Have you given thought to the benefits of a mock survey? Many organizations use mock surveys to make certain they are ready for their next Accreditation or Regulatory Survey; however, mock surveys can benefit your organization in other ways. This month’s article will explore how the information collected from your mock survey can be used to improve your hospital’s quality and safety efforts, making you a step above the rest.
Assessment of Readiness – Benefit #1
Of course, on the surface, the number one reason organizations will undertake a mock survey is to determine how ready the organization is for its upcoming survey. Whether preparing for a TJC, DNV, AAAHC, other accreditation agency surveys, or preparing for a regulatory survey to assess compliance with the CMS Conditions of Participation, completing a mock survey 6-12 months prior to your anticipated survey will help your organization identify areas where additional process improvement work is required.
Discovering the Undiscovered- Inconsistencies in practice- Benefit #2
Discovering the undiscovered is also a great benefit to the mock survey process. Organizations and their employees will often develop normalized deviation when looking at their own organizations. Normalized deviation is the process by which deviance or variation from the correct or proper behaviors becomes the normal operating process within the organization’s culture. The use of an external mock survey team often leads to the discovery of non-compliance, either due to changes within the standards and/or regulations or due to the impact of normalized deviation. So often when we are conducting mock surveys staff will say to us, “But, we have always done it like this,” equating that since it has always been performed that way, the process must be compliant. The mock survey process when designed properly will compare staff performance across the organization, in comparison with the organization’s policies and procedures and alignment of both performance and written policies/procedures to the standards and/or regulations. Through this process, inconsistencies in practice and/or policy will be identified. Remember, mock surveyors typically do “deeper dives” to find out the cause of the finding allowing them to educate and recommend solutions to help your organization be successful.
Testing internal knowledge & communications- Benefit #3
Another great benefit to the mock survey process is the opportunity it creates for leaders to observe and assess their staff’s knowledge of the applicable regulatory and accreditation requirements in addition to observing how well the entire team communicates. The engagement of staff in the mock survey can provide vital feedback on the flow of information through the organization.
Understanding the why- Benefit #4
Healthcare is a complex business with complex processes. Your mock survey should not only identify process improvement opportunities but also staff education opportunities. Understanding the intent, or the why, for each standard or regulation helps to convince staff of the importance of modeling their practice to be compliant.
Performance Improvement Initiatives- Benefit #5
Mock surveys will identify a wealth of opportunities for organizations to improve upon. These non-compliant practices make perfect Performance Improvement initiatives. Utilizing small or large teams, focused on an identified opportunity allows the organization to use its PI methodologies, such as Plan-Do-Check-Act or another methodology. The more often staff utilize the methodology, the more familiar and comfortable they will become with it.
Reward and Recognition – Benefit #6
The intent of a mock survey is to identify deficiencies. The concept in and of itself sounds punitive however, organizational leaders should take the opportunity to recognize the team for a job well done or an earnest effort. Recognition of the team and its performance, not the individual’s performance, helps the team to grow. Highlighting the areas that went well, balanced with the areas that need improvement help keep staff motivated.
Transparency Opportunity- Benefit #7
Sharing the entire report with staff is a terrific way to continue to deliver on promises of transparency. Reports may present leaders the opportunity to share “the good, the bad, and the ugly.” Executive leaders should use the opportunity to focus the team. Evidence supports that transparency has the greatest impact on building trust amongst team members.
In Summary
There is no doubt that mock surveys have a direct impact on survey execution and outcomes. The mere exercise of the organization executing the simulated survey process develops greater comfort amongst staff. Keeping staff at ease and honing their communication skills helps to reduce the stress often associated with the survey process. The added benefits of hardwiring your Performance Improvement methodology into your post-survey work will also help staff become more accustomed to using those skills to solve problems. Having your team focused on identifying improvement opportunities and using improvement methodologies to drive improvement is a major culture change that is needed to continue the journey to becoming a high-reliability organization.
To learn more about how Courtemanche & Associates can support your organization through mock surveys, performance improvement training, and understanding the steps needed to achieve high reliability, contact us at info@courtemanche-assocs.com.
