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CE Article: Florida hospital system weathers survey surprises*

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After reading this article, you will be able to:

  • Describe unexpected changes encountered during a Florida hospital system's Joint Commission survey
  • Discuss the benefits of using an emergency management plan as a basis for survey preparation
  • Describe the makeup of a survey team meant for a large-scale healthcare system
  • Identify what a Life Safety Code surveyor is looking for during a Joint Commission survey

One survey. Five hospitals. More than 40 ambulatory and outpatient locations. When Joint Commission surveyors arrived at Lee Memorial Health Systems in Fort Myers, FL, in November 2008, the result was a weeklong survey on an epic scale. But the health system was ready, having mirrored its survey readiness plan on an unusual but appropriate model: an emergency management plan. Each surveyor was assigned a chaperone and a scribe.

"Everyone was educated in their roles for survey," says Chris Crawford, RN, MHA, LHRM, system director of standards and quality at Lee Memorial. "We had a command center set up, and if the surveyor had a need, the scribe could call the command center to ensure that whatever documentation the surveyor was looking for was made available to them."

The scribe also kept the command center aware of the surveyor's location, next destination, and his or her findings and concerns. At the end of each day, the health system held a debriefing session and discussed possible requirements for improvement officials believed were imminent.

'Our plan got blown up'

The Joint Commission (formerly JCAHO) sent eight surveyors to survey the five hospitals and their combined 1,400 beds, plus 44 related outpatient and ambulatory sites. Get a general overview about the survey process here.

"Our plan got blown up the first day," says Crawford. Lee Memorial had initially anticipated that the surveyors would break up and go to different hospitals, with one surveyor to each hospital, two surveyors to the outpatient and ambulatory sites, and a Life Safety Code® surveyor. In anticipation of this, each hospital had a vice president of patient care service ready to act as a chaperone, as well as someone who knew the system well to act as a scribe.

"Of course, the surveyors made the decision to stay together and do each hospital as a group," Crawford says. This led to some quick thinking and restructuring of the health system's plan.

"We had to rethink who we had stationed at each hospital," says Crawford. "As soon as we walked out of the opening conference [with the surveyors] ... we immediately met to deploy staff to the hospital that would have all five surveyors at once." This meant redistributing experts already primed for the survey.

"That first day, we recruited vice presidents from other campuses on short notice to be scribes at the lead campus," says Lisa Sgarlata, RN, MS, MSN, CEN, vice president of patient care services at Lee Memorial's campus.

Essentially, the first lesson of the survey was to be ready to change. "This was all about being able to make adjustments on a dime," says Kathy Bridge-Liles, vice president of patient care services at the Children's Hospital campus.

The day of a hurricane

The November 2008 survey was Lee Memorial Health Systems' first unannounced survey, and the first since acquiring two additional hospitals. The survey seemed destined to be exciting.

"They originally showed up in September on the day where we were preparing for a possible hurricane and had to turn around and leave," says Crawford.

By comparison, unexpected tactics by surveyors were not nearly as difficult to deal with as a natural disaster. On day one, five surveyors remained in the first hospital while two others surveyed the ambulatory and outpatient centers. The LSC specialist worked independently. Read about how to prepare for the LSC specialist, which is a new addition for 2009.

"He moved much more rapidly," says Crawford. "We really didn't know where the LSC specialist was going to next or where they'd be the next day."

The ambulatory settings checked in with the command center to get updates on findings and surveyor progress. "They were using the command center just like the other campuses," says Crawford.

The command center was composed of a quality standards department program manager and administrative assistant, members from the information management and HR departments, as well as other staff members.

"We had them log all calls that came in as well as the [notes] scribes would send in ... at the end of the day," says Crawford. "They acted as a repository of information."

An opportunity for collaboration

The Lee Memorial campus was selected first by the surveyors. "It was interesting to see how they were going to work," says Sgarlata. "We had an opportunity to see what they were looking for, themes of where they would be headed for the rest of the campuses."

Also interesting was how the surveyors worked together. The five surveyors who surveyed the five hospital campuses had never worked together previously and were typically in a leadership role in other surveys.

"I thought they worked well together as a team themselves," says Mary Kirkwood, system director of medical staff quality at Lee Memorial. "They worked well with us but also collaboratively with each other-it was one of the best teams I've encountered."

Ground rules established for communication were beneficial to both sides. Surveyors went through their team leader with requests for information, and information was funneled back through the team leader from the hospital rather than sent directly to the requesting surveyor to keep the transfer of information steady and accurate.

Representatives of the health system were pleased at the collaborative nature of the survey. "Because we were small teams supporting the surveyors, there was opportunity-if there was need for immediate clarification-for it to be very collaborative," says Cindy Boily, RN, MSN, vice president of patient care at Southwest Florida Regional Medical Center/Gulf Coast Hospitals, a branch of Lee Memorial.

Survey preparation team members also noted that the level of staff preparedness dovetailed well with the interest in education surveyors demonstrated.

"On the occasions when the questions were directed at the staff, I think the staff felt less threatened," says Cindy Brown, RN, BSEd, MHA, CAAMA, vice president of patient services at Lee Memorial's Health Park Medical Center branch. "We really enjoyed the time with the surveyors. There were two times when they brought staff and educators to the boardroom in Lee Memorial to talk about the process of education and how to prepare staff and make sure they're confident. It wasn't a 'gotcha' discussion; it was a 'share what we've learned' discussion."

Learn more about the on-site survey process here.

There were numerous opportunities to learn on the fly. For example, early on surveyors spotted a hand washing sink without a clock in one of the cath labs. When the command center discovered that this was something the surveyors were looking for, clocks were immediately installed over all sinks in cath labs systemwide.

"They were very impressed with how quickly a big system responded to an item like that," says Bridge-Liles.

"One thing we learned is to be very flexible," says Brown. "We went in with a plan in our mind that we'd rehearsed and educated everyone on many times. On a dime, we had to change our whole strategy.

Source: Briefings on The Joint Commission, an HCPro, Inc., publication.


  1. Accreditation Process Overview:
  2. Spaanbroek, S. Put it in Writing. Hospitals & Health Networks.
  3. Facts about the On-Site Survey Process:


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