In theory, preparing for a hospital survey shouldn’t be difficult. If hospitals implement the right protocols and are careful about following procedures, they’ll pass with flying colors, right? If only it were that easy. The reality is much more complex. Hospitals are housed in facilities that are sometimes outdated and sometimes break. Hospitals also are run by humans, and under stress, sometimes these humans forget to follow procedures. Meanwhile, surveyors also are human and can be finnicky—or in some cases just downright wrong—about a perceived safety issue. Because of this, tuning into safety standards shouldn’t just happen a few months before the survey is expected to take place—it should be a 365/24/7 endeavor.
Ernie Allen, a life safety consultant for HealthTechS3, aims to show why safety standards need to stay top of mind in the webinar, What’s Wrong With This Picture?, coming up on March 12. In this interactive event, Allen, who’s a former Joint Commission Life Safety surveyor, will show photos taken during mock surveys and invite participants to find the faults.
Hospitals are highly regulated when it comes to safety—there are CMS regulations, OSHA rules, state laws, local fire codes, and Joint Commission standards, if applicable. But rural hospitals, especially, are at a disadvantage for keeping up with these due to the lack of qualified staff they usually have dedicated to the topic.
“It’s a big issue for them, because staff doesn’t always have that expertise,” Allen says. “A facility manager at a rural hospital may have just grown up in the community and was mechanically inclined. That doesn’t make them a safety expert.”
What’s more, resources at the local level are often lacking. Sometimes even the fire departments are run by volunteers who lack both the critical understanding of hospital fire codes and the resources to conduct the survey.
But that’s no excuse to skirt compliance. Safety issues can add up quick on a surveyor’s score card, and the effect can be detrimental. Not only does it put a hospital in fix-it mode—finding the funds it doesn’t have to correct safety issues it didn’t know it had—it also can be damaging to a hospital’s public image and bottom line.
“If CMS finds some serious deficiencies, they can put hospitals on a watch list,” Allen says. “At a minimum, conditional accreditation means you have to tell the news stations and put a notice in the newspaper. If you don’t pass the follow-up inspection, CMS can withhold funding or cancel your hospital’s contract.”
Staying in compliance is less onerous than being forced into compliance by a safety survey, Allen says. And while this safety mindset may start with gauging your ability to spot the safety issues in a photo, it can’t stop there.
Allen recommends a routine mock safety survey for any hospital—conducted at least one year before you’re expecting the real survey. Larger hospitals with established safety expertise might be able to conduct these in-house, but for smaller hospitals strapped for resources, engaging an outside safety consultant will help ensure it’s not an exercise in futility. “It’s helpful to have outside eyes and ears,” he says. “Sometimes you can’t see the forest for the trees and a lot of times people don’t realize some things aren’t compliant.”
Don’t miss Allen’s webinar to help you identify gaps in your hospital safety knowledge. Invite everyone on your safety committee, including the facility director, risk manager and infection control nurse. Really, everyone in the hospital, including the CEO, can benefit from understanding what it takes to ace a safety survey. Reserve your spot today.