Quality Scenario 1

Survey Preparation

Guidance and tools to help make sure you are prepared for the next unannounced survey.

Workflow Automations

About this Scenario

You have recently joined ABC hospital, a critical access hospital in Arkansas, as the new hospital quality director. You are a department of one for the quality department, and you also oversee infection prevention and risk management for the hospital in this new role. ABC Hospital is a 25 bed critical access hospital with an average inpatient daily census of 3, and you have 5 swing beds, plus the community’s only emergency department and hospital for over 100 miles. You have been informed that your hospital’s unannounced triennial accreditation survey from The Joint Commission is due within the next 6 months. What are the steps you need to take to adequately prepare for this survey?

Workflow Automations for Survey Preparation

Take a look at the Workflow Automations that you can use to better address Survey Preparation.

Workflow Automation

1. Locate, Analyze & Validate

The goal here is to group individual deficiencies into larger, systemic issues. Surveyors think in themes, and you should too. This prevents you from playing "whack-a-mole" with individual problems and allows you to fix the root cause.

Workflow Automation

2. Surveyor Priorities & Focus Areas

The goal here is to group individual deficiencies into larger, systemic issues. Surveyors think in themes, and you should too. This prevents you from playing "whack-a-mole" with individual problems and allows you to fix the root cause.

Workflow Automation

3. Systemic Review & Action

This workflow addresses both scenarios (if a location exists vs. if it doesn't) and champions a "best practice" hybrid approach of a primary physical binder with a mirrored digital backup.

Workflow Automation

4. Quality Council & Committee Review

This workflow is designed to be highly efficient and to produce a clear, evidence-based assessment of your hospital's compliance monitoring.

Workflow Automation

5. Monitoring the Action Plan

This workflow is designed for efficiency and to produce a clear, evidence-based summary that will inform your survey preparation strategy.

Workflow Automation

6. Survey Readiness

This workflow is structured as an investigation, following the logical paths your questions have laid out. It moves from reviewing documents to validating at the point of care.