Registry Partners Consultants play an important role in survey preparation with many clients throughout the year. Our clients often ask questions like: “What will the survey day be like?” “What do you know about the surveyor?” “Will he be tough like the JCAHO?”
Our Consultants have the great opportunity to explain to our clients that surveys are not meant to be stressful. They are an opportunity for growth and education and often, a time to “shine”. We have experience with many of the surveyors and they recognize our consultants and definitely our name! With that experience, we often can provide little anecdotes about a surveyor and already know some of their interests and common questions.
Preparing the Survey Application Record and supporting documentation is a service we provide but just as important is sharing our experience about the dialogue that occurs on the survey date. We prepare key committee members by asking them questions similar to what the surveyor may ask. We emphasize the importance of all committee members answering questions. If only one member is answering all of the questions from the surveyor (especially if it is the CTR), the program is going to receive a short sermon! The surveyor is going to emphasize the importance of a multidisciplinary committee and involvement of everyone. We also recommend each committee member be prepared to answer, “What is your role in the cancer program and what do you do to improve their care?” Most committee members have good answers but they do much better when they have had time to prepare.
If a program has had a gap in compliance in some areas, be honest and emphasize that the problem was recognized and the steps that have been taken toward compliance. Identifying an issue and developing an improvement plan is the first steps to already resolving a deficiency. The surveyors understand hospitals have been undergoing rapid changes in services and leadership. This has resulted in difficulties with implementing certain programs and sustaining others. Emphasizing what has been done well and what is being done to improve are the first steps to success.
The CoC Surveyors study the Survey Application Record (SAR) and have done their homework. The committee members also need to be aware of what has been included in the SAR and be able to speak to the documentation the surveyor is referencing. The SAR is the best tool for preparation and it is essential to use the comment areas to explain the scenarios specific to your facility. Sharing the strengths and the passion for the oncology services of a program is essential. The CoC standards are only the framework to develop a quality cancer program for your patients. The dialogue and presentations provide the details needed for the Surveyor.
If you feel like you need assistance as you prepare for survey or would like to schedule a consultation with our team, please fill out a request for information here or contact Linda Reimers at 336-226-3359.