When I was a surveyor for Joint Commission, I had a few surveys where the hospital invited their consultant to join in on the building tour. Back then surveys were scheduled with the hospital and were not unannounced, which allowed them time to have their consultants at the facility. The consultants were typically architects or engineers who had expertise in the Life Safety Code and wanted to observe the survey process. For the most part, they were very polite and respectful of the survey process and did not cause any problems.
But there was one survey where the hospital had their consultant stalking me. He found out what hotel I was staying at and showed up at the breakfast table and introduced himself, and announced that he would be joining me at the hospital. I thought that was odd, because the survey hadn’t even started yet. Back then surveyors typically stayed at hotels recommended by the hospital, so finding out where we stayed wasn’t that difficult.
Sure enough, when I arrived at the hospital there was Mr. Consultant with a sly grin on his face that implied “I told you so”. I had the sneaky feeling I was going to have a bad day. During the building tour, Mr. Consultant seemed to contradict everything I said, and before too long it was apparent to me that he was grand-standing in front of his client. I suspect he thought if he could discredit what I was finding deficient during the survey, it would put him in a favorable light with his client. After an hour of his constant interruptions and disagreements with my observation, I told him he needs to remain quiet and if he couldn’t I would ask the hospital to remove him.
That didn’t work and only seemed to pour gasoline on the fire. I then went to the survey team leader and explained the problem to her, and together we approached the CEO and explained the situation. Shortly after that meeting, Mr. Consultant was gone and out the door.
Why do I tell you this story? Because, at times hospitals want their consultant(s) present during the survey in order to provide answers that the facility manager may not know. That’s okay and permitted by most accreditation organizations, but when the consultant becomes disruptive, then it is a problem that must be dealt with.
Here are some basic ‘unwritten’ rules concerning consultants present during the survey, that I have developed. These are not based on any particular accreditation organization’s policy or procedures:
The surveyor’s questions and comments should be directed towards the hospital staff, such as the facility manager, safety officer or other such employee, and not to the consultant.
If the surveyor asks a question, the answer should come from the hospital staff.
Avoid the situation where the consultant tries to debate or argue with the surveyor about an observation.
- Use the consultant as a resource only when the hospital staff is unable to answer a surveyor’s question.
Remember, the hospital staff can always share the report with the consultant after the survey.
Whatever happened to Mr. Consultant? I ran into him a couple of years ago at the annual ASHE conference and he remembered me (and I him). He picked up where he left off and continued to tell me I was wrong in my observations. Perhaps I was… I don’t remember the issues, but some things never change. Mr. Consultant was still grandstanding only this time there was no one there to observe him.