Part I of our “Compliance Cues’ series dealt with setting the tone for survey either by The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS). In this installment, we will focus on the critical role of clinical staff in helping to assure a successful survey process.

Clinical staff – whether physicians, registered nurses, pharmacists or other allied health professionals – are at the core of what we do at hospitals. Without exemplary clinical staff, hospitals are just hotels for sick people, and not very good ones at that. So it should go without saying that the attitudes, communication and knowledge conveyed by clinical staff on survey can make or break the outcome.

Often very competent staff members can take a less than helpful stance with surveyors. No one likes to be “inspected,” especially clinicians. The resentment that the idea of “inspection” can generate can be too easily communicated. So, the first step toward projecting an excellent clinical staff image is preparing the staff for any eventual survey event.

One of the most important elements of survey preparation is communicating with staff members about the purpose of survey. The core purpose of TJC or CMS scrutiny is assuring patient safety; it’s not a punitive or bureaucratic exercise. If staff members understand that surveyors are focused on assessing the integrity of patient care processes and documenting compliance with standards, it may become easier and more appealing for them to be cooperative and communicative.

Make certain that the purpose of accreditation and the relevance of this process to the organization’s future is clearly communicated. Unprepared clinical staff members can project a sense that surveyors are interrupting important work when surveyors believe they too are doing important work – not an attitude conducive to a successful outcome.

Here is a quick guide to preparing staff members for the survey process:

1. Make certain that all staff members are comfortable with the basics. Ensure that they are able to speak with confidence to emergency procedures, their role in the organization and their clinical preparation.
2. Help staff members learn to answer spontaneous questions calmly, efficiently and succinctly. Give the information asked for, no more. Staff members who ramble on, seem indecisive or over-answer can just generate new areas for surveyor inquiry.
3. If staff members don’t know the answer to a question, don’t let them “wing it.” Rather, encourage them to ask for assistance from a colleague or manager.
4. Encourage staff members to ask clarifying questions if a surveyor’s inquiry is confusing or uses terminology with which they are unfamiliar. For example, if the surveyor asks, “Tell me about your role in obtaining informed consent,” the staff member might ask, “Are you referring to our consent documentation form?” Thus, the staff member can address the exact question and not wander into other territory inviting further scrutiny.
5. This is a tough one, but it is very important that clinicians project a professional image. First appearances create first impressions. Dirty lab coats, overly informal dress and generally unkempt appearance give surveyors subtle cues about how clinicians perceive and manage their roles and responsibilities to patients. (They can also invite scrutiny of infection control practices!)

Survey success is a matter of demonstrating multiple cues that your hospital is compliant. The role of clinical staff in projecting the true quality and compassion of an organization is integral to this success. To learn more about these and other “Compliance Cues,” check out Part I of this series, which discusses some of the “little things” that set up expectations of a well functioning hospital. And, stay tuned for Part III, which will deal with preparing executives for their role in communicating compliance expectations.

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