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An educational, open, and nonpunitive survey experience

After reading this article, you will be able to

1. -recall at least two tips for preparing for an unannounced survey

Monday-the day Karen Holland, RN, BSN, religiously checked the JaycoT extranet site to see whether it was unannounced survey time for her hospital-passed by quietly.

She only occasionally checked the Jayco site on Tuesdays. She had heard that most surveys start on a Monday, rarely on a Tuesday or Wednesday, and almost never on a Thursday or Friday. However, on Tuesday, July 11, as Holland got ready for work, she decided to check the site from home.

"I was brushing my teeth and just figured I'd check it," says Holland, director of quality and regulatory compliance at the 359-bed Jackson Hospital in Montgomery, AL. "It wasn't a day we were expecting [a survey]."

The JCAHO says surveyors can arrive on any day of the week despite any anecdotal evidence to the contrary. About the only thing that you can predict, the JCAHO says, is that surveyors will arrive during weekday business hours.

Although the Tuesday morning notification came as a surprise to Holland, she was able to mobilize everyone before the survey team arrived.

"We did an alert exactly how we had practiced it," she says, adding that it was successful.

Living about 20 miles away from the hospital, Holland says she used the time during her commute to call all senior management.

"When I got [to the hospital], I had to make sure that we had the [conference] room ready for surveyors, [and] the PowerPoint set up," she says. "We were almost ready. We would have liked a half hour more. I was so nervous, you could have asked me my name and I would have forgotten it!"

Despite feeling hurried at the beginning of the day, Holland says the four-day survey with a nurse surveyor and physician surveyor-plus a Life Safety Code® (LSC) surveyor-on the first day, played out smoothly and proved to be an educational experience for all staff.

Surveyors waste no time getting into tracers

After Holland gave surveyors a short PowerPoint presentation to orient the survey team to Jackson Hospital, the surveyors began tracing patients with the data sets outlined in the Survey Activity Guides (SAG), including patient census data.

Each surveyor did about three or four tracers, Holland says, visiting departments such as the intensive care unit (ICU), obstetrics, the emergency department, the cath lab, and radiology. Holland and a scribe-a staffer who takes notes during a tracer-shadowed the physician surveyor on a tracer that began in the ICU.

Holland says each surveyor picked a patient and observed the staff caring for patients to see whether they checked for two identifiers and practiced good hand hygiene. The surveyor interviewed a nurse caring for a patient and a respiratory technician, because this particular patient was on a ventilator.

"They were really nervous, but the surveyor put them at ease," Holland adds.

The surveyors moved from unit to unit, going up or down a new stairwell, and effectively conducting an informal building tour separate from what the LSC surveyor was doing. Among all the surveyors, Holland says they checked everything "from the rooftop to the basement."

Along the way, the surveyors-the lead surveyor in particular-would ask staff about their responsibilities.

This is an excerpt from a member only article. To read the article in its entirety, please login, subscribe, or try out BOJExtra! for 30 days.
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