It's always this feared phenomenon, the accreditation surveyor! However, they are really just giving you an open-book exam to which you have already received the questions. But it's scary because of the element of the unknown. We've been preparing for the accreditation survey for two years now (we are accredited for a period of three years...preparation for the next survey starts after approximately six months of peace and quiet).
I was nervous because I was named administrator for five areas. As a complete accreditation newbie, I had no idea what to expect. As a result, I ended up walking numerous hospital hallways, escorting surveyors and racing in front of revised surveyors' plans to visit units. I was absolved from time on the treadmill this week!
On Day 1, I had two of my units surveyed, inpatient dialysis and hospice. I knew we'd have a dialysis survey and did NOT know we'd have a hospice survey. We rent space to a hospice company and they have their own accreditation. So when I tried to be proactive and ask four months ago whether the survey team would visit hospice, I was told "heck no."
I was furious then, when I heard in the mid-afternoon that the survey team HAD visited hospice and that I had two minor citations: a partially-uncovered clean linen cart and an outdated I.V. pump that Biomed had not reviewed lately.
Dangit!!! At least they don't count because they rent the space. But still!!! Dangit!!!
Two other areas surveyed well and then my last big clinic was to be surveyed yesterday afternoon. Again, I was nervous, as I had the "badass" surveyor with me. I held my breath while my clinic staff fielded the questions like pros. I could've hugged my medical director for the way he answered the questions. Actually, I *did* when I returned today with three boxes of the softest Kleenex I could find in the hospital.
Why? Because, three hours earlier, I did a walk-through of this large clinic and found several violations of the 18" rule (any area with sprinklers must have 18 inches in clearance between the highest item and the ceiling tile). So we quickly rearranged a few things and while digging around the medical records room, I found four gross-looking half-used roles of toilet paper. The manager said it was their makeshift kleenex.
Sigh. Seriously? So I stole some premium kleenex from the physician storeroom and supplied the clinic a few boxes. It was the least I could do for them having garnered another perfect survey! I crept across the street to the clinic and, of course, ran into two Sisters from the Corporate Board. Nothing like having a covert Kleenex operation intersected by some nuns inquiring about why you are carrying four boxes of Puffs!
So I survived my first accreditation. As soon as the summation conference ended at 11:30 this morning, I had a massive stress let-down migraine. Fighting through my afternoon (and a totally random visit from a Corporate VP for whom I'm now ghostwriting), I texted my pal, Vera, and asked for chocolate. She's the keeper of chocolate in Administration.
Two minutes later, she appeared in my doorway with a cute bag of these:
They're bath salts shaped and scented like dessert treats (from Lush). She told me it's still Lent and that I need to back off the chocolate and use the bath salts instead. Now there's a friend for you...worried about your stress relief AND your immortal soul! What can I say? She *gets* me.
I have a few more stories to share, but I have a bath to take!
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