Mock Survey: Methodology for Measuring Compliance and Facilitating Change

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Every nurse executive is responsible for maintaining compliance to current externally established standards. As standards change, the nurse executive must evaluate the organization, making sure it continues to demonstrate compliance. This article describes how one organization used the Joint Commission on Accreditation of Healthcare Organizations' Agenda for Change as an opportunity to examine its nursing practice. The process included: 1) analyzing compliance to the 1991 standards; 2) developing an action plan to address deficiencies; and 3) developing and conducting a mock survey to monitor and evaluate effectiveness of the action plan. Increased staff comfort with the survey process, monitoring tools, and data regarding compliance to standards were the primary outcomes of this process. Leadership development, team building, and networking were also outcomes.

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