How to Maintain a State of Continued Readiness
Generally I change the battery in my smoke detectors each year on the date we "fall back" to return to Daylight Standard Time
I use this date as a convenient memory jogger to make sure I always have fresh batteries in what an essential part of my home emergency system. I need my alert system to be fully functional in case I need it; before I actually need it.
Regulatory agencies like The Joint Commission and College of American Pathologists (CAP) require that organizations they accredit be in a state of continuous readiness as well. CAP inspects laboratories on a biennial basis but require that during the off year each lab conducts essentially their own mock survey, documents its findings and makes adjustments to address any deficiency found. Joint Commission requires a similar Periodic Performance Review (PPR) in which the organization self-surveys and turns over its findings (warts and all) to the Joint Commission.
The other aspect of being on "ready alert" is that surveys are unannounced so that organizations are encouraged to "embed" standards into daily operation to the degree they will not be surprised or thrown off if a surveyor suddenly shows up.
While this is a great concept, many labs still dread a survey and ramp up activities and self-inspection when a survey is anticipated. The problem with having lax standards is that after a while deficiencies become background noise and are not even noticed.
A consultant who helps to keep organizations constantly ready suggests that one way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Survey process conducted by someone external to your organization. This ‘someone' could be a consultant or an experienced peer professional from a neighboring facility. If, however, you elect to manage the process using your own personnel, incorporating the following approaches can facilitate objectivity:
- Assign department heads to ‘survey' departments other than their own. It is often hard to see your own forest for the trees. Let them use the official accreditation/regulatory standards to see how each department stacks up.
- Even if the staff knows that a Mock Survey will be taking place at some point, it could be more beneficial if direct care staff and other workers were not informed of the exact timing
- Even though the internal ‘surveyors' know that the process is planned, the Mock Survey itself should be unannounced. An administrator or Lab Director walks in one morning and proclaims it to be Mock Survey Day. This element of surprise simulates the unannounced survey.
Get the entire staff involved in a plan of action listing deficiency, responsible party, time frame and so on. Use deficiencies as an opportunity for education. Change procedures and processes if warranted. For example using the "tracer methodology" following a few specimens from collection to resulting might provide valuable information about areas of vulnerabilities or point to areas where improvements are needed.
She suggests that doing this a couple (or more) times each year will keep standards fresh in the mind of employees, make them more attuned to deficiencies that would otherwise be overlooked and also conditions them to take an "inspection" in stride.
If you think about it, it's like changing that battery before you really "need" to.