Q&A: Evaluating the success of the organization's unannounced survey plan

Q: How do I evaluate whether my organization’s unannounced survey plan is effective?

A: Treat the completion of your unannounced survey as a performance improvement (PI) outcome and assess the strengths and weaknesses against your survey readiness plan. You should do this in two separate sessions: one in which you conduct a debriefing of the implementation of the plan, and a subsequent session in which you discuss the findings related to noncompliant standards.

Session one: This first session should be a retrospective review of your organization’s methods of preparing for the survey and should include members of your Joint Commission preparation team. Consider what went well, what wasn’t anticipated, and what concerns were raised. This will allow you to gather input to revise your preparation plans. Of course, you will still need to work on your clarifications, ESCs, and MOS as indicated.

Session two: You want to gather staff members who can help you determine the best path for solving noncompliance issues. Perhaps this includes the chapter leaders or specific area champions in the organization. You should use the survey report to review areas with findings and to identify how these can be corrected. Prioritize your actions.