Survey Readiness: What Facility Managers Need to Know

If you manage a healthcare facility, you’ve probably heard the term survey readiness more times than you can count. 

And when you’re prepping for a visit from the Joint Commission, your state’s health department, or another accrediting organization, being prepared is essential.

But, for facility managers also juggling everyday operations and urgent repairs, being survey-ready can feel like another layer of pressure. 

The good news? 

With a little planning and a proactive approach, you and your team can support successful survey outcomes.

This article is about survey readiness and what facility managers need to know.

What is the survey process, anyway?

In short, surveys are evaluations. You can think of them as report cards for your facility. And during surveys, your entire facility is under the microscope, from behind-the-scenes mechanical systems to front-line workflows.

These inspections are meant to ensure you’re providing high-quality care in a safe healthcare environment.

So, what does the survey process actually look like?

Surveyors typically begin with documentation reviews. They’ll look at permits, maintenance records, life safety reports, and compliance documentation to ensure everything is up-to-date and accurate. 

Next comes direct observation. They walk through your facility, checking things like HVAC systems, lighting, emergency exits, fire doors, medical gas systems, and even ceiling tiles. 

Finally, surveyors conduct staff interviews to verify understanding and implementation of protocols.

Because of the high stakes for surveys, many organizations run mock surveys as a proactive measure. These practice runs mimic the real thing and help you catch gaps in compliance or documentation before they become citations. They’re a great way to involve your team, test your processes, and build confidence before the real visit.

How to Run A Mock Survey

Running a mock survey is one of the most effective ways to prepare for the real thing. It helps your team practice, spot compliance issues early, and reduce anxiety around the actual survey process. 

It’s important to note that mock surveys are not about catching people off guard. They’re about building a culture of continuous improvement. The more you practice, the more confident and prepared your team will be when surveyors walk through your doors.

A Mock Survey Plan

1. Set clear goals.

What kind of survey are you preparing for? Is it a Joint Commission, CMS, or a state survey? Then, outline which standards or focus areas you’ll review (e.g., life safety, emergency preparedness, environment of care).

2. Build a mock survey team.

Assemble a team that includes your facility manager, department heads, safety officer, and quality compliance staff. If possible, invite someone outside your department to get a fresh set of eyes on your environment.

3. Use a survey tool or checklist.

Base your walkthrough on an actual checklist or regulatory standard. Many organizations use checklists that align with the Joint Commission, NFPA, or OSHA requirements. Your checklist will likely include sections for the following:

• Documentation and permits
• Equipment logs and inspection tags
• Fire doors, exit signage, and egress paths
• HVAC
• Plumbing and medical gas systems
• Cleanliness and infection control
• Staff knowledge of emergency protocols
  

4. Walk the “code path.”

Surveyors usually follow what’s called a “code path,” meaning they physically walk through the facility as they evaluate compliance. Do the same in your mock survey. Walk hallways, inspect utility rooms, check signage, and look for any red flags.

5. Interview your staff.

Include brief, informal interviews. Ask team members how they would respond to an emergency, locate key shutoffs, or find life safety information. This practice prepares them for what to expect and reinforces their knowledge.

6. Document the findings.

Take notes as you go, take photos, and log any deficiencies. But also, be sure to highlight the team’s successes. If you treat this like a real survey, your documentation will guide your corrective action plan.

7. Build a corrective action plan.

Hold a debrief session with your team to share what went well and what needs work. Assign follow-up tasks, set deadlines for corrections, and repeat the process regularly, ideally every 6 to 12 months or after any major system change.

Survey Readiness Tools and Resources 

Contact us to learn about our custom survey readiness course.

If you need a more in-depth look, we can create a custom survey readiness course tailored specifically for healthcare facility teams. We’ll walk you through mock survey prep, compliance alignment, documentation best practices, and how to train your frontline staff.

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