Practicing Survey Readiness All Year Round

Preparation is key

 

It is important for all sterile processing departments (SPD) to provide high-quality products and medical devices that are safe to use on patients. The sterile processing (SP) environment requires the use of highly technical equipment and machines to prepare surgical instruments through intense cleaning, disinfection, and sterilization practices. Just like the SPD each department of a healthcare organization is responsible for different aspects of the patient care journey. These duties and responsibilities are to be validated and verified for compliance, safety, and quality to ensure patients are receiving the services they pay for and that the healthcare organizations are delivering the care they promise. One way this is done is through the accreditation process.

The purpose of the accreditation survey process is to validate compliance of the work the healthcare organization and its personnel is doing, in this case the sterile processing department (SPD). It is not intended to be scary, frightening, or confrontational by any means, but rather to provide a meaningful assessment and to share best practices and resources that the surveyor might observe during their visit. These visits include observations, interviews and investigations into the activities that are taking place in any healthcare environment providing care.

Surveys are meant to be transparent, collaborative, and educational. The necessary steps for becoming prepared in the SPD should be discussed in advance of the facility’s next scheduled visit or survey “window”. Every SPD professional's role is driven, and can be influenced, by many different regulatory bodies from the federal to state and even local levels. The preparation should be happening in a routine and methodical way, so no team members are left surprised, or rushed and the surveyors are not blindsided when they arrive. Many agencies will help you to prepare, and some will help you plan.

Many agencies expect that the sterile processing team, as well as the organization’s leadership, are familiar with and trained to these expectations and have a clear understanding of what is expected of them. It is very important to be knowledgeable of the relevant standards impacting the SPD and infection prevention practices, ahead of the survey site visit. If you are not familiar, or haven’t been properly informed, make sure to ask questions throughout the year and be a part of the proactive planning committee or team.

Expectations

 

The surveyor will expect SPD staff to be able to speak to their role in all the activities they are responsible for completing to include reprocessing instruments and their impact on patient outcomes. It is all around the practices the workers complete every day. While we have heard this memo many times, it doesn’t hinder the fact that nervousness sets in and anxious responses may come from the team. 

Really staying true to what you do every day is going to result in the best outcomes. If it is the day of the survey and everyone runs from the department leaving only the manager to speak, what does that really accomplish? How can the true processes of that department be evaluated?

Being proactive when it comes to survey readiness is the best option in planning with your team, here are a few key tips to help you incorporate survey readiness all year round.

 

• Understanding what regulations, guidelines, and standards your organization is following, in particularly with infection control, aseptic practices and surgical services. This will help you to prepare with your team based on these agencies and resources.
• Review, prepare and distribute the policies and procedures related to your work area, making sure your department is practicing what is stated in your policies. These operating procedures are critical to the staff and the organization’s success and should be easy to locate and read.
• Provide useful information and resources to your team that can help them prepare. For example, the Joint Commission’s sentinel events and safety alerts or SAFER matrix tool can be found on their website and, along with their standards, will help with.
• Review previous survey findings and reports to ensure you are prioritizing the right things before the next on-site visit takes place.
• Build a cohesive multi-disciplinary team to create mock audits and surveys you can complete throughout the year to ensure compliance stays sharp.
• Practice survey questions in your shift huddles and team meetings and practice these conversations with answers with your team so they feel confident in their responses when the day comes to speak with a surveyor.
• Work through opportunities together and make plans for those opportunities you can’t complete before the survey takes place. For example, if an opportunity requires budget and construction to take place, make sure to have the entire plan of action mapped out so you can share that with the surveyor. They are looking for progress, not perfection, and will be happy to see the development and timelines associated to each project you might be working on.