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Survey 101: The accreditation survey isn't your only concern


September 1, 2019

Does your compliance calendar run on a one- or three-year schedule to match when you expect surveyors from your accreditation organization? It shouldn’t.

In this excerpt from the 2019 edition of HCPro’s book, the “Chapter Leader’s Guide to Environment of Care,” author Thomas J. Huser, MS, CHSP, CHEP, MEMS, offers reminders of the other regulators to watch out for as you strive for patient safety and compliance overall:

Other Regulatory Agencies

As I mentioned previously, we as humans tend to fall into the survey cycle, rather than striving toward continuous readiness. One person cannot maintain survey readiness for the entire facility, but you can fight the cycle mentality within your areas of responsibility. Keep pushing the information you learn up your chain of command. You can promote involvement from other departments through performance improvement (discussed in the next section). Share what you learn, challenge others to rise to continuous readiness, and partner with other chapter leaders who share the goal of fighting the survey cycle.

It is amazing to me how people can focus so much of their time and energy prepping for one particular survey agency and forget about the others. Your state or local fire marshal can implement fines and penalties, and the Environmental Protection Agency (EPA) conducts inspections to ensure compliance with hazardous material and waste regulations. Then there is the Occupational Health and Safety Administration (OSHA), which can arrive at your doorstep for a random survey or in response to a complaint from a disgruntled employee concerning any number of items for which it has jurisdiction. The Department of Transportation (DOT) has begun conducting surprise site surveys to ensure compliance regarding preparation and shipping of biohazardous and hazardous waste.

If you have a laboratory or research department, they may also receive a surprise inspection from the DOT to ensure that the laboratory or research staff is properly trained on the laws related to interstate shipment of dangerous goods (e.g., biological samples and live organisms). Most hospitals also receive unannounced annual surveys from their state health department, yet they are more concerned about The Joint Commission, even though both represent CMS. There is also the potential for a focused survey if your facility performs transplants or has other specialty programs that receive reimbursement from state or federal health programs. We have even had inspections from the International Air Transport Association concerning the shipment of biological samples via air and compliance with their regulations.

Continuous survey readiness does not just apply to The Joint Commission; it applies to any regulatory or enforcement agency that may arrive at your facility. Anything that is found by a non–Joint Commission agency is also subject to being part of your Joint Commission survey, which in turn can affect your facility’s accreditation and ability to receive reimbursement from federal and state payers along with private insurance. Yes, sometimes you will feel as though you are talking to a wall as you push for program compliance; however, do not give up, because your job, along with the jobs of others in your facility, can hang in the balance.

Thomas J. Huser, MS, CHSP, CHEP, MEMS is a health and safety professional with more than 33 years of healthcare and public safety experience. He has served as a security supervisor, safety officer, and manager of health and safety, and is currently the safety and emergency preparedness coordinator for a multi-physician system attached to a multihospital system. Learn more about the “Chapter Leader’s Guide to Environment of Care,” Second Edition at http://hcmarketplace.com/leaders-guide.


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