The International Organization for Standardization provides a process-oriented approach to achieving quality management.

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The health care environment is a high-risk landscape that requires various types of periodic regulatory review. To maximize the effectiveness of the services provided, health care facilities are examined for areas of improvement by one or more authorities having jurisdiction.

Although the substance of the regulations being reviewed is not a secret and, for the most part, an open-book test, the structured design of compliance with codes and standards forces health care facilities to react to “findings” from a state survey or a survey from an accrediting organization approved by the Centers for Medicare & Medicaid Services.

The unintended consequence of this design establishes a mindset of reactive quick fixes rather than hospitals and health care facilities developing their own long-term, sustainable processes that emphasize and promote continual improvement with a preventive action mindset.

When the mindset of front-end preventive action processes becomes a part of everyday thinking, the term “survey readiness” is cemented into the mission, vision and values of the health care facility.

Continual improvement processes

One of the most dangerous and overused phrases in health care today is “We’ve always done it this way!” The average person applies the mistaken presumption that the absence of a negative outcome equates to everything working fine with no reason to make any adjustments. In other words, “If it isn’t broken, don’t try to fix it.” However, this is mistaken because it does not guarantee that relevant processes have been planned, implemented and maintained as designed. For instance, if someone has never been in a motor vehicle accident, does that automatically mean the driver is following all traffic laws? Not necessarily. Some are simply luckier than others.

A common misconception about continual improvement is that it requires wide-ranging structural and immediate change. In fact, the intent is the opposite because the concept involves an ongoing effort to incrementally improve over time rather than all at once. Continuous improvement is a gradual, never-ending change that is based on increasing the effectiveness and/or efficiency of organizational processes.

The International Organization for Standardization’s ISO 9001 specifies requirements for a quality management system. The introduction of the ISO 9001 quality management concepts into health care has boosted the concepts of “continued readiness” or “always ready” for a survey.

This formalized design is based on the plan-do-check-act (PDCA) methodology and provides a process-oriented approach to documenting and reviewing the structure, responsibilities and procedures required to achieve effective quality management in an organization. When implemented as designed, the result ensures health care organizations are always ready for a survey regardless of current conditions, staffing acuity or the time of year.

Three key continuous improvement processes for health care facilities to consider include feedback, efficiency and evolution, as described here:

1. Feedback. The core principle of this continuous improvement process is reflection and self-reflection. Common themes of feedback include, “How did everything go? What worked, what didn’t work and what needs to change?” Feedback should not be viewed in a negative tone. While easier said than done, honest and open communication is paramount from all levels of an organization to maximize the opportunities to improve. Feedback should be given in a manner that will help improve performance.

All forms of feedback, regardless of where it comes from or even if it is intended to be positive or negative, are valuable forms of information for continual improvement. Although directors and managers prefer to present information in a positive way so it doesn’t negatively affect organizational morale, feedback must be accurate, factual and complete. Hospitals would much rather have honest and necessary conversations to address noncompliance before an on-site survey than as a consequence of an unexpected finding from a surveyor.

Another option is for feedback to be provided often and automatically through a measurement or monitoring system. Feedback can be designed into a work process or a measurement system so that it is received automatically by the staff and decision-makers alike. This can be achieved through developing and monitoring performance measures for different areas of the physical environment. What is expected during hazardous surveillance rounds or a drill? What is considered a measurement of success? Once determined, these expectations should be shared so everyone is aware of what success looks like.

Health facilities professionals can gather feedback from all types of interested parties, including patients, patient representatives, visitors and, most importantly, colleagues. How does feedback improve a survey process or make a health care facility survey-ready? Facilities managers cannot be everywhere all the time. The more sets of eyes and ears on alert for infrastructure issues, missing medical equipment, safety/security issues or any other type of variation can only assist in compliance with codes and standards.

A common physical environment finding during an on-site accreditation survey is missing and stained or dirty ceiling tiles in both clinical and nonclinical areas. Empowering and encouraging hospital staff or anybody else to communicate these types of infrastructure issues can dramatically affect the timeliness of corrective action to ensure the integrity of smoke barriers and the overall sanitary environment from an infection prevention standpoint.

Physical environment surveyors will typically not identify a finding because of the mere existence of the condition but because there is no process in place to report, communicate and address the condition in a timely fashion. Although the cause of the missing or stained ceiling tile is ultimately some type of leaking roof, pipe or other source of condensation, escorting staff members with the surveyor typically indicate they are unaware of the observed condition. If this is an existing condition in a department, why hasn’t anyone shared these issues with those responsible for correction? Could it be a training issue or an awareness or communication opportunity? The main reason for the survey finding is a missing or broken process.

