The morning of the survey

From HMCwiki

Experiences of the first hour of the morning of the survery

The surveyors immediately asked for a list of patients, diagnoses on each unit, contact people for individual departments
They presented at the front desk and after the Director of Quality Gloria Swanbon showed up, requested a planning meeting with the senior leadership in about 15 minutes and another planning meeting shortly thereafter with the other managers.

1 What are the first things you should do?
2 Personal experience
3 Related links
4 References and resources

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What are the first things you should do?

Check the JCAHO website! Check the Joint Commission’s Extranet site every morning at 7 a.m. EST. This will tell you if you’re being surveyed today and who the surveyors will be, along with their biographies. For people on the West Coast, you’ll have 4 hours of advance warning. Mountain – 3, Central – 2, and Eastern just one. Surveyors arrive at 8:00 am.
Verify the identity of surveyor - reports of imposters exist.
Alert everyone!

- Practice Drills

- Vacation schedules - have a policy/contingency plan so you always have alternative individuals identified

- Designate tasks (you-call the caterer! you - greet the surveyor! you - bring the documents! you - page everyone!!!)

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Personal experience

At Holyoke Medical Center, they used the same beeper system they use for emergencies to notify staff. Mike Zwirko, VP said “That was very effective, and the surveyors were impressed how quickly the hospital staff were notified. We also provided a runner to get them the needed policies and documentation.”

Prepare for surprises!

1. Select Specialty Hospital (31 bed) hung a checklist in the break room and nursing station that explained what would happen in the first hour of an unannounced survey which answered:
- How do you identify the surveyor and verify his identity?
- Where do you take the surveyor for set up?
2. One hospital that was surprised with a visit had the switchboard announce that "Merrimack Valley Hospital welcomes the Joint Commission to our facility today and we hope you enjoy your stay."

Set up the room.

About the Room: DESIGNATE THE ROOM beforehand!

Notify the caterer
Obviously make sure there is phone access and internet access.
Recommendations from Pat Wardell, VP of Quality Management and Patient Safety Officer at St. Jude Medical Center in Fullerton California offered these suggestions^[1]:

a. Choose a room for the surveyors that is distant from your main file review areas. “Don’t make them too close together,” recommends Swain. “While you are previewing personnel files, medical records, and strategizing, you do not want the surveyors bumping into your commotion. What is presented to the surveyors, is cool, calm, and without surprises!”

b. St. Jude Medical Center also staffed the room with two people so that the surveyors needs could be met quickly.