Do External Surveys and Survey Readiness Feel Like March Madness?

March Madness isn’t just confined to the basketball court; it can also manifest itself in the dialysis industry, mainly when working to stay prepared for a survey on the CfC (Conditions for Coverage) rules written by CMS (Centers for Medicare & Medicaid Services). A CMS survey of a clinic can occur anytime, and the fear of an unplanned inspection can be stressful for all staff and patients. Some organizations try to control the unknown timing by acquiring certification or accreditation from an outside organization. We will go into details of this approach in a future blog.

I believe that if we take a different approach to survey preparation, clinic staff will no longer feel frenzied, like they are in the middle of a March Madness tournament.

Ask yourself: When the external surveyors are in your clinics, are they just asking questions to the clinic manager or person responsible for performing internal survey readiness audits? Your likely response is NO! They watch and ask the technicians and nurses questions because they are the ones who provide direct care to the patients. Inspectors watch and talk to social workers, dietitians, and biomed staff to review areas of their responsibilities. Additionally, they speak to the administrative assistant, manager, and medical director. In other words, they speak to ALL STAFF!

It makes sense that survey readiness programs should involve all staff. In my thirty-plus years working in the dialysis industry, I have often found that survey readiness programs include minimal education about the Conditions for Coverage rules. When they do, it is not inclusive of all the roles in the clinic. Typically, internal audits are performed by just a few staff members, who then leave the manager a report of all standards that are “Not Met.” This person checking for survey readiness is often internal to the company but external to the clinic. In my experience, this method has proven to be “Not Helpful,” and I believe it’s time to change how we educate and train clinic staff so they are ready at any moment for an internal or external survey team to walk in.

One critical component of a successful survey readiness program is the involvement and preparedness of the entire clinic staff. When the staff is ready, the feelings of “March Madness” chaos diminish.

Tips for Clinics to Tackle the Madness:

1. Create an environment that prioritizes correctly following patient safety standards at all times. This means following policies that (hopefully) meet or exceed the Conditions for Coverage rules.
2. Educate all your staff on the rules of the Conditions for Coverage. There are 304 pages of Interpretive Guidance to “help” us understand the rules, and that feels like a HUGE undertaking! However, education is necessary because each clinic meets these standards during a survey. Proactively educating and involving staff assists them in following standards as a cohesive unit.
3. Engage all staff in your clinics’ survey readiness program. It is only minimally helpful when your survey readiness program consists of one or two people who perform internal audits and then write up a POC (Plan of Correction). It gains a bit more momentum when the areas not meeting the CfC are discussed with the entire staff. The most valuable gains are made when engaging all the staff in survey readiness.
4. Create your pod assignments so they can be worked safely and independently by the assigned caregiver. This leaves one or more nurses (depending on clinic size) free from needing to assist with turnover and fully available to provide oversight and feedback if non-compliance with policies is noted.

Navigating the survey process can indeed feel like March Madness for clinics. The key to success lies in comprehensive preparation that involves all staff members. This preparation should include education and a formal auditing program that helps the clinic self-identify areas of non-compliance, tracks trends, monitors for compliance with the rules of the Conditions for Coverage, and helps the clinic staff create a Plan of Correction.

Staff is constantly prepared for any survey when a cohesive survey readiness program is implemented and maintained at a clinic. Then, when an actual survey occurs, staff will be calm, ready, and welcoming. The survey team will feel like they entered a spa, not a March Madness game!

SurveyWise was developed with this approach of educating and involving all staff members in survey readiness. If you want to learn more about SurveyWise and how it can help your organization to always be survey-ready, let us know, and we can schedule a talk.

Does survey readiness feel chaotic and frenzied for you? Does an approach of involving all staff members resonate with you? We would love to hear your feedback in the comments

Mary Kay Hamilton

After staying on the sidelines for the first few years of the company start-up, I joined full time January 2015. Having a thirty-year dialysis career background in multiple roles from staff and charge RN, clinic manager and director of clinic services, I have an understanding of the clinical side, business side and Medicare regulations. I earned my Master’s in Healthcare Innovation from Arizona State University and love to help clinics and organizations find new and sustaining ways to solve challenging issues.