2. Efficiency. The purpose of this continual improvement process is the identification, reduction and elimination of subpar or irrelevant processes. Common themes of inefficiency center around too many committees, too much time spent in meetings and facilities being top heavy with decision-makers. More specifically, observations include meeting minutes from committees such as safety and security, environment of care, physical environment, hazardous surveillance, risk management and quality safety oversight that all have similar attendee lists and similar topics with equally common corrective action plans.

Facilities professionals shouldn’t be afraid to ask questions and have open communication about whether there is too much redundancy. One of the biggest challenges in any organization — and especially a health care facility — is effective communication. 

Although there isn’t an exact science or research that offers a target amount of time spent in meetings discussing issues of the day versus ensuring designed plans are effectively implemented in the facility, the more time spent away from the patient care area equates to less time validating planned processes, verifying that nonconforming conditions don’t persist and evaluating the effectiveness of previous actions taken.

Resource management and understanding what can and cannot be controlled from a resource management standpoint are challenges commonly reported by health facilities professionals. Short-term impacts can occur by more efficient time management, while additional financial support, new equipment and more staff usually involve long-term planning.

A common myth about code compliance in the physical environment instills the belief in many hospitals that numerous committees and meetings are required on a frequent basis. Departmental meetings and committees are born through a belief that there is a requirement when, in fact, they are typically internally developed because they’ve always been done that way.

What does this have to do with survey readiness? As stated earlier, an abundance of discussion without validating planned processes, allowing enough time to receive feedback and validating the effectiveness of actions taken in the facility allows for more opportunities for process breakdowns. The main reason for the survey findings in these instances is the inability to validate corrective actions with a root cause of inefficient resource management.

3. Evolution. The emphasis of this continual improvement process is on incremental and continual steps rather than giant leaps. Survey teams do not expect an on-site survey to go perfectly without any type of finding or nonconforming condition. As noted earlier, although never a guarantee, physical environment surveyors will typically not cite a condition that occurs; rather, they will review what the facility has done about it or is going to do about it.

Health care facilities are living, moving and active environments open 24 hours a day, seven days a week and 365 days a year. Inevitably, unexpected calamities are going to occur, and conditions are going to change, whether they are expected or not. From a risk management perspective, emergencies never happen at convenient times or places and can never be completely eliminated. However, they can be mitigated.

At times, health facilities professionals may spend too much time trying to make things perfect rather than planning, implementing and evaluating the effectiveness of various actions taken. Evolution as a continual improvement process refers to a change in mindset from a reactive corrective action perspective to thinking in advance before a condition exists. In addition, facilities professionals should eliminate the expectation of perfection.

This is easier said than done because, historically, health care facilities professionals over the past several decades have focused more on correction than prevention and doing whatever it takes to “pass the test” rather than the long-term sustainable health of the organization.

For example, a hospital is in its “survey window” and department managers begin to prepare for the survey by staying late after hours to update policies or procedures and review all records to make sure they are complete and not missing entries. 

Deep cleaning of sensitive areas begins, cleaning out closets and filling dumpsters in the back parking lot. Anything worth keeping is stored in a rented trailer parked far away in the back parking lot and locked securely. 

Managers review with staff common life safety training acronyms like RACE (rescue, alarm, confine, extinguish/evacuate) and PASS (pull, aim, squeeze, sweep) and remind all staff to only answer questions with a “yes” or “no” and not offer any other information. 

Once the survey is over, there is a collective sigh of relief, and everyone goes back to what they were doing before the survey window began. That is the antithesis of continual improvement.

A journey

Continual improvement is a journey, not a destination, because it never ends and is never intended to end. That is why the PDCA cycle was created. It is an important tool for continuous improvement because it provides a structured and systematic approach to problem-solving and process improvement by requiring organizations to develop formalized protocols using data-driven decision-making to ensure the highest likelihood of success. PDCA also increases efficiency and effectiveness, and promotes overall teamwork. 

When PDCA is utilized as designed, facilities are always survey-ready, regardless of when it happens, what staff are at the hospital or what conditions exist on the day of survey. 

By changing the mindset from passing the test to how staff can continually improve what is done in the hospital, the stress and anxiety that typically cloud a hospital when it is in its survey window tend to dissipate — and focus and energy return to patient care.

The accreditation survey should truly be a tool to assist in the never-ending journey of continual improvement. 

About this article 

This article is one of a series contributed to Health Facilities Management by DNV Healthcare USA Inc.

Brennan P. Scott, CHOP, CHFM, is program manager for acute care/critical access hospital services, head of surveyor development and educator/trainer for DNV Healthcare USA Inc. He can be reached at