Continuous survey readiness ensures that healthcare organizations are consistently prepared for accreditation surveys (e.g., Joint Commission, CMS) by maintaining compliance with standards. Tracers, which involve following a patient’s care journey to assess compliance with standards, are a key tool for identifying gaps and ensuring ongoing readiness.
Option A (Facilitate a failure mode and effects analysis (FMEA) on patient consent): FMEA is a proactive risk assessment tool for specific processes, not a broad strategy for survey readiness. It may be used for targeted improvements but does not address overall compliance monitoring.
Option B (Conduct time studies for patient registration processes): Time studies are useful for process improvement (e.g., reducing wait times) but are not directly tied to survey readiness, which focuses on compliance with accreditation standards across multiple areas.
Option C (Map the value stream for elective surgery patients): Value stream mapping is a Lean tool for process optimization, not a method for ensuring survey readiness. It is too narrow in scope to address comprehensive compliance needs.
Option D (Perform tracers on patients in restraints): Tracers are a cornerstone of survey readiness, as they simulate the survey process by tracking patient care across departments to verify compliance with standards (e.g., restraint use, documentation, safety protocols). NAHQ CPHQ study materials recommend tracers as a best practice for continuous readiness, particularly for high-risk areas like restraint use, which is heavily scrutinized by accrediting bodies.
[Reference: NAHQ CPHQ Study Guide, Domain 4: Performance and Process Improvement, emphasizes tracers as a critical tool for maintaining continuous survey readiness by assessing compliance with accreditation standards., , , , ]
