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Community Hospital Blog

Mock Surveys – A Best Practice

By Amy Boykin, CHC SVP of Quality, Patient Safety and Care Management

 

Hospital accreditation is considered a standard of excellence for safe, high-quality care. Accreditation helps organize and strengthen patient safety efforts, improves risk management and risk reduction, and provides deeming authority for Medicare certification.

 

Mock surveys are a best practice to keep hospitals in a “stay ready” mode for an actual survey from a state survey agency on behalf of the Centers for Medicare and Medicaid Services (CMS) or accrediting organizations such as The Joint Commission or the Center for Improvement in Healthcare Quality (CIHQ). The good news – proactive community hospitals are following the practices of larger healthcare systems and implementing a mock survey process. Simply, it’s an industry best practice.

 

Mock surveys conducted every 12 to 18 months are a valuable component of quality improvement initiatives. This process provides a “snapshot” of compliance before an actual survey, while helping to teach, train and educate leaders and staff members. The goal is to improve care and patient care processes.

 

Like actual CMS certification or accreditation surveys, mock surveys are often unannounced and can be conducted by an outside consulting firm. Community Hospital Corporation conducts mock surveys for its owned and managed hospitals, involving a team of generally three to five “CHC surveyors.” Onsite at the hospital, the mock survey team conducts a review following guidelines outlined by CMS or the accrediting organization. Following the mock examination, CHC reviewers address hospital leaders personally in a verbal debrief. Within two weeks, the hospital receives a written report summarizing any deficiencies and recommendations for an action plan for improvement. Also, after a hospital goes through its actual survey, CHC compares the mock survey report to the final report from the accrediting organization to see how recommendations align.

 

Here are some insights and best practice tips for mock surveys.

  • Keep the ultimate goal in mind — improving the organization and patient care — when it comes to the mock review. Don’t think of it as a time-consuming, intimidating task.
  • Examine patient care processes. Are processes compliant with survey standards and requirements? Pay particular attention to environment of care and life safety categories, including new or revised standards such as fall prevention.
  • Focus on the process, not people. Your survey preparation should be process-driven. The responsibility for meeting any standard rests with the organization, not the individual in a particular role or position.
  • Infection control is a high-focus area. For instance, is a patient room clean or dusty; is equipment properly cleaned and disinfected? In kitchens, are food prep areas clean and orderly? Are designated isolation rooms kept at negative pressure?
  • Hospital buildings and the physical plant are part of the review process. Related to the environment of care, is an older facility in disrepair? Are electrical systems well maintained? Are floors and ceilings well-kept; are there stains on ceiling tiles? It may be necessary to call in a plant manager or engineer to remediate issues.

CHC Consulting also provides mock surveys for consulting hospital clients upon request. For more information on mock surveys, including how this process dovetails with a hospital’s Compliance Program described in last month’s CHC blog, see CHC Clinical Quality services.

Tags: Mock Surveys

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