What do you do when a surveyor tells you (you have to do) something?

But then, when you get a chance to review the contents of the survey report, what the surveyor told you in the moment isn’t anywhere to be found …

It seems that lately, there’s been a spate of folks who, in trying to do the “right thing,” are stymied because what the surveyor(s) told them during the survey doesn’t show up in the report. Let’s use a medical equipment management example (mostly because I don’t get to talk about this topic as much). A surveyor takes you to task for the length of time you’ve identified for the removal of a piece of equipment from your active inventory because it cannot be located. Generally speaking, this tends to involve devices that are either really small (and can, for example, fit in somebody’s desk drawer) or really portable, like an infusion pump that journeys with a patient to their next destination in the healthcare continuum (say, a rehab facility). While we devoutly wish for all our equipment to stay within the “four walls” of the organization, these things do happen periodically (hopefully not too often). There are, of course, various strategies for trying to locate equipment that heretofore cannot be located: messages to the patient care environment that “owns” the device, perhaps an all-points bulletin/be on the lookout for a device, maybe even a bounty system (whoever finds this infusion pump will be made wealthy beyond their wildest dreams—maybe not), but if the device has actually “left the building,” you’re not going to find something that no longer exists in the care environment.

So, how long do you wait to declare it “lost” and remove it from the inventory? I would submit that, beyond accounting for the lost device as a “widget” that potentially counts against your preventive maintenance (PM) compliance percentage, if you have a robust rounding process to identify devices that are not current for PM activities, it doesn’t really matter how long you keep an eye out for the device as much as it matters that you have more than a snowball’s chance in Aruba of identifying the device if it “comes back” to your care environment and can be inspected, etc. before it gets used again on a patient. That’s the process that’s going to safeguard your patients; there’s nothing you can do until the device comes back (perhaps nothing is a little hyperbolic—you could venture out to local nursing homes, long-term care, and rehab facilities to do a scavenger hunt for your “stuff”—but who has the resources to do that).

When it comes to regulatory requirements, there is very little that gets into the specifics of how one is to be considered in compliance, so it’s up to each organization to self-determine based on the risks that need to be managed—in each, specific organization. Although some of the issues could be described as being “common” or “frequently encountered,” those challenges tend to manifest themselves differently in different environments. The crux of the issue is surveyors that make statements regarding the compliance of an existing process, only to find that when it comes time to put the survey finding in a report, they recognize (presumably) that what they said during the survey was not backed up by what is required by code and regulation. Ideally, surveyors would be sufficiently conversant with the standards to understand when they are giving advice as opposed to actually identifying a compliance issue, but that is not always the case.

When the survey report arrives, the folks who were with the surveyor are anticipating seeing a finding based on what the surveyor said but are at a loss to find it. They know what they were told, and it doesn’t occur to them that the surveyor might have been over-interpreting the actual requirements as identified during the survey. A clue that the surveyor is engaging in “consultative advice” is if the surveyor disagrees with “how” you are doing something as opposed to clearly indicating how what you are currently doing isn’t compliant, and they don’t tell you that it’s based on something they’ve seen or practiced in the past, but not clearly out of compliance with the standard.

In general, I don’t have any problem with consultative surveyors; hearing about what other folks are doing to address whatever challenge is being considered can be incredibly helpful. The bottom line is when it comes to corrective action plans, respond only to what is in the report, and if there’s nothing in the report, you don’t have to respond or change what you are doing. At least for the moment (and, I hope, for all times to come), we are only on the hook for what’s actually in the report, not what someone said during a survey.

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.