Have you ever asked yourself, do I really need a mock survey done at my ASC every year? Well, if you want to enhance patient care, boost staff morale, and ensure regulatory compliance, an annual mock survey goes a long way in helping you achieve your goals. The most successful ASCs build and maintain a culture of continuous compliance. Conducting an internal or self-survey can bolster your level of preparedness and increase staff involvement. However, a self-survey is not a replacement for a formal, third-party mock survey.
A well-done mock survey will evaluate your operations from an objective perspective and highlight what is working, identify potential areas of risk, and provide a guide for improvement efforts. An outside mock survey can also provide your leaders, owners, and governing board confidence that your ASC is ready for a real survey. A formal mock survey is a tool that should be in every ASC Leader’s toolbox.
Accreditation or Regulatory Survey Readiness
The arrival of surveyors to your ASC should never be a surprise. Staff should feel prepared and confident answering questions, locating documentation, and walking surveyors through your facility. Whether you are conducting a mock survey or a self-survey, practice is key. Practice that utilizes the accreditation or regulatory materials is essential. An informal walk-through of your facility is valuable but may not provide your team with the thoroughness of an actual surveyor. Make sure that your mock survey is as real as possible.
A third-party mock survey should also provide an exit interview and a detailed written post-survey report with specific findings and action items to address. This will allow your Team to address any findings on your timeline rather than under the pressure of a formal Plan of Correction. Proactive preparation is one of the most cost-effective ways to keep you in good standing and avoid pauses in surgical cases.
Communication & Knowledge Can Be Challenging to Assess
When determining if a mock survey is right for you and your ASC it is important to understand the ways it can elevate your center. Mock surveys can provide an assessment of readiness but also identify performance improvement initiatives and evaluate internal knowledge and communication.
Clear communication is the backbone of any successful organization, and a mock survey can provide vital feedback on how information is flowing through your ASC. During a regulatory survey, staff are often asked about policies and procedures, record keeping, and documentation standards. A skilled mock surveyor helps identify gaps in knowledge and coaches team members throughout the survey providing teachable moments and educational opportunities along the way. Mock surveyors help staff and physicians understand the how and why behind existing policies and procedures and give tips on how best to respond to questions in a survey, helping ensure your team is confident and prepared.
Acting on Findings with Your QAPI Program
We all know that having a robust Quality Assessment and Performance Improvement (QAPI) program is a must for ASCs. Having a clear purpose and rationale significantly enhances the effectiveness of implementing change. Mock surveys can identify non-compliant opportunities that become perfect QAPI projects. Linking QAPI projects to survey readiness provides a purpose for the work. Don’t forget, QAPI programs are not just for direct clinical care. Physical plant projects, HR documentation projects, and even revenue cycle improvement projects all fit into your QAPI program. If you can measure and improve it; document it and take credit for it!
Key Things to Look for in a Mock Surveyor
When selecting a mock surveyor, you want to ensure that you will be getting everything you need from the process. Be sure to ask:
How big is the mock survey team & how long will they be onsite?
You want to ensure that your mock survey is comprehensive enough to mirror a real survey. Depending on the size of your ASC, the mock survey should be 1 to 2 full days on-site with 1 to 3 surveyors.
Does the team have clinical qualifications?
While not essential, it is helpful to have mock surveyors with a clinical background to effectively question staff and observe clinical practice.
What will they be using as a guide document?
Ensure that the materials guiding the survey and their approach on-site are from the right regulatory or accreditation organizations.
Will you receive a detailed post-survey report?
Your mock survey should include a detailed post-survey report. Ideally, the report provides photos and recommendations.
