Courtemanche & Associates (C&A) has been partnering with clients for over 30 years and has conducted hundreds of mock surveys during that time. Our experienced consultants have traveled throughout the United States and have seen thousands of deficiencies as well as best practices along the way. Over the years, some organizations have elected to bring their mock surveys in-house, utilizing their own staff as surveyors. For some organizations, this has worked well, but there is a substantial number for which it has not. It is not uncommon for this latter group of organizations to call us back to have our consultants do their mock surveys again. Our team often hears immense appreciation for what their expert ‘set of consultants’ eyes’ brought forward, as clients acknowledge it is challenging to stay apprised of all the changes and quite easy to become blinded to the ‘every day.’
There can be financial savings to doing surveys in-house without the aid of external experts, and we realize healthcare organizations are navigating tight budgets, inadequate staffing, and issues that arise. However, in multiple cases we have observed patient care and safety being compromised. This is why we encourage organizations to engage an external expert to survey your organization.
What Can a Consultant Do for Your Organization?
A mock survey by an outside healthcare expert is crucial because it provides an unbiased assessment of an organization's readiness for accreditation and regulatory compliance. Here is why it matters:
Objective Evaluation
Outside consultants can walk through your organization and see things that are non-compliant, things you walk past every day and no longer notice. Items that are familiar many times are overlooked. How many times have you walked through the hallway lined with gurneys and never given it a thought. It has become part of the décor. Our experts look at things differently than those who look at them daily and provide a fresh perspective!
Regulatory Readiness
Our team helps healthcare facilities prepare for Joint Commission, CMS, DNV, CIHQ, AAAHC, or state regulatory surveys by simulating real assessment conditions. Through their vast experience the consultants have seen it all. On occasion, we come across something that is unique to an organization but not compliant with the standards, and in these instances, we inquire WHY. Knowing the "why" is essential because it provides clarity, direction, and purpose. It helps identify gaps, thus facilitating informed decision making to drive an improved connection between actions and outcomes. Consultants can guide the organization into understanding why things may need to be looked at more closely and processes put in place to bring things into compliance. Some fixes are quite simple, others require a more in-depth look at what is happening.
Process Improvement
Mock surveys are intended to highlight inefficiencies and inconsistencies in practice, allowing organizations to refine workflows and enhance patient safety. Patient safety is the priority!! Our consultant team has been to some of the most efficiently run healthcare organizations in our nation. They have seen some phenomenal best practices in their journey. They carry this knowledge with them on their travels from one facility to another, sharing perspectives to aid organizations in addressing their challenges and enhancing their processes to ensure that the patients are getting the best care possible. By reviewing performance improvement processes and the organization’s collected data, the consultant gains insights into the organization as well. We may look at how the organization collects its data, analyzes it, and implements the plans of correction to prevent harm to patients. Is the organization collecting data that will impact the areas that affect patient outcomes?
Staff Engagement & Training
Our consultant team provides ‘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. This helps to foster a culture of continuous improvement and prepares them for a survey with an accrediting surveyor. Our consultants will interview not only leadership and managers, but also staff at all levels. While performing a tracer, we speak with staff asking them questions related to policy and procedures, manufacturer’s information for use as well as occasionally asking staff to do a show and tell. For example: show me how you clean the glucometer, how does the insulator tester work, and show me how you use the borescope. This line of questioning and coaching helps build confidence in the team and makes them more comfortable when they need to speak with an accrediting agency surveyor. Along with asking questions and going through medical records, consultants educate the team as to why their findings are not in compliance with the standards and make recommendations on how to resolve them. By educating everyone, it is our hope that there will be improved patient care as well as improved preparedness for your accreditation survey.
Risk Mitigation
Identifying potential compliance risks early can prevent costly penalties, legal issues, and reputational damage. Legal expenses for things that have gone poorly can be very costly. No organization wants to make the newspaper or Becker’s due to an adverse event. Bear in mind that there could also be a significant impact on an organization’s CMS reimbursement.
Reports
When organizations do their own mock surveys, they do not always have a platform for developing a meaningful report. C&A has proprietary report writing software that allows the consultants to capture the findings, along with images, and provide the information in a severity ranking manner. Our consultants will provide organizations with an executive summary outlining the high-risk findings, tagging those that have the potential to be cited as an “immediate threat to health and safety” or “immediate jeopardy” before we walk out the door. We also provide a list of priority findings that should be addressed sooner rather than later. A final report with detailed findings is sent soon thereafter, along with our priority matrix and pre-populated spreadsheet with all the findings, in a format that allows the organization to utilize it as an action plan document.
Summary
An outside consultant has experience seeing what is occurring around the country including not only the bad things but also the good. They bring with them a treasure chest of best practices they have gleaned, from various organizations as well as an eye for spotting the non-compliant issues. They are there to help your team be more aware of where efforts stand today and how to address gaps for improvement.
In house mock surveys may save you money initially, however, is it at the cost of patient safety and quality care? As expert consultants – we are here to help you be the best of the best in healthcare.
References
- The Joint Commission FAQ - Mock Surveys.
- How Mock Surveys Are Beneficial to Your Healthcare Organization, March 1, 2022 / By Patricia Cook, BS, R.Ph, HACP-CMS.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
