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Quick and easy ideas to help you plan a mock survey

Ambulatory Safety Monitor, May 6, 2004

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When JCAHO surveyors arrive at your organization, they will first want complete lists of all current and recently discharged patients. The surveyors will randomly select patients from the lists to use as tracers and will then ask for their medical charts and complete records.

Assemble a sample list of patient tracers to begin your own mock survey. The tracers should represent your primary patient populations. A facility with a large number of surgical patients, for example, should choose patients who have undergone a variety of procedures, such as a cardiac patient who required a catheter or a general surgical patient who was admitted through your emergency department (ED).

Next, choose someone to act as the surveyor for your mock survey. Your JCAHO coordinator may be a good candidate.

What will surveyors want to know?
A surveyor who approaches a nurse with questions about a surgical inpatient might ask how the nurse managed the patient's pain. Some questions your mock surveyor could ask include the following:

• I see that this patient receives about two or three milligrams of morphine every three hours for pain. What concerns do you have when you administer morphine to a patient?
• What have you told the patient about morphine?
• What is the process you go through when you administer morphine to a patient?
• Did the patient receive information about managing pain after surgery?
• Can you show me in the record how you documented the patient's pain level?
• How often do you assess the patient's pain level?
• After intervening to decrease the pain, how often do you reassess the patient's pain?

Corrective action plans
When surveyors identify an issue, be ready to provide any corrective action plans that you may have developed. It is to your advantage to prove that you have already identified the issue and are working to address it.

The surveyor will review the plan to verify that you are carrying out corrective actions and will evaluate how it has affected tracer patients. The surveyor may also be able to provide you with additional suggestions for achieving compliance.

Tip: Consider staging a conflict between a surveyor and staff member during your mock survey.

For example, stage a situation in which the survey reaches a conclusion that staff don't agree with.

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