Imaging Matters: Surviving a Survey

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By John Garrett

The CEO of the hospital calls your office or shop. You can hear the panic in their voice. The world is coming to an end. Nothing will ever be good again. Why? There is a surveyor from The Joint Commission, DNV, CMS or the state health department on campus.

The panic or fear that the administration has is not based on anything being wrong in the hospital. The fear is of the unknown. What is the surveyor looking for and does the person hired last week know the answers to the most likely questions that will be asked of them? Of course, there is also the fear of missing documentation or outdated procedures that haunt the mind of the CEO when the surveyor steps through the door. There will always be some apprehension, but there are ways to survive a survey.

The first and best technique for surviving a survey is preparation. Having a system of documenting the work performed on equipment that is thorough and in line with CMS is crucial. This is something that cannot be fixed on the day the surveyor walks into the facility. Having the system is only the first step. Keeping a “clean” database is a constant effort. Having all of the equipment listed, ensuring service reports are entered in a timely manner and verifying the service reports are complete requires continual vigilance.

Be fluid, flexible is too rigid. Notify your team that the surveyor, don’t call them inspectors, is on the premise and that they are a priority. The surveyors do try to cover a lot of ground in a short time, so be ready to meet requests for information and data. Making sure that they have what they need to evaluate your operation means that the inspection can be done quickly. Providing accurate information quickly and candidly lets the surveyor know you have nothing to hide.

The biggest issue may be a rouge surveyor. Most surveyors have a clinical background. They are typically individuals who do not know the clinical engineering side of the equipment. They know how to operate the equipment and deal with the patient. They are often unaware of proper maintenance procedures or practices. Yet some will insist that since they are a surveyor, and you are not, that they are right. Even when they are not. Typically all you can do is smile and nod your head. Of course you provide documentation and present why you do what you do. But brace for impact and expect that they will be sure that they are correct, even when they are not.

This is where the system breaks down. If you have a rouge surveyor that steps beyond their scope or ability, the hospital can file a complaint. But typically a hospital will not a file a complaint simply because the next survey is likely to be more difficult. There is no real protection from rouge surveyors. So, have your program in place, compliant and in constant review. Then, relax and get through the survey.

John Garrett has 20 years experience in imaging service including general radiation, mammography, CT and nuclear medicine. He has worked for third-party service companies, manufacturers, sales companies and in-house imaging teams.

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