Preparing for an accreditation survey can feel daunting for a facility manager. However, with good preparation and a proactive mindset, you can retain control of the process and use it to highlight your hospital's dedication to safety and compliance. Let’s explore the essential steps for a successful outcome.

When Does the Survey Start?

An accreditation survey doesn't start when the surveyor walks through your doors - it begins much earlier. Surveyors may review your Facility Demographic Report (FDR), Life Safety drawings, and previous survey findings well before arrival. Their on-site evaluation will start in the parking lot or during a pre-survey drive to familiarize themselves with your facility's layout and entry points.

This highlights the importance of thorough preparation and continuous survey readiness. Your goal is to present your facility in the best possible light, starting with that first impression.

Building Your Toolkit

Documentation is your safety net. Keep these ready and updated:

• Facility Demographic Report (FDR)
• Waivers and Equivalencies
• Life Safety Drawings
• Emergency Operations Plan
• Physical Environment Management Plans
• Safety Officer Appointment Documentation
• Alternative Life Safety Measures Policy
• Smoking/Tobacco Policy
• Fire Response Plan
• Safety Committee minutes
• Drill Critiques

The goal is to anticipate what the surveyor will request and have it readily accessible, minimizing delays and showcasing your preparedness. Consider assembling a binder (paper or digital) with the documents listed here that will likely be requested during the survey. 

While a binder is not required, this best practice is a practical solution that ensures the facility manager has one less thing to scramble for during the survey, allowing for a smoother and more controlled process. Delivering this binder to the survey team at the opening conference provides them with immediate access to key materials, creates a strong first impression, and demonstrates readiness. Ensure these documents are always kept up to date for optimal efficiency and preparation.

The FDR is more than just a description of your building or a compliance tool—it's your chance to narrate your facility's unique story and demonstrate your own understanding of the facility’s operational intricacies. To make this document an asset:

• Review and update it annually. Significant changes to your building should trigger an immediate review.
• Provide details for equivalencies and waivers. Include times when a CMS categorical waiver has been employed. Clearly document these to avoid ambiguity.
• Provide context. Explain unusual features or answers, such as the presence of a flywheel, BESS, or SEPSS.

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Be The Expert Tour Guide

Approximately 65% of survey findings are identified during the building tour. As the designated guide, you will need to be confident and ready to maintain control of this critical part of the survey process. Here are some tips:

• Know your building systems. Stay updated on the status of critical panels, including fire alarms, generators, and medical gas systems. The answer "I don't know" when it comes to a fire alarm panel's condition is the wrong answer. When coming for the opening conference, go by the alarm panels to observe the status. If there is an issue, have someone get you the information about the condition as soon as possible.
• Use practical tools. Provide the surveyor with readable Life Safety Drawings, whether printed or digital. These drawings serve as the source of truth for your hospital’s passive fire protection systems, offering critical information about barriers, compartments, and other safety measures. If possible, give the surveyor a set they can annotate, ensuring they clearly understand your facility’s compliance.

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Anticipating Surveyor Hotspots

Certain areas are almost guaranteed to draw a surveyor's attention. Here are some examples:

• Main Fire Alarm Panel: Ensure proper labeling, clear status indicators, and compliance with NFPA standards.
• Master Medical Alarm Panel: Ensure clear status indicators and compliance with NFPA standards.
• Emergency Generator: Confirm the "run/off/auto" switch is set to "auto," the room is fire-rated, and remote manual stop stations meet location requirements.
• Operating Rooms and Surgery: Be ready to discuss temperature, humidity, and air change standards. Provide documentation, such as T&B reports, for critical spaces like sterile supply and decontamination areas.
• Areas Under Construction: Be ready with pre-construction risk assessments (PCRA), including Alternative Life Safety Measures (ALSM) and Infection Control risk assessments (ICRA). The surveyor will observe whether the measures identified in the risk assessments have been initiated and whether they are effective.

Proactively addressing these high-risk areas streamlines the survey process and demonstrates your command of the facility's physical environment. To further enhance your readiness, walk the route from the opening meeting space to the main fire alarm panel, viewing the path through the eyes of a surveyor. Look for any potential issues, such as improper labeling, blocked exits, or visible maintenance needs, and address them before the survey begins. This practice helps you anticipate findings and maintain control of the process.

Effective Documentation Management During Surveys

A significant portion of findings - 35% - stem from documentation issues, often linked to deficiencies identified in reports without corresponding corrective action records. Closing this loop is critical to ensuring building systems operate as intended and comply with standards. Surveyors will validate during the review that building systems observed during the tour have been properly maintained.

Whether your documentation is on paper or electronic, being organized is essential. Use any worksheets or checklists your accreditor may provide, and structure your materials to support an efficient review process. Organizing documentation in the order that a surveyor is likely to follow not only reduces stress but also ensures a logical flow during the survey. 

On-the-Spot Corrections and Evidence Collection

It's not uncommon for surveyors to identify findings during their visit. While these will still require a Plan of Correction (POC), you can take immediate action:

• Start corrections promptly. Don't wait until the survey is over.
• Document everything. Take before-and-after photos, log work orders, and retain emails. These serve as evidence when submitting your POC.
• Request follow-ups. If time allows, ask the surveyor to revisit corrected areas to confirm compliance.

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While the Clock is Ticking

As the survey progresses, time becomes a valuable commodity. Making proactive corrections gives a facility manager some relief from the stress of timelines because each deficiency requires a response. Getting a head start allows for better time management and planning for corrections. The surveyor’s review doesn’t end with their visit; findings are often evaluated further post-survey. Your task is to ensure every correction is documented clearly, understanding that the reviewer may not be the same person who conducted the survey.

Preparing for a Re-Survey

A re-survey will occur when a facility is cited for a condition-level finding. A condition-level finding could result from the number or the severity of noncompliant standards. A re-survey should include planning similar to a routine triennial survey. The advantage is that it is focused on the deficiencies cited during the original survey. This allows the facility manager to plan the path of the building tour better and have the documentation ready for immediate review. Use the lessons learned from the initial visit to refine your processes and bolster compliance. Demonstrating improvement is key to a successful outcome.

Final Thoughts

Managing a survey is both an art and a science. It demands meticulous preparation, proactive problem-solving, and a deep understanding of your facility. By embracing these principles, you can confidently navigate the process, turning a potentially stressful event into a showcase of operational excellence.

Remember, preparation isn't just about checking boxes - it's about demonstrating that your facility is a safe, efficient, and patient-centered environment.

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