Act. Don’t React.

When you are tested, do you react or purposefully act? Below you will find an example of reaction vs action to use as a guide to know when you may be entering a reactionary response and what to do instead.

Transitioning from a Joint Commission Surveyor to an Advisor has allowed me to observe the focus that many organizations place on passing their accreditation survey over an actual focus on patient safety during the survey. Many leaders will say that the goal is continual readiness or continual focus on patient/staff safety and quality, but the following response can reflect that this might not be the case. This instant answer phrase usually signals a red flag that there is at least a lack of openness and occasionally, a stubbornness to remain ignorant.  

“We have never been cited for that before” (Or anything resembling this sentiment). This is a reactionary challenge that begs an unwise assumption that the surveyor cannot be right because you may be unaware of an issue. In short, it’s defensive and doesn’t promote professional dialogue. Consider that for each survey you host, the surveyors are only getting a screenshot of your organization on that given day. With almost 2,000 combined standards/elements of performance, there is no possible way to observe each one during a survey. Be aware that each surveyor has their own background and expertise. For example, you may have a radiologist assigned to survey your radiology department. This will have a different feel. Embrace their intimate knowledge of the area as it relates to the standards. Grow and learn.

“I was unaware of this issue but let’s work together to make sure we fully understand the process. We desire to learn and be challenged to make great greater”. Consider this phrase as an alternative to the reactionary version above, then purposefully act by doing the following:

1.       Ask the surveyor to explain any issue they suspect with non-compliance and make sure you understand what they are communicating by asking questions for clarification.

2.       Ascertain that the surveyor fully understands the process. There may be details that you are aware of that the surveyor would find helpful in determining compliance.

3.       Provide any additional documentation or validation for your process including evidence-based practice, policy, and/or electronic health record information.

4.       If needed, schedule a special issue resolution session with the survey team as soon as possible to bring the key stakeholders needed from your organization to provide a clarifying conversation.

5.       Ask the surveyor if they have any best practices to share that other organizations use to accomplish compliance.

Effectual leadership requires considering the meaning behind your words (introspection) and what they may be communicating to others (extrospection). Don’t be reactionary in your responses. Instead, be diligent to purposefully act to validate compliance where there is compliance.