Hospital Regulatory Survey

Command Center Training

Sarah Yelton, RN, CPHQ, HACP, LSSGBSLH Quality Resources

Updated 2/20/18

Purpose of a Command Center To assemble a small, coordinated, supportive team “working behind the scenes” to help make the survey go smoother.

The Command CenterTypical Tasks:• Prepare and gather data, reports, documents, & policies.• Take the desired items to the surveyors after cleared by the

team to do so.• Communicate with the senior leaders and others via phone,

email, etc.• Meet the needs of the surveyors. (e.g., meals, water/coffee,

folders with their names on them, etc.)• Arrange for scribes, runners, and surveyor escorts.• Keep track of “issues”, observations, and where the

surveyors are going next.• Determine if the surveyor is stating opinions or regulations.

Where is the Command Center?

The Command Center should be a conference room with a table to accommodate several people.

Needed in the room:• Conference phone (know the phone

number/extension)• Electrical outlets for laptops• Printer (or access to one nearby)

Command Center Team

Team Lead – Director of Quality & Patient SafetyOthers:• Regulatory Compliance Quality Analyst• Risk Management Attorney• Senior Leaders and physicians will visit the

command center off and on as they are available

Chain of Command for Survey

Team LeaderDir. Of Quality

Quality Analyst/Regulatory

Scribes

Escorts

Electronic health record expert

Policies & Procedure Expert

Flip Chart Pages

It is helpful to put up big self-adhesive flip chart pages on the wall. For example:1. Citations noted in AM briefings2. Surveyor Issues (e.g., hand hygiene) to relay to the clinical nurse

managers throughout the hospital. The scribes will share this information with the command center.

3. Requested items (e.g., reports, policies, documents, 1:1 conversations, etc.)

4. Questions (e.g., “Ask (name) about xyz.”)

5. Small group meeting information (time, location, attendees, info, etc.)

Be sure the markers used won’t mar the wall!

Provisions Needed• Private conference room (usually in the executive office)

• The Survey document “Black Box” or Binders• Laptops (several)

• Communication info./phone numbers of key personnel• Phone/conference phone• Power supply cords (several)

• Access to the regulations• Office supplies (pens, paper, highlighters, flip chart pages, folders, markers,

stapler, binder clips, etc.)

• Access to printer (you will be printing a lot!)

• Small chocolate candies (helps calm folks and keeps energy up)

Attitude & AtmosphereThe command center will be very busy. Stress and

anxiety run high during regulatory compliance surveys. People react differently.

• Keep a cool head.• Be kind.• Be helpful.• Try to relax and go with the flow – survey days

will be long ones.• Some things are within your control and some are

beyond your control.• Eat meals, keep hydrated, and take short breaks.

Try to staff only “calm natured” people in the command center.

Chocolate Helps

Quality dark chocolate is rich in Fiber, Iron, Magnesium, Copper, Manganese and a few other minerals.

Enjoy a stress-busting chocolate fix!

Tips• Wear comfortable shoes.• For women, be sure your jacket has pockets.• Have an iPad available if possible.• Have your cell phone with you.• Keep the command center phone number

with you.• Bring the rolling survey suitcase that is full of

info and provisions.• Laminate the survey contact list – makes it

easy to find in a stack of papers.

Action Photo’s!• Put up the flip chart sheets

These are suggested. You can customize.

Kudos: Keep track of the nice things the surveyor says about the hospital and your staff! So encouraging!

Possible Issues: The topics that may turn into citations. Or “hot topics”.

Cell phone numbers: Helpful to have! These are in addition to your regular phone list.

Flip Charts Continued

• Staff: Ask the scribe to keep track of full names of people the surveyor talks with. These are usually the very ones that are asked for during the HR credentialing and competency session.

• Requested Documents: Keep a list of the policies/documents/proof that surveyors ask for. Also note who is obtaining the info.

• Patients: Keep track of patient names during tracers. (Grab a sticker.) This will help narrow down units during corrective action writing.

Flip Chart Markers

• Be positive that your markers won’t bleed through the paper and onto the wall!

Action Photo’s!

• The Command Center helpers!

There are several laptops where people can search for policies, documents, regulations, etc.

Also a telephone is on the table to contact units or individuals.

Note the surveyors bios and photos on the table.

Phone a Friend“Hello 6 East, they are coming your way next.”

“They are focusing on crash cart logs – be sure you only have one month on the clipboard.”

“The surveyor asked about PI projects on 5 North.”

“Be sure to show individualized care plans & education.”

“The surveyor has been talking with new grads and float nurses.”

Action Photo’s!

• Snacks help! Snacks & water there are for anyone who needs a quick burst of energy.

Scribes and tour guides need to keep hydrated and fortified.

Office Supplies: There are many small items in the blue pencil boxin the photo.

Action Photo’s!

• Keep Calm and Carry On!

There are clipboards ready for the scribes on the table.

Scribes like the four color ink pens too. That way they can emphasize important things.

My Survey BagLaptop bag on wheels. Most of the contents are pre-packed. Organized and easy to “grab and go”!

• Hard plastic pencil case with assorted small office supplies, post-it notes, and a “presentation clicker with pointer”.

• Assorted colors of flip chart markers• Laminated list of hospital units/department contacts and

phone numbers (on bright pink paper)• Laminated list of key personnel cell phone numbers• Laminated color copy of the TJC Safer Matrix • Laptop, mouse, power cord• Cell phone, iPad, ear buds, charging cord• Comfort items: Advil, Kleenex, lip balm, hand lotion• Steno-pad of paper• May need a hospital approved power tap for extra plugs

Update contents annually

Expected SurveysPre-pack a small cart to roll into the Command Center:• Flip chart pages• Document binders• Rolling survey bag with laptop etc.• Scribe clipboards, paper, & pens• Bowl of Snacks/bottles of water• Master laminated copy and several additional

copies of agenda, scribe/tour assignments

Unexpected Surveys• Recover from the shock!• Get the surveyors settled in their home room• Notify the senior leaders and others that surveyors are in-

house• Print a hospital census and OP/Procedure schedule• Grab the rolling cart with your laptop inside & flip chart sheets• Get your document binder• Set up the command center• Secure meeting rooms as needed

Daily Survey UpdatesA survey leader sends a recap email each evening to the senior leaders, directors, and managers.

Communication,Communication,Communication!

Who, What, When, & Where?

The 2 sided “cheat sheet”!

• Make several copies• Keep a “master” version in a

clear sheet protector

Keep Track YearlyIt is amazing how quickly we forget!

When preparing reports, hospital leaders often ask: “When was that survey?”

You will always know!

Thank you!