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Ask the Expert: How Should a Facility Prepare for an Accreditation Survey?

November 2017 - Vol.14 No. 11 - Page #4

Implementing a strong survey readiness program that is designed to keep the organization survey-ready at all times, not just immediately prior to the triennial survey, is key to proper preparation. Such a program requires creating a schedule of multiple tracers that evaluate the organization’s level of survey readiness throughout the medication-management process. These tracers are critical to identify areas that require changes in policy, process, or practice. In addition, maintain a consistent schedule of rounding on all units to identify potential weaknesses.

Closely monitor incident reporting to identify problem areas. For example: What types of incidents are being reported? Could they have been prevented? What corrective action plans have been implemented? Most incidents can be traced to a break in process, so it is critical to evaluate every incident to identify the process issues and correct them.

Conducting a mock audit that mirrors an actual Joint Commission survey is another valuable tool. The mock audit team should include representation from accreditation, environmental safety, nursing, pharmacy, infection prevention, and, if possible, health information. At our hospital, the findings are compiled and placed in the Safer Matrix to present to facility leadership (more information about the Safer Matrix is available at

Certain areas typically require intense focus. Pay particular attention to:

Pharmacy. Accreditors focus extensively on cleanroom compliance. For example, they will review hood-cleaning documentation, cleanroom cleanliness, and verify that the area is free of debris. No outside shipping containers should be stored on the shelves alongside items that have been removed from their boxes, as shipping containers are considered contaminated and should be removed as soon as possible after delivery.

Infection Control. Infection prevention in the pharmacy involves more than hand hygiene, it requires maintaining a sanitary environment for patients. Maintaining the requirements for compounding drugs is paramount. Many illness outbreaks and deaths have been traced to inappropriate compounding practices.

Antibiotic Stewardship. Antibiotic stewardship is critical to prevent the development of multidrug-resistant organisms, which can be life altering for patients. Patients should be educated to finish their complete antibiotic regimen, even if they are feeling better. Monitor physician-prescribing practices and compare them to the antibiogram to identify patterns that can lead to resistance. In addition, be sure the organization is in compliance with The Joint Commission’s latest standards for antibiotic stewardship (effective as of January 2017), available at

Drug Diversion. Drug diversion is a serious problem that affects the safety of patients and health care workers. Monitoring the amount of pain medication administered to patients and their responses can help identify diversion. For example, if a patient complains of pain only when cared for by a certain nurse, this should be a red flag. Monitor medication overrides to track which types of medications are overridden and why to identify trends.

Injection Practices. Staff education is vital to ensure safe injection practices. With the current focus on doing more with less, staff may take shortcuts that could lead to patient harm. For example, not properly cleaning the hub of the IV tubing prior to injection can result in a deadly bloodstream infection. Failure to use a clean needle and syringe each time a vial is entered can lead to contamination, as can using single-dose vials on multiple patients. Frequently observing staff during medication administration can help improve practice. When a staff member is observed not following recommended practice, use it as an educational opportunity.

Life Safety Code Standards. The Life Safety Code Standards require enhanced focus, as this chapter is commonly associated with findings. For example, accreditors evaluate fire hazards, such as storage too close to sprinklers, equipment blocking fire extinguishers, or blocked means of egress. Accreditors will also check the ceiling to make sure there are no penetrations through fire walls or wires resting on sprinkler pipes. More information is available at

Following an audit, the accreditation professional will work with facility leaders to develop a corrective action plan related to the findings. These plans may require the collection of additional compliance data, which typically occurs for at least 4 months. By their nature, action plans are fluid and often change as they progress. The most commonly employed rapid cycle improvement process is Plan, Do, Study, Act, or PDSA (more information is available at Each time an intervention is performed, its effectiveness must be evaluated, which helps identify the next intervention. This cycle continues until the issue is corrected and hardwired with staff.

Finally, leadership support is vital for ongoing compliance. If leadership does not support the audit readiness effort, staff will not deem it a priority. Engage frontline staff in process improvement, as their input is critical to ensure success. It is important to develop a positive rapport with staff that leads them to trust your judgement.

Brenda Helms, RN, BSN, MBA/HCM, CIC, CPHQ, is the regional director of clinical compliance and accreditation at Baylor Medical Center in McKinney, Texas. Brenda is a past president of the Dallas/Fort Worth chapter of the Association of Infection Prevention, Control, and Epidemiology (APIC) and of the Texas Society of Infection Control and Prevention (TSICP). In 2015, She received the Gerry Haynes award for excellence in infection prevention from the TSICP.


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