Are You Accreditation Survey Ready or Just Compliant?

Have you experienced an accreditation survey and been surprised by the amount of deficiencies? I bet most of them were a result of the surveyor’s observations, not your carefully prepared documentation and meticulous tracking.

I call this compliance sufficiency. Your organization is technically compliant, but employees are not demonstrating readiness, which results in deficiencies and time-consuming corrective action plans. If you think about the arduous OSHA and HIPAA compliance responsibilities, there’s a significant risk if there are no periodic checkpoints to ensure employees are following through on their compliance duties.

As a compliance professional, it’s very frustrating to be cited for these deficiencies and it is even more difficult to correct the compliance attitudes and employee habits that are not always visible. In this blog post, I’ll explain how to know if you’re accreditation survey ready, tips to maintain that readiness, and how technology can help.

The Difference Between Accreditation Survey Ready and Compliant

Just because healthcare staff have been required to complete annual training courses, competency assessments, and have acknowledged hundreds of policies, it does not guarantee “daily” compliance. That’s the difference between being survey-ready and compliant.

Compliant	Survey Ready
All operations comply with established standards set by regulatory bodies, such as the Joint Commission, Centers for Medicare & Medicaid Services (CMS), or state health departments.	Staff are able to demonstrate knowledge of operational policies as they apply to these standards if asked by a surveyor — or can identify policy and explain how it applies to their role.
Risks are identified and mitigated.	Identified risks are reviewed periodically to ensure compliance and training is provided when staff are observed lacking knowledge of risk mitigation methods to comply.
Accurate records and documentation are maintained to demonstrate compliance during audits or inspections.	Surveyor (or person conducting a review) finds that observations of staff behaviors and knowledge are consistent with documented training and policies.
All staff are adequately trained and informed about compliance requirements and best practices.	Training records include a mechanism to test knowledge (competency) via a quiz or other demonstration. Policies are acknowledged by staff and easily accessible.
Policies are regularly reviewed and updated to enhance compliance and address any deficiencies identified during audits or inspections.	Staff acknowledgement of policies are documented for all policy versions. Able to demonstrate how updates are communicated and accessible by staff.

Implementing Multi-Dimensional Compliance To Be Survey Ready

Your reports indicate you’ve checked all the boxes for plans, policies, and mandated staff training. How do you take this compliance and translate it to a survey-ready workforce? Here are my suggestions.

Look Beyond the Regulations

You probably have an informed consent policy and form and have trained your staff on the appropriate use and documentation requirements. But, The Joint Commission explains that informed consent is a process of effective communication between a provider and patient and not just a signature on a form. Have you checked in with patients that are characterized by social determinants of health, such as those with literacy deficiencies or who have been identified to have cultural or language barriers? By periodically interviewing patients that meet this criteria, you can better prepare your staff for daily compliance — and to move the quality needle.

Management By Walking

When I was a director at Long Beach Memorial and Miller Children’s Hospital, I made rounds with the Senior Vice President every Monday morning. During these rounds we looked at compliance from a surveyors perspective. It created visibility and accountability, as well as helping me to see where “daily compliance” had fallen off. Ask questions to staff to check for their understanding of compliance policies. Can staff identify the correct policy and explain how it applies to their role and responsibilities?

While taking a closer look at compliance adherence, bring a checklist to review the workplace environment. Does the patient care staff have access to PPE? Are there items blocking fire exits? When was the last time a fire drill was conducted? Do staff really understand their role in maintaining a clean and safe work environment?

In today’s healthcare environment, many healthcare leaders feel that they don’t have time for weekly rounds, regardless of the size of the organization, but I really believe this is key to a successful multi-dimensional approach to compliance.

Combine Compliance Tactics

There are four main areas that have the most impact on your organization’s compliance — HIPAA preparedness, corporate compliance, safety compliance, and infection control/prevention. Each of these is complex, which makes a multi-dimensional approach ideal. For example, you’re tracking the approval and acknowledgement of specific policies and training completion. But, you might also want to survey five or more employees to see if they know how to handle a request for Protected Health Information (PHI) and ensure their answer aligns with your current privacy notice and policy. This combination of documentation and human interaction is what will help your organization to be survey ready, and not just compliant.

Use Technology To Achieve Compliance Sufficiency

Keeping your organization survey ready, and not just compliant takes a multi-dimensional approach, which can be enhanced with technology. Instead of having employees review a policy once and not see it again until it is updated in a year or two, put it at their fingertips in a document management system designed for healthcare. Use a learning management system to easily assign additional training based on your observations in the facility. Managing compliance electronically allows the organization the ability to scale and prevents data silos (and information hoarders) by facilitating transparency and accountability.

Hopefully after implementing multi-dimensional compliance, deficiencies will be a problem of the past. But, if it does happen, incorporating technology into your Plan of Correction can be very powerful. Adding, or demonstrating use of, a compliance solution in response to a Corrective Action Plan is a great way to show your commitment to compliance — while also helping to complete the steps in your plan.

Using an all-in-one compliance platform, like MedTrainer, can help you take your compliance program from good to great. Customers passed 99.8% of surveys in the previous year. See how MedTrainer can help you.

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