Overview of the Survey Process
The transition from a survey process centered around the physical structure of a facility to an evaluation of the primary functions of the entire organization has resulted in significant changes to the survey process. The revised accreditation standards focus on the activities that most influence the function of the organization including the overall organizational and governance structure, professional staffing activities, patient care and management, quality assessment and improvement and facility safety protocols.

On-site visits to the patient care settings play a major role in the survey process. The majority of compliance evaluation takes place through leadership and staff interviews and observation of the daily activities within the organization. In fact, review of formal documents is limited to the survey portion known as "Documentation Review".

How To Prepare For Your Survey
In order to facilitate the most effective and efficient on-site survey most reflective of your organization, it is recommended that the following issues be thoroughly addressed prior to the survey:

Preparation
Prepare all affiliate locations for a visit by the surveyor(s).

Prepare all documents for review prior to arrival of the surveyor(s)

It is very important for participants in each survey activity to be aware of the purpose and scope of the activity. Please share the appropriate activity description from these Guidelines with the participants prior to the survey date.

Availability
Be sure to designate a private area to serve as the Central Location throughout the survey. A key contact person must be designated to assist the surveyor(s) throughout their stay

Members of the governing body, administrative, clinical and technical staff will be requested to meet with the surveyor(s) during the Leadership and Staff Interview sessions of the survey, and may be called upon at other times throughout the survey to provide assistance or information

Scheduling Your Survey

The number of days required for the survey, and the number of surveyors in the survey team are based upon the information provided in the Application for Accreditation. Organizations of four or more sites of care will generally require two to three days and a team of two or more surveyors.

Once the Application is received and reviewed by ABC staff, your organization will be notified of the surveyor(s) assigned and the number of days necessary for the survey. The lead surveyor will contact the organization directly to arranged a convenient date and time for the survey to begin.

The Accreditation Award
Approximately one week following your on-site evaluation of compliance, the lead surveyor will return the Survey Report to ABC headquarters. ABC staff will review the Report and apply established rules of scoring and aggregation to arrive at a final accreditation score. The organization should receive notification of the final results of the survey within two weeks of receipt of the Surveyor Report. The award will include a formal letter of notification, a summary of identified standards in partial or non-compliance and a sample press release for use in informing outside parties of the award. In addition, a certificate of accreditation will be ordered and forwarded within six weeks.

Accreditation is awarded based upon an overall aggregated score of compliance against the standards. Organizations will be awarded accreditation as follows:

Decisions regarding Conditional, Provisional or Non-accreditation will be forwarded to the Facility Accreditation Committee.

In accordance with policy, an organization will have 30 days to appeal the decision of the Facility Accreditation Committee. Please consult the Standards of Performance Manual for more information on filing of an appeal to the Board of Directors.

Model Survey Agenda: Single Site Organization (One-Day Survey)

¹ Includes review of policies and procedures manuals, selected clinical files
and QA Program (see List of Verification Documentation on page )

Model Survey Agenda: Multi-Site Organization (Two-Day Survey)

Day 1

¹ Includes review of selected clinical files, policies and procedures manuals
(see List of Verification Documentation on page )

Model Survey Agenda: Multi-Site Organization (Two-Day Survey continued)

Day 2

¹ Includes review of selected clinical files, policies and procedures manuals
(see List of Verification Documentation on page )

Opening Conference

Purpose
To provide organizations key contact person with brief overview of survey process.

Location
The location of this Opening Conference should take place in a private area. The organization is requested to make appropriate accommodations for this meeting. This location will also serve as the Central Location for the remainder of the survey for documentation review, interviews and the Final Summation Conference. A telephone in or near this area would be very helpful.

Participants
The primary contact person and the surveyor(s).

Summary
The Opening Conference will allow the surveyor and the organizations key contact person to discuss the survey process. The Surveyor will provide a list of required documents for review later in the survey. The Surveyor will review the survey agenda and answer any questions that may arise. The key contact person will provide an overview of the organizations primary activities, personnel and their functions and a description of any affiliate locations.

Materials to be available
None

Orientation Tour

Purpose
To provide the surveyor(s) with organizations key contact person with brief overview of survey process.

Location
Primary Applicant Site

Participants
Primary contact person and the surveyor(s)

Summary
The organizations key contact person will provide the surveyor(s) with a brief tour of the site. The guide will explain the function of each area and answer any specific questions the surveyor(s) may have regarding the practice.

Materials to be available
None

Documentation Review

Purpose
To review documents relating to the performance of the organization, to prepare surveyor(s) for the interactive portions of the survey through better understanding of the organization, and to begin the process of assessing compliance with the standards.

Location
Central Location at Primary Applicant Site and Affiliate Sites as necessary

Participants
The primary contact person should be available to orient the surveyor(s) to the materials provided. After this time, the surveyor(s) will independently review the information. The primary contact person should remain within the facility to provide assistance as necessary during the documentation review session.

