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Flexibility was Key to Successful Hospital System Survey

Matt Phillion, for HealthLeaders Media, May 19, 2009

One survey. Five hospitals. More than 40 ambulatory and outpatient locations. When Joint Commission surveyors arrived at Lee Memorial Health Systems in Fort Myers, FL, the result was a weeklong survey on an epic scale.

The health system was ready, though, having mirrored their survey readiness plan on an unusual, but interestingly appropriate model: an emergency management plan.

Each surveyor was assigned a chaperone and a scribe.

"Everyone was educated in their roles for survey," says Chris Crawford, RN, MHA, LHRM, system director of standards and quality. "We had a command center set up, and if the surveyor had a need the scribe could call the command center to assure that whatever documentation the surveyor was looking for was made available to them . . . Our plan got blown up the first day."

They had initially anticipated that the surveyors would break up and go to different hospitals, with a surveyor to each hospital, two surveyors to the outpatient and ambulatory sites, plus a Life Safety Code® (LSC) surveyor. In anticipation of this, each hospital had a vice president of patient care service ready to act as chaperone, as well as someone who knew the system well to act as scribe.

"Of course, the surveyors made the decision to stay together and do each hospital as a group," says Crawford.

This led to some quick thinking and restructuring of the health system's plan.

"We had to rethink who we had stationed at each hospital," says Crawford. "As soon as we walked out of the opening conference [with the surveyors] . . . we immediately met to deploy staff to the hospital that would have all five surveyors at once."

Essentially, the first lesson of the survey was: be ready to change.

"This was all about being able to make adjustments on a dime," says Kathy Bridge-Liles, vice president of patient care services at the Children's Hospital campus.

This was Lee Memorial Health Systems' first unannounced survey, and the first since acquiring two additional hospitals. The survey seemed destined to be exciting.

"They originally showed up in September on the day of where we were preparing for a possible hurricane, and had to turn around and leave," says Crawford.

So by comparison, unexpected tactics by surveyors were not nearly as difficult to deal with as a natural disaster.

The Lee Memorial campus was selected first by the surveyors.

"It was interesting to see how they were going to work," says Sgarlata. "All of the surveyors at the same time. We had an opportunity to see what they were looking for, themes of where they would be headed for the rest of the campuses."

It was also interesting to watch how the surveyors worked together. The five surveyors who worked to survey the five hospital campuses had never worked together, and were all normally in a leadership role in other surveys.

"I thought they worked well together as a team themselves," says Mary Kirkwood, system director of medical staff quality. "They worked well with us but also collaboratively with each other—it was one of the best teams I've encountered."

Beneficial to both sides were some ground rules established for communication—surveyors would go through their team leader with requests for information, and information would be funneled back through the team leader from the hospital rather than sent directly to the requesting surveyor, in order to keep the transfer of information steady and accurate.

Representatives of the health system were pleased at the collaborative nature of the survey.

 "We really enjoyed the time with the surveyors," says Cindy Brown, vice president of patient services at Health Park Medical Center. "There were two times when they brought staff and educators to the boardroom in Lee Memorial to talk about the process of education and how to prepare staff and make sure they're confident. It wasn't a ‘gotcha' discussion, it was a ‘share what we've learned' discussion."


Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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