Do’s and Don’ts for Managing a Regulatory Survey

On top of all the other challenges rural hospitals face is a surprise survey. On any given day, a regulator from CMS, OSHA, the Joint Commission, or the state can show up unannounced at a hospital or other healthcare facility to conduct a survey. Because the results of these surveys can have a huge impact on a health system’s financial success, a survey citing numerous deficiencies can be detrimental to a hospital’s ability to maintain normal operations. We chatted with John Coldsmith, a HealthTechS3 clinical consultant with more than 40 years of nursing, leadership and administrative hospital experience to discover his top do’s and don’ts for managing a regulatory survey.

Do alert all hospital staff when the surveyor arrives

At no point should a hospital staff be unaware of a regulatory surveyor’s presence at their facility. To that end, the health system must have a plan when it comes to receiving a regulatory surveyor as soon as he or she steps foot in the door.

“As soon as a surveyor arrives at your facility, you’ll want to walk that surveyor into a conference room to chat with someone in an administrative position,” Coldsmith said. “This announcement alerts everyone and gives nurses a chance to do a sweep through the facility to make sure there’s nothing that will fall out while the surveyor is there.”

Don’t let the surveyor roam free

Since visits from surveyors are unannounced, a bit of light scrambling from the moment the surveyor arrives is to be expected. Still, once a surveyor is on hospital grounds, he or she should be accompanied by a hospital representative at all times, preferably someone in a leadership position.

“When surveyors come to see us, I clear my schedule for the day, and they have my full attention up until the moment they leave,” he said.

Along with someone from the leadership team to act as host, Coldsmith recommended a “scribe” to tag along to make notes about which departments are being assessed, which patient records are being requested, and other pertinent information.

Don’t overwhelm the surveyor

Often, in order to get a feel for the day-to-day goings-on within a healthcare facility, a surveyor will speak directly with a member of the hospital staff. If too many members of the administrative team are standing by listening in, the chances of this conversation going poorly can increase.

“It can be stressful for your hospital staff when there’s a whole cadre of people walking around with a surveyor,” Coldsmith said.

Do have an EMR-savvy staff member guide the surveyor through your patient records. Once a surveyor delves into the electronic medical records of a patient, the possible pitfalls related to a lack of documentation and other deficiencies increase exponentially. For this reason, it’s imperative that the surveyor is paired with someone who knows that EMR system inside and out.

“Back when health systems were still using paper records, it was relatively simple to navigate a patient’s medical record,” Coldsmith said. “Now that every health system has electronic records, and because there are so many different systems, you’re going to want someone who knows just where to find those pieces of documentation that will keep you out of trouble.”

Do work with your HR department to ensure all employee records are up to date. 

Often, near the end of the visit, a surveyor will want to examine the files of one or more employees. “Every time the surveyor speaks with someone on staff, you’ll want someone to communicate that to your HR department so they can cross-check that employee’s file and make sure everything is correct and up to date, in case the surveyor requests it.”

Bear in mind, each of these tips depends on a team that is engaged and adaptive and communicates effectively from department to department. Keeping staff members engaged in their daily processes not only enhances the facility’s ability to manage a regulatory survey, it’s also likely to result in fewer deficiencies.

“In your day-to-day practice, your staff has to be completely engaged in what they’re doing,” Coldsmith said. “If there’s any hint of team dysfunction, the survey is not going to go well.”

Want more tips on getting your facility survey-ready? Check out Coldsmith’s recent webinar, Survey Savvy: How to Manage a Regulatory Survey. (View the recording here.)