There are two types of recommendations that can come out of a mock survey: good recommendations and unhelpful recommendations.
If you’ve had a mock survey before, it may have been delivered with recommendations like:
- “Staff should be educated…,”
- “Be sure to remind the physicians…,” or
- “Don’t do this anymore!”
Two of these are “managed loose” accountability black holes. The other is a hard stop with no alternatives offered, which is a very hard direction to follow. Neither is going to solve the problem, and both will likely compound issues further. Unhelpful.
A good recommendation from a mock survey should be helpful. It should do one or more of the following:
- Make an actual recommendation like, “The policy should be reworded to say…”
- Reward critical thinking by reinforcing a care facilitation approach and concurrent monitoring suggestions.
- Provide a practical tool like a form or checklist to assist with quality control.
- Define a path for next steps when more analysis is needed to determine if a cited issue is isolated or related to a significant process flaw.
When you receive a report from a mock survey, and there are findings outlined, you should feel like a root cause is known, or that you have a path to find it. If recommendations you receive are falling into the “unhelpful” category, you are left to either find the root cause yourself, or make changes without a real understanding of what the root cause is.
A mock survey should leave you with:
- A clear understanding both requirements and findings,
- An understanding of root causes of noncompliance (or likely culprits and how to single them out and address them), and
- Practical solutions for policy/process/care delivery to get you to compliance without undo complexity.
No matter where you are in your accreditation cycle, it’s never too late to get an independent and objective evaluation of your level of preparedness.
For more than 30 years, The Greeley Company has partnered with hospitals to solve the toughest regulatory compliance challenges through our clinical expertise and practical, straightforward application of regulatory requirements.
A Greeley Mock Survey can help you avoid some of the common vulnerabilities that trigger 90-day CMS terminations, immediate jeopardy, or preliminary denial of your accreditation:
- Suicide screening and assessment
- Ligature resistance in the behavioral health setting
- Restraint and seclusion
- Sterilization and high-level disinfection
- Medication ordering, safety, and security
- High-risk procedures
- Assessment of care planning
- And other areas of high vulnerability
If you would like to start the conversation about partnering with Greeley for a mock survey at your facility, please contact us by completing the form below or calling 888.749.3054.