Demystify unannounced accreditation surveys

Tuesday, September 30, 2008

Q. What should I expect to happen during my unannounced survey, and how long will it take?

A. The amount of time it takes to conduct a survey is based on company size, the number of branches operating and the services/products being accredited for.

The inspection will take place unannounced, with the surveyor identifying himself and asking for your accreditation contact person. If that contact person is not available, the survey will continue as scheduled, so be sure there are other associates that can work with the surveyor during this inspection. The surveyor will conduct an opening meeting where he will discuss the survey in detail. You may ask the surveyor questions about his timeline; this is a good time to address specific dynamics about your company. The surveyor will usually conduct a facility tour as part of your opening meeting to help familiarize himself with your business.

The surveyor will interview your associates and will review both patient files and personnel files. The surveyor may want to observe a delivery, preventative maintenance work or a new patient setup. When the surveyor picks files to review for your associates and patients, he has sole discretion on which files are reviewed. A list of all associates along with their job titles and hire dates will help the surveyor pick files to review. A patient list will also be helpful. Your quality management/improvement, compliance and safety personnel will also be interviewed, and the surveyor will review all required documentation as outlined within their specific programs. Remember, the main reason for the survey is to confirm compliance with your policies and procedures.

At the end of the survey, an exit meeting will be conducted. The surveyor will address their findings and recommendations, and will note any deficiencies. The surveyor may inform you of the outcome during this meeting. Or he may explain that their findings will be forwarded to an Accreditation Review Committee and you will be informed in the near future.

Industry consultant Bob Weir is an accreditation surveyor and president of Weir & Associates. Reach