Survey readiness, refers to a healthcare organization’s ongoing state of preparedness for an accreditation survey. It means being consistently compliant with accrediting organization’s standards—not just scrambling to prepare when a survey is imminent. Being prepared will reduce the stress of the survey and reduce the number of citations/findings the surveyors will find.
So, what can you do to be prepared?
The accrediting organizations offer numerous resources to help organizations prepare for a survey. For example, The Joint Commission and CIHQ have their Survey Activity Guides (SAG). These comprehensive documents outline the necessary preparation for facilities to conduct a survey, covering everything from greeting surveyors and verifying credentials to presenting documentation and demonstrating compliance with care standards. Also, there are the CMS Interpretative Guidelines on the CMS.gov website.
In addition to the SAG, it is also important to review other available tools, such as tracers, competencies, and checklists. Courtemanche and Associates has a wide variety of tracers, competencies, and checklists on their website, under the Accreditation Resource Companion ARC).
In addition to the tools, other resources available are as follows:
- Perspectives – published by TJC
- EC News – published by TJC
- Previous Survey Findings
- Evidence of Standards Compliance (ESC)
- CMS Transmittals and Worksheets
- State and Federal Regulations
- National Guidelines
- Courtemanche and Associates Newsletter – published by C&A consultants
- CIHQ Newletter – published by CIHQ
You also want to ensure that you have existing internal activities in place to help you identify vulnerabilities and mitigate them before your survey. These may include, but are not limited to, EC Committee and rounding activities, IC Committee and surveillance activities, documentation audits, and tracer activities. You may also develop teams to review each chapter of the regulatory manual and ensure that all required documents are available to the surveyors.
Tracers … an effective way to stay prepared!
Tracers can be specifically focused on, but not limited to, areas such as plan of care, moderate sedation, procedure consents, point-of-use cleaning, sterilization, restraints, environment of care, life safety, and other areas outlined in the standards that may be problematic. Compliance is a crucial area that should encompass activities such as focused tracers, reviewing medical staff and human resource files, education, training, and competency assessments. A tracer can be thought of as something like a circle, in which one area of activity directs another, then another, and so on.
To assist in identifying and prioritizing mock survey topics, you want to:
- Identifying the most challenging standards
- Review previous survey results
- Review your evidence of standards compliance (ESC)
- Establish a schedule and add it to the master calendar
- Determine the scope of each tracer and keep it focused
- Decide which staff members will perform the tracers
Additionally, assigning frontline staff to tracers may be most effective, as they will be most familiar with their departments, the issues they face, and the solutions that would work best. And finally – after the tracers have been performed, gather, report, and debrief. What went well, and what did not? How will any issues that were identified be addressed? What processes need to be established to meet the standard? Most important…FOLLOW UP.
The development of team leaders, under the guidance of the accreditation leader responsible for the overall effort, is possibly the most crucial aspect of ongoing survey readiness. The best leaders are genuine Subject Matter Experts (SMEs) who can assist with interpreting standards and help facilitate compliance and education around standards and elements of performance through tools such as staff education, newsletters, bulletin boards, audits, and tracer reports. The SME will be the face of the initiative to clinicians, leaders, medical staff, and staff throughout the organization. The champions or chapter leaders will assist with assessing compliance with standards and elements of performance within their assigned chapter and utilize other staff knowledgeable in those areas to form their own team for their particular chapter.
Another set of eyes is always helpful.
A mock survey by an outside healthcare consultant is crucial because it provides an unbiased assessment of an organization's readiness for accreditation and regulatory compliance. Here’s why it matters:
- Objective Evaluation
- Consultants will see things that you walk past every day and no longer notice. They will provide you with a fresh perspective.
- Regulatory Readiness
- A mock survey consultant will simulate real assessment conditions. They will be asking the “WHYs” and guiding the organization in understanding why things may need further examination and recommending processes to be put in place to bring the organization back into compliance.
- Process Improvement
- Mock surveys are designed to identify inefficiencies and inconsistencies in practice, enabling organizations to refine their workflows and improve patient safety.
- Staff Engagement and Training
- Consultants provide ‘just-in-time’ education throughout the mock survey. As they share their expertise in identifying what to look for, it helps ensure that the organization’s employees understand compliance requirements and feel more confident in their roles.
- Risk Mitigation
- Consultants can identify potential compliance risks early, preventing costly penalties, legal issues, and reputational damage.
It’s never over!
Continuous Readiness is a proactive approach where organizations always maintain compliance, not just during the survey window. It involves regular internal audits, staff education, policy reviews, and mock surveys, and helps reduce stress and ensure that patient safety and quality care are always a priority.
Here are some things that you can do to stay survey-ready:
- Conduct focused tracers and practice system tracer sessions
- Help with Evidence of Standard Compliance (ESC)
- Review/update policies
- Review and interpret data – implement a plan of correction as needed and follow up
- Provide input into drafts of plans developed by the organization
- Interpret and review new standards – 2026 is going to be a big year for changes
- Provide education to leadership or medical staff
- Provide education on standards and hot topics
- Help to prepare department leaders and committees
- Facilitate robust process improvement workouts
In summary
Healthcare organizations must be proactive regarding survey readiness, and the reasons for doing so are much more important and profound than simply satisfying any given set of criteria every three years. As the healthcare landscape continues to change and challenge organizations, remembering that preparedness is not only for the next survey, but also for the next patient and all those that follow, is the key.
References
- That Extra Set of Eyes Could Help!, Denise E Smith, RN, BS, MS, CLNC, HACP-CMS and Ronda Katzman, BA, Courtemanche and Associates Blog, May 2025.
- Tips for Continuous Joint Commission Readiness, JCR.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
