Do you ever wonder what a mock survey consultant does prior to visiting your organization? Have you been curious about the extent of preparation that occurs, how we are able to identify areas for improvement (or regulatory gaps) in a short period of time, and how it all comes together in a final report to enable effective resolution? Let me take you through the consultant’s days leading up to your mock survey and give you a peek into what brings you a stellar mock survey experience.
Here we go!
Once the Services Agreement is signed and the organization has selected its dates for service, a consulting team is assembled based upon the specific needs of the client. A Consultant Team Leader is designated to guide this team through the mock survey process. This Team Leader facilitates the development of the client agenda, serves as a conduit for information between client/team/C&A Leadership, and functions as a logistics specialist and problem solver. Once on-site, the Team Leader will keep an eye on the overall survey process and continually monitor to ensure that the client’s goals and objectives are being met or exceeded, while also serving as a consulting member of the team.
As the dates for service draw closer the client contact of the organization will receive C&A’s agenda planning template. In addition, a copy of the most recent accreditation report is requested from the client. Both C&A’s Lead of Administrative Services and the Team Leader will continue to work with the client contact to develop an agenda that includes time dedicated to visit and/or explore areas and /or topics that the organization wants to ensure get attention. You, the client, decide the areas of focus you want the team to concentrate on during the survey visit and our consultant team members are assigned to the respective focus areas based upon their credentials and expertise. At about 10-14 days prior to the visit, the Team Leader will reach out to schedule a planning session with the client contact to review the ‘final’ plan. Even with all the planning, we recognize things might come up to warrant changes to the plan, such as making a discovery during the survey of an area that would benefit from a deeper dive, or perhaps a Regulatory Agency may make an unexpected visit. For reasons such as these, the agenda is considered flexible and dynamic. Remember, our team is on-site to address needs and objectives unique to our client’s organization and works with the organization’s contact to ensure a thorough consultation is provided in the least stressful manner.
With agenda in hand, the team gets to work on their assigned areas. This means extensive reading, studying, tool development, and research! Each consultant reads through the organization’s previous regulatory survey and outlines a tentative plan specific to their assigned area(s). We review the standards that were cited on your previous survey, see if there are any updates to those standards as well as researching current professional articles on the topics. We utilize a host of professional healthcare/industry resources to review the latest standards of practice or guidelines. Then it’s a visit to our consultant’s toolbox to gather tracers, competencies, articles, best practices, and other resources for each area assigned. During this part of the diligence the consultant team members may identify areas for focus and submit a request, via the Team Leader for documents to review prior to their visit. The Team Leader will also let you know what documents the team would like to have available on arrival, such as blueprints, plans, contracts, competencies, employee files, credentialing files, additional policies, etc. These are typically the documents that are requested by the applicable accrediting organization or CMS.
Once the requested documents are received the team members read through them to ensure congruency with the standards and ensure they are prepared to offer appropriate refinement(s) suggestions, once onsite. This preliminary review of policies serves another function as well, to enable the consultant to identify alignment or deviations in staff practices as they observe and speak with them during the mock survey. Recall that failure to follow the organization’s policies and procedures is a citable deficiency.
Our objective is to know as much as possible about your organization before we get there, so even with the vast information in hand the diligence continues and may include review of your organization’s website, as well as your Quality Check reports.
As the days to survey come closer, the team is now ready for travel and the arrangements are made. The consultants typically arrive the day before and meet as a team to solidify the survey strategy and address any last-minute questions or updates. Bright and early the survey begins……
We at C&A are honored that you have chosen our company to partner with you for your mock survey(s). We are committed in helping make sure that your organization is the best that it can be. We invest the time prior to our visit to make sure that we provide you with the most thorough and comprehensive survey possible. Why do we do this? To deliver the best insight and guidance to each organization we visit to ultimately provide the best quality of care for each and every patient, one consult at a time.
It is my hope that you now have a better glimpse as to what goes on behind the scenes.