From the August 2017 issue of HealthCare Business News magazine

In a perfect scenario...

• You have at least the following manuals on site and know how to use them: NFPA 101 Life Safety Code 2012 Edition; NFPA 99, 1999 and 2012 editions; FGI Guidelines, 2010 and 2014 editions; and any other code manuals that are referenced in your accreditation standards (if they can be found).
  
• You have the most current standards from your accreditation organization.
  
• You have current LSC drawing(s) containing the "exact" information that is required.
  
• You have current/accurate inspection/testing records as required by code and by your accreditation organization.
  
• You have a list of any known deficiencies that are presently scheduled for correction, or are in the process of being corrected.
  
• You have information pertaining to any CMS categorical waivers you have elected to utilize (and make sure your CEO knows what they are).
  
• You have a code consultant (not necessarily an architect).

Since trying to develop a relationship with an accreditation surveyor is somewhat impossible, since the same surveyors very seldom return to the same facilities every three years, it is important that you develop a good relationship with your state surveyor. They are typically assigned to areas within the state and to the health care facilities within those areas. They will also be involved in renovation and new construction projects, and will work with the architect and engineer during the code review process. They will follow-up on patient complaints that are major enough to prompt a full team survey visit of the organization, including life safety, and they will pick a percentage of organizations that recently went through the accreditation process by conducting a validation survey, which typically finds things missed by the accreditation surveyor(s).

Some suggestions from lessons learned.

• Work on developing a business-level relationship with your surveyor. Getting a little personal also helps to break the ice sometimes, but don’t cross that thin line and get too personal.
  
• Watch and learn the personality and characteristics of the surveyor over time, and use that knowledge to help strengthen the working relationship.
  
• Don’t take the deficiencies found during a survey personal. Having any deficiency found is frustrating, but unless you totally ignore the condition of your facility, findings are all part of the job.
  
• Don’t get defensive. Realize deficiencies are going to be found. There are no perfect organizations. Almost all have some level of life safety deficiencies.
  
• Don’t threaten to call the surveyor’s supervisor. Listen, learn and know the code enough to challenge, or have your consultant available to discuss after the surveyor leaves. Learn which battles are worth fighting using the proper channels.
  
• Ask questions. Make the survey process educational for both you and the surveyor.
  
• If deficiencies are found and it is totally unclear to you how to resolve them to the satisfaction of the code, ask the surveyor for suggestions. They don’t necessarily have to provide those suggestions, but if you have a good relationship and are sincere and not argumentative about resolving them, you might be surprised by the assistance a surveyor will decide to provide.
  
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August 2017 Magazine

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