Getting back to whether surveyors are always correct

Since I sort of went off on a tangent in my last posting, I neglected to come right out and answer the question of whether surveyors are always correct. The answer to which is, of course, a great big fat NO.

Let's back up and trace what happens: A surveyor will see something at an organization that he or she really likes, for whatever reason. Maybe it's something different, nifty, or simple. The surveyor asks for a copy of the policy, form, etc., and then--flash, bam, alakazam--that form becomes the "standard" for that particular surveyor.

Just now, as I was penning this missive, I received an e-mail from a survey coordinator feeling the hot, fetid breath of a surveyor on his neck. The issue? The organization couldn't document performance and safety testing of medical equipment between patient uses. Crikey--that's some standard!

Just step back for a moment and consider EC.6.20, element of performance #2, which states that the "hospital documents performance and safety testing of all equipment identified in the equipment management program before initial use."

It appears the surveyor in question has extrapolated "before initial use" to equate with "before initial use on each patient." Can you imagine how big your clinical engineering staff would have to be to meet this mandate? How could you possible capture every single piece of equipment in the program, like infusion pumps and blood pressure devices? Can you imagine the chaos? In a flash, why you'd probably need to have as many clinical engineering techs as nurses. Ouch!

You need to have a very clear sense of what makes the mark and what doesn't. There are surveyors who are fond of the devil's advocate question, just to see how comfortable you are with your process. If they cite something out in the environment that is clearly not compliant, you can certainly take your lumps.

But if surveyors start chasing you about "how" you are doing things, then keep all your options open, such as:

• Special resolution time with that particular surveyor or with the team leader
• Red-flagging the citation for review at Joint Commission headquarters
• Making full use of the clarification process post-survey

Don't make the error in thinking that because you are not perfect, you are thus not in compliance with a standard. A lot of the elements of performance are rate-based, but surveyors only need to find three instances of noncompliance with any "C" element to issue a requirement for improvement. For "C" elements, if your compliance level is greater than 90%, then you are considered compliant; you don't have to be perfect.

I can tell you from personal experience, there are few things more frustrating than trying to "fix" something that is not truly broken. You've got more than enough to do--don't go looking for more work (last cliché, for now).

Safety is as safety does (thanks Forrest!),
Steve Mac.
smacarthur@greeley.com