The Present and Future of Survey Readiness: A Conversation with Michelle Hilburn MSN, RN, CPHQ, CPPS
Written by
Michelle Hilburn
AVP Quality, Compliance and Standards
Accreditation surveys don’t have to be a last-minute scramble, but for too many hospitals, that’s the reality. Michelle Hilburn, MSN, RN, CPHQ, CPPS, AVP of Quality, Compliance & Standards at Vastian, shares insights from her years in hospital Quality leadership on navigating these realities and reimagining what sustainable survey readiness can look like.
- Survey Preparation Challenges
During your time as a hospital Quality Director, what were the most persistent challenges you faced in preparing your organization for accreditation and disease-specific certification surveys—especially when it came to documentation, standards interpretation, and readiness across departments?
Answer: One of the most common challenges I faced as hospital Quality director was an inconsistent organizational understanding of the regulatory standards across departments. I often spent significant time clarifying requirements, offering examples, and aligning practices so compliance didn’t drift over time.
Maintaining a state of continuous readiness was difficult when operational pressures increased. Focus was heavy 60-90 days ahead of the survey, but, for the clinical department leaders, sustaining focus year-round while dealing with competing priorities such as staff shortages, throughput pressures, and competing organizational initiatives was an ongoing challenge.
- Documentation & Record Management
Healthcare Quality work like accreditation survey preparation and action planning often involves managing large volumes of documents such as policies and procedures and other types of evidence of standard compliance; what issues did you see arise from fragmented, siloed, or paper-based systems during survey preparation, and how did that affect your confidence going into a survey?
Answer: One of the most ongoing struggles was ensuring that every leader completed their assigned periodic reviews and approvals of policies and procedures to ensure that the frontline team members had access to current, approved documents.
- Action Planning Roadblocks
What were the biggest barriers you encountered in moving from issue identification to effective action plans—especially when manual processes, disparate tools, or lack of automation made tracking corrective steps and accountability difficult?
Answer: In my role as a hospital Quality Director, the biggest barriers to moving from issue identification to effective action plans almost always came down to manual processes, fragmented tools, and a lack of automation to support accountability.
First, manually tracking corrective actions across spreadsheets, emails, and shared drives made ownership unclear and follow-through inconsistent. Even when issues were identified quickly during tracers or audits, consolidating everything into a single source of truth was time-consuming. Without automated reminders or dashboards, action items frequently stalled unless I personally followed up—sometimes multiple times.
Second, disparate systems created gaps between recognizing a problem and executing a response. Quality data lived in multiple locations—incident reporting platforms, EMR audits, infection prevention logs, Education competency systems—none of which connected to each other. Translating that information into a cohesive action plan required significant manual effort, and it was easy for departments to lose track of corrective tasks. A specific example I’ll share is receiving repeated deficiencies for patient education not being individualized to the patient’s specific risk factors or current health problems. I believe the root cause was never solved—the perception of busyness or rush. When time is limited, clinicians default to generic because it’s faster, easier, and checks the box. Additionally, clinicians cannot personalize care when they lack real-time visibility into patient risks.
Third, accountability suffered when responsibilities were spread across multiple departments without clear workflow triggers. Many action plans required multidisciplinary involvement and manual processes made it difficult to monitor progress in real time. Without automated escalation or visibility, tasks were often delayed, misunderstood, or completed inconsistently. Without an automated QMS, I set expectations through structured forums like committees where I tied action items and performance metrics to specific leaders and their teams. Most resistance was rooted in lack of time and fear of scrutiny. My Quality team and I countered this resistance by never acting as “Monday morning quarterbacks” but rather as a safety net that wanted to partner with the other departments and leaders to make it easier for them and ultimately, safer for the patients.
Fourth, documentation of progress was often incomplete because updates required manual entry. Leaders were busy, and if there was no streamlined way to upload evidence, attach files, or log progress, documentation lagged behind actual work. This became especially problematic close to surveys when the organization needed to demonstrate preparedness.
Finally, sustainability was challenging because manual systems do not support continuous learning. Corrective actions were implemented, but without automated tracking, analytics, or trend reporting, it was hard to evaluate whether the actions actually reduced the risk long-term. This often meant repeating the same issues in different departments because lessons learned were not systematically captured or shared.
