Q&A: Ongoing survey readiness tips

Accreditation Insider, April 17, 2012

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Q: I was just promoted to manager of accreditation at my facility. What are some things I should keep in mind as I strive to implement and maintain a successful survey readiness program?

A: Successful organizations keep the momentum going by incorporating ongoing compliance readiness into their day-to-day operations. There are practical ways to accomplish this:

  1. Incorporate operational practice into policies and procedures supporting the standard practice of care rather than creating a document in which practice must follow.
  2. Hard-wire compliance.
  3. Keep ongoing compliance front and center for staff members. Use communication vehicles such as posters and staff newsletters to highlight efforts and standards. Use fun ways to do this, such as asking a Patient Safety or Quality Question of the Month, creating a crossword puzzle of important terms and requirements such as the NPSGs, or simply noting an issue or tabletop tents in the cafeteria.
  4. Celebrate positive accomplishments. Staff members are always motivated when they realize their hard work has yielded positive results. Highlight those involved.
  5. Keep leadership involved. This cannot be stressed enough. Leaders have their own perceptions of the process, and the degree of difficulty is often based on unofficial sources of information. You can’t change an attitude, but you can keep leadership informed of issues and progress towards resolution.
  6. Follow through on any issues. This includes seeking assistance from department leadership when you have reached an impasse or a team member is struggling.
  7. Be aware and accept that compliance issues never go away. Standards are added, EPs are changed, expectations change, and FAQs are released to challenge you in remaining survey ready.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Beck at and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.

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