Nursing

Last-minute tips to help staff get ready for survey day

Nurse Leader Weekly, January 21, 2005

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It's only natural to be nervous before your Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey. To combat her and her staff's anxiety, Sandy Gee, CPHQ, quality improvement director at Valley Regional Hospital in Claremont, NH, created a tip sheet prior to her hospital's September survey. It highlights how staff should conduct themselves, and gives tips on how they should answer a surveyor's questions.

The following tips were culled from Valley Regional's tip sheet:

  • Conduct a last-minute readiness assessment. Do a quick sweep of your unit before the survey. Ask each other questions to prepare for the real survey. Share your findings with each other. The more you do this, the more comfortable you will be during the survey.
  • Remember the three-second rule. Try to answer the surveyor's question within three seconds. If you don't know the answer, here are three responses (1) Ask the surveyor to repeat the question,  (2) ask for clarification if you don't understand the question, and (3) redirect the question to someone who can answer it
  • Answer only the question asked. Approach surveyor questioning as if you're in a courtroom. Do not elaborate or provide extraneous details about a process or procedure unless the surveyor asks. The surveyor will ask a follow-up question if he or she needs to know more.
  • Help each other respond to questions. If you are in a group interview and the surveyor directs a question to you but you're unsure of the answer, it's okay to deflect the question.
  • Listen to surveyors. If the surveyor goes into teaching mode, listen patiently and thank him or her for the information. Surveyors can have interesting solutions to complex issues that plague hospitals.
  • Focus on the excellent service or care you provide. The surveyors will observe staff. Don't worry about performing for surveyors. Concentrate on the tasks you do every day (e.g., washing your hands, dressing a wound, identifying patients before administering medications, responding to clinical alarm responses, reading back orders).
  • Buy a little time if there's a problem. Explain to the surveyor that you will look into the matter and gather information. Try to get the information to him or her in a timely fashion.

Source: Adapted from Briefings on Patient Safety (January 2005), published by HCPro, Inc.


 



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