Special Edition: Survey Readiness

May 16, 2023

Supporting survey success

CHCS is in its Kansas Department of Health and Environment (KDHE) state survey window. As you may remember, we sent a series of Survey Readiness newsletters last year around this time. It's now time to review these important steps to ensure that we are ready!

This survey will be of hospital services only. Our success will require the cooperation and support of the entire staff and depends on everyone's familiarity with regulatory requirements in their particular area. We will send out regular communications to help each of us prepare to demonstrate our competence and our commitment to excellence in all we do.

KDHE is the organization that measures hospital performance in Kansas. KDHE is required to survey hospitals every 5 years. Achieving accreditation means that the hospital has met or exceeds state and federal regulatory standards. CHCS's last state survey was in the spring of 2017.

Accreditation is a seal of approval. Without accreditation, our hospital would lose its professional standing and community image. It would also affect financial reimbursement for services provided for patients because we would not be able to bill and, most importantly, would not reflect our dedication to providing top-quality patient care as we strive to enrich the health and lives of the people we serve. In preparation for the unannounced visit, every hospital department will be reviewing policies to ensure they are up to date, physical environments will be evaluated for cleanliness and safety, and education will be provided to ensure that you have the knowledge you need to be successful during the survey.

--Todd Willert, CEO

Building relationships and communication

Although a successful survey depends on a number of elements, a major key to success is the ability of our associates to interact with the survey team and demonstrate the exemplary care they provide. Our goal is that the information contained in this and future newsletters will prove useful in preparing for this survey interaction.

Please remember that every associate plays an important role in the organization, and has an impact on the care provided to our patients.

Survey Q&A

How will we be surveyed?

A team of at least two surveyors will be onsite for four days. They will review our documents and policies so they understand our processes. They will then move throughout the building observing practices, documentation, and the environment, and they will interview staff and patients. Surveyors will ask questions about the care each patient received and the steps taken to ensure that is was safe, of high quality, and follows our policies.

How will I know KDHE is conducting an unannounced survey?

Upon their arrival, communication will be sent to the managers and directors. Your manager will keep you informed of survey progress.

What is my role in the survey?

You and every hospital employee at every level are very much responsible for upholding the hospital’s mission and providing excellent patient care.
Surveyors will speak with you about your individual job. Start by checking and making sure all your licensures are up-to-date. Then check in PowerDMS and be sure you have reviewed all policies and procedures assigned to you for review.
Also be prepared to answer questions from the survey (see "What should I do..." below). They may ask of anyone in the facility, including managers, dietary staff, laboratory staff--anyone. They may ask you what you would do in case of a fire or chemical exposure. It could be anything!
Please pay special attention to good handwashing and appropriate infection control practices, including for patients in isolation, at all times.

I work in Home Health or the Onaga Clinic (not the hospital). Will I be asked a question?

Although Community HomeHealth, our clinics, and our long-term care facilities are surveyed separately, we should always be ready for an unannounced survey. Remember that a surveyor can ask anyone questions -- even if you're from one of the departments listed above -- and you should be prepared to respond.

Who is in charge of survey preparation in my area?

Your department director and manager are responsible for survey readiness in your area, but YOU are also responsible for your own participation and preparedness.

Who sees the results of our survey?

Anyone who wants to. The results are made public and are available on the internet. Our competitors, payers, referring physicians and — most importantly — our patients and their families will be able to read the details of our performance. We will be sure to share results with our associates.

What should I do if a surveyor asks me a question?

Listen and stay calm.
Think carefully before answering a question.
Only answer the question asked by the surveyor. You do not need to elaborate. Keep your answers focused and specific to the question. It is OK to ask your manager to be there with you.
If you don’t understand a question, ask for clarification.
If you do not know an answer, say so, and tell the surveyor where or to whom you would go for the answer. You may use any resources available to you, such as policies, department resources or your manager. And remember to use your resources (i.e. PowerDMS, MSDS, Department resources at the computer)
Always be honest. Falsification or misrepresentation can cause the organization to lose its accreditation.
NEVER argue with the surveyor. Be professional and use appropriate language and behaviors.
Whenever possible, mention our practices and procedures that support your answers.
Show off your successes and the things you know and do well.
Exhibit pride in your department.
Show enthusiasm and interest!

Review our mission, vision, and values

It's important to review the Community HealthCare System mission, vision, and values as we prepare for the survey. You can find these on the About page of our website.

The Mission of Community HealthCare System, Inc. is to Enrich the Health and Lives of the People We Serve.

Our Vision

We will be the trusted resource for quality, innovative, personalized care;
We will be the integrated healthcare system of choice, allocating resources to be responsive to the unique characteristics of the communities we serve; and
We will be an outstanding environment for our associates.

Our Values

True to our heritage, we hold the following values.

Integrity
Excellence
Respect
Compassion
Commitment
Innovation
Loyalty
Collegiality
Kindness
Citizenship
Accountability

Questions? Send them to news@chcsks.org