Unannounced Surveys: Are You Prepared?

August 19, 2013

The Joint Commission visited us recently for an unannounced survey. Here are a few areas to consider before your next encounter.

A few weeks ago The Joint Commission descended upon East Cooper Medical Center to do their unannounced survey. I believe this was the eighth Joint Commission survey I have been associated with, and in my opinion the Joint Commission going to unannounced surveys was an excellent idea. By doing this as managers/directors we always need to be prepared in providing a safe environment for our patients and staff.  

Obviously the Joint Commission survey is not the only survey we encounter in our day-to-day operations. We have the MQSA survey, and the CMS and our state Bureau of Radiological Health division also do unannounced surveys.   

Even though surveys can be an inconvenience, we should welcome them with open arms, as they give us another set of eyes to look at our processes and ensure we are providing a safe environment for those who walk through our doors. Being prepared and keeping staff up to date definitely takes time and organization. Remember to document, document, document! In the eyes of surveyors if it is not in writing it did not happen.

Below are suggested items to be aware of and topics raised during our Joint Commission survey:

  • MRI safety has been given more attention on Joint Commission surveys. Make sure the MRI zones are identified in your facility and staff is knowledgeable about the four zones. I did an in-service on MRI zones and then required the staff to take a ten-question quiz to demonstrate competency on the definitions of the four zones and where those four zones were located in the imaging center. In addition, I did the in-service and quiz with the support staff and physicians from a practice that rent space in one of the facilities I manage. One important point: Reception staff should be considered the gate keepers for MRI safety in the patient waiting area. 
  • Storage areas under sinks should be empty. This is an environment of care issue.
  • Do yearly staff competencies. These can be on a wide range of subject matters: starting IVs, how to deal with infiltrations, disinfectant use, how to handle a code in MRI, where fire extinguishers are located, what are the fire escape routes and anatomical site marking.   
  • I-Stat. At both imaging centers use I-Stat devices for creatinines. Staff who use this device do both as written test and an observed competency.
  • Do annual radiation apparel integrity testing and keep results in a spreadsheet.
  • Child proof electrical outlets.  
  • The physician surveyor asked both the MRI and CT technologist about patient screening processes. We have a patient screening form for both modalities and the surveyor was impressed that a four question screening form was used to asses for patient fall risk.
  • The surveyor recommended that vaginal probes be placed in a plastic bag when not in use.

Finally, our leadership is critical in promoting a culture of safety.  I offer the following suggestions on what we need to do as leaders.

  • Demonstrate the support of safe practices through actions. Walk the talk!
  • Engage employees in discussions on patient and employee safety.
  • Empower employees to address safety violations. My motto is: If you see it you own it.
  • Encourage staff to engage patients to discuss their health history. In general, no one knows more about their health than the patient.
  • Commend and reward employees for reporting.