3. Expect the unexpected
Of course, things will come up that you wished you knew about
beforehand. Ms. Merriman found this out when surveyors conducted
a building inspection. "On my first survey, because it was a new facili-
ty, we missed some building codes and minor things like not having a
safe distance between a fire alarm pull station and the floor," she says.
"I wish the [accreditor's standards were] more descriptive about what
they wanted you to follow."
Have a good understanding of how every aspect of your facility
works, including seemingly obscure things like your voicemail system.
"I found out surveyors call the main line after hours to check if the
phone greeting is appropriate," says Ms. Merriman. "They wanted to see
if they could reach someone on-call and made sure the normal business
hours were mentioned on the recording."
4. Plan ahead
Leadership at Northside Hospital created an Excel spreadsheet to
help organize what needed to be done before the accreditation survey.
"We listed accreditation standards in one column and noted if we
were meeting those standards in another," says Ms. Thompson. "If we
weren't meeting a requirement, we noted what had to be done to meet
it, who would make sure we did, and by when."
Her preparation and planning began about 6 months before the
expected survey date. Working that far in advance helped with imple-
menting the changes she needed to make before the survey was con-
ducted. Ms. Thompson says staff have to be educated about meeting
accreditation standards, and constantly reminded about the impor-
tance of doing so until the surveyor arrives.
"Staff get busy and forget, so for example, we had somebody in
charge of observing them to see if they complied with hand hygiene
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