Surviving your next survey

Hospital Safety Insider, May 19, 2016

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If you're like most, and hopefully, all hospital safety professionals, you spend most of your career preparing. In fact, you're likely preparing for the visit your facility gets every 18 to 36 months from The Joint Commission's surveyors, making sure that you're abiding by the rules they set forth. It's not an easy job. The standards they set can be the fuel of nightmares: complex, hard to understand, and in some cases vague.

But while the accreditor's standards may not always be easy to understand, there are secrets to not only passing your next survey with a high grade, but also using each survey as a stepping stone to better improvement as you go. Even Joint Commission officials have released advice that will significantly help you as you go through your preparations.

We asked some of our most trusted sources-seasoned professionals who have been through the process many times-to share some time-tested advice and tricks of the trade to help you get ready for and ace your next survey.

First, be positive. We've heard all of the complaints about the survey, and they are valid. It's a surprise, sprung upon your facility and staff when you least expect it, and in all likelihood it will take place on the worst day, when nothing is going as it should and nothing is in place.

But relax. The surveyors know they are dropping in on you and causing you stress and upheaval in your day-to-day life. In addition, they will be there for a few days, so you better get used to each other. In most cases, surveyors are current or former hospital safety officers, nurses, physicians, and administrators themselves, so they get it.

Remember that at the core of the Joint Commission's survey process and the standards they set, the mission is to provide top patient care, a safe environment, and an educational process designed to make things better. It's supposed to be positive; this is meant to help you. If you can learn to breathe, have faith in your preparations, and accept the surveyors' criticism and guidance, you will come out of the process a better facility.

Become a lifetime tourist.
Speaking of your facility, how well do you know it? The most successful safety officers make facility tours a regular part of their work week, if not their daily tasks.

Very simply, there's just no way you are going to notice the little things wrong with your facility unless you get out and take a look around. Always think like an inspector: What are the things they will look for? From a life safety standpoint, you might notice the clutter around the oxygen shut-off valves in the nurses' station, the boxes left in front of exit doors from last night's deliveries, or the can of spray paint left by a contractor in the hot cabinet in the elevator maintenance room. These are the things a surveyor will ding you on, and you won't find them sitting in your office.

Study, and know the standards. If you're a hospital safety professional, this should be a no-brainer if you want to keep your job for long. Especially if you are new to the job, you need to take time to study the standards that The Joint Commission will hold you accountable for.

If you don't know where to start, go to and download a copy of the Joint Commission standards to review. It's a long list, and many of them are vague, but knowing the standards will virtually give you a written road of the specific things a surveyor will look for. If you frame your survey preparation around the standards themselves, you give yourself a head start at succeeding on survey day.

Solidify your paper trail.
There's a saying in many circles that if you didn't write it down, it didn't happen. The same thing goes with surveys. Joint Commission officials have said publicly that a solid paper trail is one of the biggest things surveyors look for at a hospital, and the lack of proper records, meeting minutes, and other documentation is a clear sign of a weak compliance program.

What does this mean for you? Well, if you've recently had your sprinkler system checked in your facility, you should have documentation from the contractor who did the work. Where are the Safety Data Sheets (SDS) that document all the hazardous materials in your building? When was your last fire drill, or your last recurring staff training? Your agendas and attendance sheets should tell the clear story to anyone who needs the information.

Have you recently completed a walkthrough, making sure that your fire doors latch properly? Make sure you have a checklist filled out documenting who did the tour, when, and which doors were working properly (and more importantly and likely, which ones weren't).

Where do you keep this information, and how organized is it? You might keep impeccable records, but if you can't find them to show an inspector during a survey, what good are they? Many safety officers keep binders with information organized by department, and keep documents filed depending on what those standards say is needed. For instance, if the standard says you need an emergency plan (EM 01.01.01), it might be a good idea to have a binder with a tab for that particular standard containing your emergency plan.

Know what's wrong, and plan to fix it.
This is where documentation and keeping good records comes in handy, and it's another thing surveyors will look for when they visit your facility. They want a paper trail that leads to improvement, and that's what may save you if they find something wrong.

If a visiting surveyor finds several fire doors that aren't working properly, you can expect to be cited for the problem, especially if you didn't know about the problem.

On the other hand, surveyors are people, too, and they know that not everything goes perfectly all the time. And with hundreds of doors in a hospital, a few are likely to malfunction at any one time. If you completed a tour of the building last week that uncovered the faulty doors, you need to be able to prove that you knew about the problem, and more importantly, that you have a Plan of Improvement (PFI) in place to fix it.

Remember that the survey's purpose is not only to uncover compliance issues, but also to encourage improvement; your job is to show the inspector the plan (which might even involve contractors working on the problem as they tour your building), and chances are you'll walk away from the survey with a waiver instead of a citation.

That, of course, does not mean you will always get a free ride if things are going wrong at your facility. Accreditors will clamp down on your facility if there is a pattern of violations at your facility, and you can be sure they will be watching your progress.

Look for the little things. As a safety officer or facility manager, you should develop an eagle eye for the little things that may escape the notice of others. Those things may prevent a life safety or facility safety violation.

For instance, you may be the only one who notices during your rounds that boxes in the patient ward are stacked a little too high, blocking the path of sprinklers. In the course of a busy day, perhaps no one noticed the stairwell door propped open (a major elopement patient hazard), or the spray paint can left in the hot environment of the generator room (explosion hazard), or the contractor working in the infant ward without a name badge from security (an abduction hazard and certainly a stern disciplinary topic for your next staff meeting).

Educate your staff. This can't be stressed enough. Surveyors will almost definitely spend time with your staff members during their visit. And they will ask them lots of questions; if they trip up on their knowledge, say of your fire evacuation procedures-there's a good chance you'll get written up for it.

If you haven't already, it's time to establish a staff training regimen. From a life safety perspective, you're going to need to get your staff up to speed on fire safety and fire evacuation procedures, because not only do they need to know these in case the real thing happens, they will be quizzed when faced with inspectors. The more trained they are, the more knowledgeable they will appear when survey day comes.

Put things on autopilot
. Next, schedule your trainings and put them on a recurring schedule. Infection control staff meets one week, nursing and maintenance the next, security and ER staff the next. The idea is to get staff trainings going on a regular basis, and make sure you get to everyone at least once a month. Topics can range anywhere from fire safety to hazard communications (an OSHA requirement), to bloodborne pathogens and needlestick prevention.

While you've got your calendar out, schedule your building tours. It's a good idea to get through your entire building at least once a week. Next, schedule your maintenance tasks. When's the last time your fire doors were all tested? Fire alarms? When was your facility's last emergency drill conducted? Has the sprinkler system been tested? For that matter, when did The Joint Commission conduct your last survey?

Knowing that you can expect a surveyor every 18 to 36 months, and having that information in your calendar and clearly in your view, will ensure that you are never surprised and will make it much easier for you to plan.

Enter the portal. Lastly, get to know the Joint Commission's new physical environment Web portal, a joint venture with the American Society of Healthcare Engineers (ASHE) to help hospital safety, engineering, and maintenance personnel cut down on Life Safety (LS) and Environment of Care (EC) standards, which includes fire safety, means of egress, utility systems, and life safety systems such as automatic fire suppression systems.

The new portal (found at contains online resources and tools to help hospitals with compliance of those standards.

This is an excerpt from the monthly healthcare safety resource Healthcare Life Safety Compliance. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

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