Overall, the lack of automation slowed down our response cycle, made accountability dependent on individual effort rather than structured workflows, and created significant risk that important corrective steps would be delayed, incomplete, or forgotten.
- Ideal Survey Readiness
Having lived through these manual hurdles, what does a 'perfect' survey readiness environment look like to you now? If you could go back and give yourself one piece of advice or one tool, what would it be?
Answer: Having lived through years of manual, fragmented survey readiness work, a “perfect” readiness environment today would be one where nothing depends on memory, spreadsheets, or heroic effort. Every standard, every policy, every action plan, every tracer finding, and every accountability step would live in one integrated system—updated in real time and visible to the right people at the right moments. If I could go back and give myself one tool, it would be an automated, integrated QMS like Vastian. It solves the exact pain points that consumed most of my time as a Quality Director.
- Event Management & Follow-Up
Risk and patient safety events, investigations, and corrective actions often reveal systemic gaps—what recurring problems did you see in how hospitals documented and followed up on these events, and how did those gaps impact patient safety or continuous Quality improvement?
Answer: The recurring problem was chasing events one at a time rather than being able to quickly recognize trends and then execute actions that prevent the likelihood of it recurring. It felt like Groundhog Day. Handling events as one-time occurrences negatively impacted patient safety and Quality outcomes.
Hospitals need to have a healthy preoccupation with failure and use automated tools to perform risk assessments like FMEA frequently so that their safety programs become more proactive rather than reactive.
- Staff Engagement & Competency
Maintaining consistent competency and staff engagement across units is critical for high reliability. When you were in clinical leadership, what obstacles did you see in ensuring competency assessments were meaningful, consistent, and connected to real performance expectations during periods of change or turnover?
Answer: Managing competencies manually or paper-based is nearly impossible.
Silos made it impossible to know if staff were competent to move from one location to another in times of staffing needs.
- Cross-Department Coordination
Quality and compliance aren’t siloed functions; what were common challenges you faced in coordinating Quality efforts across clinical and operational departments, and how did inconsistent processes or communication affect your ability to remain compliant and survey ready or implement meaningful improvements?
Answer: In the past, accountability required constant follow-up:
- “Has pharmacy updated the policy?”
- “Has facilities closed the deficiency?”
- “Has ED uploaded their competencies?”
An ideal environment would create role-based visibility so leaders can finally own their part of readiness without the Quality team acting as traffic controller. That’s one of the aspects I appreciate most about Vastian’s design—shared accountability is built into the system, not dependent on personalities or persistence.
- Quality and Patient Safety
We often speak about Quality in terms of compliance and accreditation survey preparation, but how does solving these performance gaps directly translate to safer outcomes for the patient at the bedside?
Answer: Vastian’s QMS strengthens patient safety because it removes the operational and communication failures that most commonly lead to harm. By standardizing workflows, surfacing risks earlier, and ensuring accountability for corrective actions, the system directly improves reliability of care where it matters most: at the bedside.
Vastian centralizes data from audits, tracers, rounding, events, and improvement work. When risks emerge—missed documentation, practice variation, environmental hazards, medication handling issues—leaders see it in real time, not months later.
- Impact on Patient Safety
- Hazards are corrected before they affect actual patients.
- High-risk trends (falls, pressure injuries, medication processes, infection risks) are discovered earlier.
- Units receive targeted interventions rather than broad “blitz fixes.”
- This reduces the likelihood of preventable harm events at the point of care.
Transform Your Hospital’s Survey Prep with an Integrated QMS
After years on the Quality frontlines, Michelle has seen firsthand how much time and effort gets wasted when hospitals treat survey readiness as a singular event. Her experience is a powerful reminder: the choices we make about our Quality systems and processes have real stakes for patients and healthcare professionals alike. By sharing her hard-won lessons, she offers a roadmap for any organization ready to break the reactive compliance cycle and build a foundation of sustainable, meaningful Quality performance.
For Quality leaders inspired by Michelle's insights and ready to explore how Vastian can help them turn that vision into reality, a personalized demo is the perfect next step. Our experts will walk you through exactly how Vastian transforms survey readiness from a scramble to a strength - and gives you back countless hours to focus on what matters most: keeping patients safe.