when a surveyor asks a question or requests certain documentation, with their bosses and other observers standing by. Some people can’t handle it.
"There have been times when we realized some people just are too uncomfortable and freeze up," Pelling says. "They may be good staff people and do their jobs well, but they’re just too uncomfortable to be put in the spotlight like that. It doesn’t do you any good to have them there when the real surveyor shows up."
When you spot those staff, try to have their work schedules temporarily altered so that they’re not on duty for the real survey. That’s acceptable as long as you’re doing it only because the person is nervous about the survey, not because the person is insufficiently trained, she says.
• Use the last mock survey to concentrate on records review and accessibility. By the time you do the dress rehearsal just before the actual survey date, it’s too late to make significant changes to operations. Instead, Pelling suggests you consider the organization’s improvement essentially finished at that point and concentrate on how well your staff can demonstrate the organization’s compliance with Joint Commission standards.
"We’re in more of a fine-tuning mode by then," she says. "When we see that staff are having trouble finding certain documents or directing the surveyor to the right documentation, we address that immediately. That’s the kind of thing you can fix at the last minute, not policy issues."
• Be sure to communicate the results of the mock survey. Pelling and Mellott say this is the biggest mistake that health care providers make with mock surveys. They may gather useful information from the survey, but then they don’t disseminate it. After each mock survey, meet with the survey process team to discuss the results. Establish what tasks are necessary to improve the results and then compare the next mock survey to look for improvement.
"You have to report the results back to three levels: the medical executive committee, the hospital administration, and the quality steering committee," Mellott says.
"Responsibility is the key there, holding them accountable for what they’re assigned to improve," she adds.