Hospital takes on three surveys in four months

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New survey coordinator weathers triennial, lab, extension surveys

When Susan Carvalho, RN, BSN, took over as director of quality and Joint Commission coordinator at Memorial Hospital Miramar (MHM) in Florida, she encountered a trial by fire: three surveys in four months.

Carvalho moved into the role from within the quality management department in October 2006. In November 2007, The Joint Commission (formerly JCAHO) arrived for the facility's unannounced lab survey. One month later, The Joint Commission was back in the facility to conduct an extension survey for a new service offered by MHM. Then, in February, surveyors were back again, this time for MHM's triennial survey.

Do what you do best

As with all triennial surveys, The Joint Commission posted the MHM survey to the extranet site at 7:30 a.m. Three minutes later, two surveyors were at the door.

"You really have to be ready. At that time of morning, you have a lot of people not yet in-house, as management staff are just arriving," says Carvalho.

"Miramar was well prepared for anybody to walk in any day," says Brenda Summers, MBA/MHA, MSN, RN, CNAA-BC, a senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. "It's not preparation; it's living what you're supposed to be doing [for survey preparedness]."

MHM sends out a beeper blast to alert the necessary management that The Joint Commission has arrived.

"It's interesting to try and mobilize while they're at home still getting ready for work," says Carvalho. "Truthfully, when I put this [beeper blast plan] in place, the main advice I gave them was: Treat it like a disaster."

Practice paid off.

"What I found was that because everyone knew their roles ... while I was busy doing one thing, a million other things were happening behind the scenes," says Carvalho. "Rehearsing your plan is key."

However, there really is no rehearsal except the real thing, says Carvalho. Still, MHM uses unannounced mock surveys to maintain readiness and holds monthly meetings to discuss the facility's overall readiness.

"We decided that each month, we'd meet to update on what surveyors are looking at, what to expect," says Carvalho, a plan that department leaders agreed kept them more prepared.

Because the hospital is new (it opened in March 2005), MHM has essentially never known a survey other than an unannounced one.

"Truthfully, as a Joint Commission coordinator, this is the only type of survey that I know," says Carvalho. "I think this made us better prepared.

Keeping your staff in survey mode

MHM, part of a five hospital system, recently moved to a newly built facility. Five days prior to MHM's survey, the healthcare system hosted Joint Commission representatives, including their soon-to-be surveyor team leader, for an optional orientation meeting.

"The system orientation ... is a good way to exchange information that you'd normally do during that initial [discussion]" at the beginning of a normal survey, says Carvalho.

The full-day orientation serves as a formal greeting to Joint Commission representatives and provides an opportunity for staff members to explain the hospital's operations.

Orientations were more common in the days of announced surveys, but MHM decided to invite The Joint Commission to the orientation after a discussion with its account representative. Carvalho says this was beneficial when surveyors arrived less than a week later for the unannounced survey.

"It did help because I was in 'Joint Commission mode,' " says Carvalho. "It was still intense, but at least we'd met the team leader."

Watch the Joint Commission's Web site

The triennial survey followed two one-day surveys at the end of 2007.

"This was unusual," says Summers. "The new service [survey] had to be done, and the unannounced survey was in the right year, but four visits [including the orientation] in that time frame was a little unusual."

When MHM opened its new service, the facility knew a Joint Commission visit would soon follow, but as for the timing of the other visits, it was a confluence of variables, says Summers. It also knew a lab survey was pending. "If you're always ready, it doesn't matter," she says.

However, no matter how ready a facility is, consecutive visits can be a challenge because the facility might still be addressing the results of the previous visits when surveyors arrive again.

"It's not that you're not ready, it's that you need to respond to things-expectations, initiatives," says Summers.

The facility's lab was surveyed in November 2007 by a surveyor with some blood bank experience; the extension survey was conducted by a surveyor with a general nursing background.

"On the lab survey, we were commended for being on top of the [Joint Commission] Web site," says Carvalho.

The surveyor arrived 20 minutes after notice was posted on the extranet site, so MHM was able to have someone waiting at the front door when the surveyor arrived.

Then, in December, an extension surveyor looked at MHM's neonatal and pediatric units. The biggest difference between a full survey and an extension survey, Carvalho says, is the number of Joint Commission surveyors who will be in-house for each.

"When you notify The Joint Commission that you've added a new service, they will come in unannounced," says Carvalho.

Staying prepared

MHM keeps a command center plan on a common drive explaining what everyone's role is during the survey and what documentation they are required to bring to meet with surveyors.

"I know some facilities practice having documentation on hand, but information can change," says Carvalho. "The directors that have that information ... were better off updating it themselves and bringing the latest documentation [the day of survey]."