Survey Prep: Telling Your Story

I’ll be the first to admit it—different surveyors approach surveying in different ways.  I lunge for the support text before reviewing documents.  Other surveyors only read the support text if they can’t find what they need from trolling through all the documents linked to an element.  In either case, the support text plays a critical role:  it tells the surveyor how your organization complies with the element. 

 

I could review a hundred documents for an element (trust me, it’s happened!) and still not get a full picture of the organization’s processes.  The support text should paint a picture, clearly and briefly describing HOW the organization meets the intent of the element.  That way when the surveyor reviews the documents, he/she has a framework for interpreting them.   

 

Remember, though, that support text does not count as one of the four identified data sources (documented process, materials, reports, and records or files).  That means that you cannot plunk a process description that sounds like it should be a policy and procedure in the support text box and have the surveyor accept it as a documented process.  Support text is meant to guide the surveyor to understand the evidence.  It is not evidence in and of itself.  Said another way, support text is unofficial—helpful—but unofficial whereas a documented process should have been officially approved by the organization. 

 

Despite my preference for support text, there are several instances where it’s not needed.

 

File review standards don’t need evidence of any sort—nor do they need support text.

 

Standards which are completely scored based on a documented process don’t usually need support text if the documented process is clear.  Look at CR 1B, for example.  There are four factors, each quite clearly described, that need to be addressed in policies and procedures.  Assuming each of these is well described in the policies and procedures that are linked to this element, support text won’t be very helpful. 

 

Support text should add something to the surveyor’s understanding.  It doesn’t really help the surveyor to use the support text box to state that the organization is in compliance with the element without saying HOW the organization is in compliance. 

 

The support text box is NOT a good place to tell the surveyor which pages of which documents to read.  Annotating documents to make it easy for surveyors to find what they need will be covered in the last blog of this series. 

 

As a surveyor, I make few assumptions.  If the combination of the support text and evidence doesn’t clearly demonstrate that an organization is in compliance with the element, I’ll ask for clarification.  With only 72 hours allowed for turn-around on such questions, an organization that gets 30 or 40 questions of clarification from the survey team will likely have a harrowing three days. 

 

Next time I’ll talk about evidence of compliance.