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In healthcare, facility directors are constantly barraged with multiple meetings and requests above and beyond their already assigned job duties. Many times they go from one meeting to another and walk halls they’ve seen a thousand times. Even when traveling, we all become desensitized to our surroundings. Before long, our environments become somewhat oblivious to us. We start to fail to see what is right under our noses. As a result, we walk by obvious deficiencies.
As a former Joint Commission surveyor, I remember many times facility directors would say they’ve walked by an area for years and never saw a deficiency, even though it was obvious. These directors are thorough and articulate, but their environment has caused them to have tunnel vision. So how can a mock survey help?
With the increase in regulations coupled with the increase in duties, many organizations have started utilizing mock surveys to help them become better prepared for accrediting surveys. Mock surveys have proven to be an effective tool to identify shortfalls within a facility. Companies or vendors providing the service are specialized and solely focused on this process. A thorough mock survey should include focusing on documentation, the physical environment, emergency preparedness, and specialized tracers.
An invaluable component of the mock survey process is to engage in open and honest communication about your facility’s deficiencies. You gain the capability to work through identified areas without facing the possibility that the issues become a formal deficiency. The process truly becomes a partnership that provides a personal advocate to your organization and assists you by providing a risk-rated report. Mock surveys not only allow you the ability to identify issues, they also provide you with a follow-up mitigation process to fix problems prior to your accrediting agencies arrival. Granted, mock surveys are not 100% accurate and never will be, but they will help you identify and minimize as many issues as possible prior to your formal survey.
A quality vendor should ensure they are available to any questions you may have beyond the mock survey and continue to work with you for future surveys. Your vendor should consider this a partnership and commit to providing you the best possible service. Being able to work with the same person or company year after year allows you the opportunity is an asset. It continues working forward in your organization, not having to provide a lot of background on the facility status and the environment with each visit. Establishing an on-going relationship with your vendor also provides your organization education on trends regarding accrediting agency and industry developments.
Today’s mock surveys should be more intrusive than in years past. Your mock surveyor should focus on all areas of the survey process and not specifically their company’s specialty. Your vendor needs to be well versed in many areas, i.e., physical environment, security, infection control, and behavioral health. Ensuring that these areas are covered prior to working with a provider will help you become more confident with your processes and give you comfort that you’re receiving a well-rounded survey to help your organization grow.
To learn more about the Soleran mock survey, click here.
Speakers Include: Lance Woolf-MBA, CHSP, Former Joint Commission Surveyor & Director of Life Safety Compliance at Soleran Chris Tokas - Deputy Director for the Facilities Development Division at California Department of Healthcare Access and Information Vic Mosby- Architect at ACI Boland Architects
April 14, 2022
Documentation over the past few years has become more of a focus during accreditation surveys. This is partially due to the many different versions of the NFPA that are being utilized today.
August 2, 2020
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