3 Unannounced survey let the panic begin! NOT! how we established a regulatory sustainability mindset
Year: 2024
Type: conference-abstract
Abstract: Background In the past, the arrival of regulatory surveyors caused panic across the organization. Non-patient care activities stopped, teams rushed to remove non-compliant items, and surveyors were treated as adversaries, creating a highly disruptive and stressful environment. Objectives We embraced a culture of continuous readiness, shifting our mindset and approach to unannounced surveys. This shift, including how we interact with surveyors, has transformed our organization and significantly reduced stress during surveys. Methods Our strategy for triennial surveys includes assigning key stakeholders ownership of each Joint Commission chapter, with regular evaluation and reporting. We conduct routine Environment of Care and infection prevention tracers across all facilities. During Joint Commission triennial surveys (12–15 surveyors over four days), we employ a detailed plan involving escorts, scribes, and command center personnel. For complaint surveys, we minimize personnel involvement, allowing regular operations to continue while trained staff collaborate with surveyors, thanking them for their objective insights. Results By changing our approach to regulatory readiness, we have reduced the raw number of Joint Commission findings by more than 25%, including no condition-level findings in our recent triennial survey at our 1,000-bed, trauma 1, quaternary care hospital. Our findings have also shifted down and to the left on the Survey Analysis for Evaluating Risk (SAFER) matrix (figures 1–3). Complaint surveys rarely result in deficiencies. Conclusions and Implications This shift in mindset has made surveys a more positive experience for both our staff and surveyors. Leaders trust in our readiness, reducing stress and disruption across the organization.
Authors: Anne Brittain, Kendra Davis
Institution: Inova Health System
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: gold
OpenAlex ID: W4404895201