Does your facility make the most of the self-survey process? We often get inquiries regarding this process and what is required for accredited facilities.
An annual self-survey is a requirement for QUAD A facilities and is a great tool to evaluate your compliance with the current standards and improve patient safety. The intent of the self-survey is to facilitate ongoing accreditation readiness and evaluate if your facility is meeting all applicable local, state and federal laws, rules, regulations, and codes, including zoning and construction codes as well as a Certificate of Need for our Rural Health Clinic facilities.
One way to approach the self-survey is to create an internal mock survey team that acts in the role of a surveyor and completes a thorough inspection using your program’s standard manual as a guide. Some facilities use an administrator, compliance staff, or other staff members who work closely with the implementation of QUAD A standards to pose as the surveyor. Some facilities choose staff that are further removed and possess less knowledge of QUAD A standards and use the mock survey as a tool to increase staff knowledge of standards and compliance.
Another approach is to print your facility’s current manual and create a binder of evidence. This binder identifies how your facility meets each standard and provides proof of that compliance.
No matter the method your facility chooses, it is important for the process to be thorough and timely. Self-surveys are a key tool for identifying gaps in compliance and developing a corrective action plan to address any identified findings. The self-survey exercise is a great opportunity to engage staff, deepen knowledge of regulatory requirements and standards, review and update policies and procedures, and prepare for your onsite survey.
QUAD A Standard 1-B-8 requires the following:
The facility must perform a self-survey review of compliance with all QUAD A standards annually before the expiration date of its accreditation in each of the two years between QUAD A onsite surveys. The self-survey documentation must be retained for a minimum of 3 years and include:
- A completed Self-Survey checklist
- A Plan of Correction for any standard identified as non-compliant
- Evidence that each plan of correction has been carried out to establish compliance with standard
- Evidence that findings from the self-survey have been reviewed, included in the facility's Quality Improvement Plan and discussed in the facility's Quality Improvement meetings.
Once the self-survey has been completed and a plan of correction has been created (if needed), please complete, sign, and email ONLY the Self-Survey Attestation Material documents to your assigned QUAD A Accreditation Specialist.
The Self Survey Attestation form can be accessed by clicking on this.
When QUAD A surveyors are onsite to conduct your reaccreditation survey, they will request evidence of the documented completed self-surveys that include all portions of the standard.
We encourage your facility to reach out to our team at standards@quada.org with any standards-related questions.
Together we can improve patient safety!
Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.