Summary
The Documentation Review portion of the survey will serve to orient the surveyor(s) with the daily operational procedures of the organization. Initial information relative to the organizations activities, personnel and quality assessment procedures is gathered for use during the interview portion of the survey.

Materials to be available
As outlined in Appendix A of this manual (List of Materials for Document Review Session)

Patient Record Review

Purpose
To survey compliance with specified Patient Care and Management Standards relating to record keeping and storage procedures.

Location
Primary Applicant Site and Affiliate Sites as needed

Participants
Surveyor(s)

Summary
The organizations key contact person will provide the surveyor(s) with original clinical patient records as specified by the surveyor(s). Compliance with standards relating to uniformity, consistency and completeness will be evaluated.

Materials to be available: Clinical Patient Charts as requested by surveyor(s)

Quality Assessment and Improvement Review

Purpose
To survey compliance with Quality Assessment and Improvement (QA) Standards.

Location
Primary Applicant Site

Participants
Key Contact Person and Surveyor(s)

Summary
The organizations key contact person will provide the surveyor(s) with a copy of the organizations Quality Assessment and Improvement Program outline. Identified indicators and available outcomes data will be evaluated against the QA standards.

Materials to be available
Quality Assessment and Improvement Program outline and supporting data

Leadership/Staff Interviews

Purpose
To assess performance relating to standards addressing the governing body and staff roles and responsibilities and organizational policy.

Location
Primary Applicant Site and Affiliates Sites (staff only at Affiliate Site(s))

Participants
Surveyor(s) and governing body, selected administrative, clinical and technical staff

Summary
Following a private session with members of the governing body (or their designees), the surveyor(s) will conduct a self-guided tour of the organization addressing specific facility employees regarding their roles and responsibilities within the organization.

Materials to be available
None

Integration of survey results

Purpose
Time allotted for surveyors to share and document survey finding and prepare for following survey day or summation conference.

Location
Primary Applicant Site

Participants
Surveyor(s)

Materials to be available
None

Summation Conference

Purpose
To provide feedback on survey results and organization compliance.

Location
Primary Applicant Site

Participants
Key Contact Person and Surveyor(s)

Summary
The surveyor(s) will meet with key contact person(s) to discuss the results of the survey. Specific areas of partial or non-compliance will be indicated, however, the final decision of accreditation/non-accreditation will be determined upon review of the survey report by the Facility Accreditation Committee. The final accreditation award will be issued by staff at ABC headquarters.

Materials to be available
None

Appendix A:
List of Materials for the Document Review Session

The Documentation Review portion of the survey will prepare the surveyor(s) with an overview of the daily operational procedures of the organization. Initial information relative to the organizations activities, personnel roles and responsibilities, record-keeping and quality assessment procedures is gathered for use during the interview portions of the survey.

Standards compliance can usually be verified through review of existing documents. It is not necessary to remove or photocopy relevant sections of these documents. However, if the organization has a large quantity of examples or large volumes of materials on a specific topic,

Please select the most relevant and recent for review by surveyors. Documents may be organized as free standing or bound.

I. Organizational Governance and Administrative Procedures

• Articles of Incorporation
  
• Names and addresses of controlling owners (if different then on application)
  
• Copies of professional staff certifications
  
• Relevant excerpts from personnel policies and procedures manual regarding staff appointments
  
• Samples of the following types of communication, if available:
  • Memos/letters relating new organizational policies or procedures - Organizational newsletter
    
  • Summaries/minutes from staff meetings

II. Professional Staff Qualifications and Responsibilities Standards

• Patient management policies and procedures relevant to:
• Privileging procedures for non-ABC certified care givers
  
• Professional staff responsibilities to quality patient care
  
• Position descriptions; roles of professional staff

III. Patient Care and Management Standards

• Personnel policies and procedures manual relevant to:
  
• proper patient care documentation (chart entry, record keeping, referrals, etc.)
  
• records management and retention - patient confidentiality - follow-up care
  
• Patient care records as requested by surveyor(s), including copies of referral notices, prescription, physician communication and patient encounter notes/entries
  
• Patient Rights statements, brochures, etc.
  
• Confidential Information Release Form
  
• Patient feedback assessment forms (patient satisfaction surveys)
  
• Documentation of basic first aid and CPR training of professional staff

IV. Quality Assessment and Improvement Standards

• QAI Program Outline
  
• Log of patient complaints and resolutions
  
• Results of patient satisfaction surveys
  
• List of indicators
  
• Data relating to outcomes, policy revisions, etc.

V. Facility and Safety Management Standards

• Emergency preparedness plan/fire plan
  
• Occupancy permits, annual safety inspection results
  
• Safety management protocols (hazardous materials, equipment maintenance inventory and log)
  
• Safety management program evaluation results