Forget Surviving: How to Thrive During Your Next Joint Commission SPD Survey



Let me just start this by saying there is no easy path or magic bullet for ensuring your department is ready for a Joint Commission, DNV, state health department or CMS survey. As ready as you think you are, there can always be hidden issues lurking behind the next page of documentation or varying levels of confusion between your department's policies and the real-life, daily application of them by your staff.


That being said, there are still a number of practical things Sterile Processing leaders should be aware of as they prepare for the end-all-be-all visit from TJC or the like. If you're like me, this is not an experience you just want to survive. It could mean your job, your reputation as a trusted expert or leader in your facility, and most importantly, it could mean your patients are not as safe as you thought they were. So let's talk a little about how to ensure your SPD team thrives during their next survey. 


Some Things Must Be Taught Not Caught


Don't get me wrong, I'm a fan of cultural change via organic relationships within a department. Or in plain English -- I'm okay with people learning by example -- monkey see, monkey do. But when you're preparing for a TJC survey, this reliance on more experienced technicians shepherding the department from shift to shift isn't good enough. When a surveyor hits your processing area and asks one of your new technicians "How do you know how to properly process that Kelly Clamp?," the answer, "Because if I have any questions I just ask Ms. Mary," is not going to fly -- and for obvious reasons. What happens when Ms. Mary is out on PTO or taking her lunch break? Even though this heavy reliance on seasoned technicians is a reality in a great many departments, it's not going to give your surveyor any warm and fuzzy feelings, and that's not a good sign of survey success. Your team can win or lose a survey by the competency of these conversations.


Even though most surveyors spend their time talking to front-line staff rather than high-level leadership, department leaders have everything to do with how those conversations go. Technicians are a reflection of their supervisors, managers, and directors. So if you want your techs to knock it out of the park, leaders have to be diligent to give them plenty of survey batting practice. Here are a few tips you should take under consideration:


1) Hire with the Joint Commission in Mind


I've said it before, but I'm going to say it again: who you hire has everything to do with your department's future success. And these survey conversations are no different. As random as it may sound, you should be interviewing and hiring with Joint Commission conversations in mind. If given the proper education and training, could this candidate explain the sterilization process to a surveyor? Would this applicant have the confidence to converse with a team of facility leadership and surveyors about our sterilization recall policy? We're not talking about hiring the next Winston Churchill or anything, but you owe it to your team to hire folks who could persuasively communicate who, what, why, and how you do what you do. If they can't do this, it doesn't matter how good your process is, the surveyor could walk away with concerns.


2) Take Them To the Water and Make Them Drink


As we discussed above, we can't expect our technicians to just point and say, "She told me to do it this way," to an inquiring surveyor. We need self-contained fountains of Sterile Processing knowledge standing at every work station. As we all know, the only way to get that kind of knowledge out of someone is to get it in them first. To accomplish this, your department needs education -- and a whole lot of it. It won't do to simply have information available to them (in the form of certification books or manufacturer's postings on the wall), you have to make them drink of this knowledge and do so on a regular basis.


Requiring certification of your technicians is a great start to inculcating a level of expertise into your department's culture. Requiring them to present an inservice or two during a department meeting each year is another great way to ensure they are thinking along the lines of why we do the things we do, not just how we do them. Have your supervisors utilize daily shift huddles to give policy reminders and mini-training sessions on proper documentation. And take the time to do random mock surveys with your team to determine weaknesses in individual knowledge or understanding. Remember, your team won't go where you're unwilling to take them.


3) Teach the Story, Track the Story, Tell the Story


Every Sterile Processing department has a story. As a Sterile Processing leader it's up to you to teach this story to your technicians (both new and old). What are your particular department challenges and how are you overcoming them? Is your department located 1/4 mile away from the OR (like one of my facilities was) or do you process instrumentation for outside facilities requiring tight logistical management and constant communication? These realities define your department and they are the stories that will contextualize and differentiate your department from the others the surveyor may have seen. Your technicians should hear this story from you on such a consistent basis that they can tell it themselves, with genuine confidence and contagious pride. 


Once your team knows your story, it's important to utilize department data and documentation to track your progress. Yes, surveyors will want to see your temperature and humidity logs or other documentation. But if you have additional data available that can demonstrate how you are overcoming your facility's challenges or setting yourself apart from other Sterile Processing departments, this can go a long way toward taking control of the surveyor conversation. How many secondary or tertiary certifications does your team hold? How many have undergraduate or graduate degrees? How have you decreased the IUS rate in your OR or tackled a large incomplete instrument list? More than likely these are not questions a surveyor will ask, but with the proper data, you can take the conversation to the next level all by yourself.





And that's where the final piece in this puzzle comes in. Regardless of who you are or how prepared your team is, it can be easy to feel like you're on the defensive when Joint Commission or CMS walks in the door. Even though they say they're here to help, it's easy to feel like they're really here to find your flaws. But keep in mind, no matter what questions they ask,  you have the ability to tell the story you want to tell. If you've invested the time and education into each individual tech to ensure they understand and can communicate your department story, all that's left is the chance to tell it. You'll get that chance at least every three years according to the typical Joint Commission survey schedule. In the meantime, commit to hiring well, educating thoroughly, and weaving your department story into the warp and woof of your technician's daily experiences.


You've got to have best practices in place to ace a TJC survey, of that there is no doubt. But as Robert Burns so eloquently taught us, "The best laid schemes of mice and men often go awry." What's even more important than best practices are best practic-ers. And those aren't born, they're made...

Use documentation and data to direct the attention of your surveyor to what you want to talk about, and allow your staff to shine as they demonstrate the depth of their industry knowledge to surveyors who have most likely never worked a day in Sterile Processing in their lives. 

You've got to have best practices in place to ace a TJC survey, of that there is no doubt. But as Robert Burns so eloquently taught us, "The best laid schemes of mice and men often go awry." What's even more important than best practices are best practic-ers. And those aren't born, they're made...


Hank Balch


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