Tanner Health Uses Smartsheet to Streamline Accreditation Processes and Focus on Quality and Patient Safety

Tanner Health  is a five-hospital nonprofit health system that provides personalized healthcare to more than 450,000 people in communities across nine counties in Georgia and Alabama. Tanner Health is accredited by The Joint Commission, one of the nation’s leading healthcare accrediting organizations. “Accreditation demonstrates our commitment to quality and patient safety, and reimbursement for our services depends on it, so it is very important for our organization,” says Regina Shelnutt, accreditation manager at Tanner Health.

To achieve accreditation, each facility or program must complete a rigorous, unannounced on-site survey every three years during which a team of expert surveyors from The Joint Commission reviews Tanner Health’s compliance with specific standards of care. To prepare for these surveys, Shelnutt and her team conduct mock surveys to identify opportunities for continuous improvements.

Until recently, this was a cumbersome, time-consuming process for a small team. They would take notes on paper, then had to type up their findings and email the survey to each department leader. “It was a really manual process, and then we had to wait for departments to email their survey responses back to us so we could copy their responses into our master document, which was not efficient,” Shelnutt says. 

“A large tracer might take up to three days to complete, and then we started using the Smartsheet mobile app during the tracer process and things just took off from there,” she says. “Smartsheet is very user-friendly to work with, so within a year we were using it to manage all Joint Commission Survey preparation and management.”

Streamlining Survey Preparation and Management with Smartsheet

After a Tanner executive suggested Smartsheet could help improve efficiency, Shelnutt adopted the platform across the accreditation team. “We initially built a sheet to manage survey results. The sheet mirrored The Joint Commission’s response tool, so the idea was that we could complete the corrective actions in a collaborative way and then move the finalized responses over to the Joint Commission website” says Shelnutt. “Previously, we touched documents multiple times, there were too many steps involved, and it was not always easy to ensure you had the most recent copy of a working document. Survey responses could go back and forth several times before completion, so having one document that everyone could work in together made the process much easier.” Clinicians have also quickly adopted Smartsheet within the organization. For example, nurse leaders have been trained and are adept at navigating and responding to assignments within the tracer.

The Tanner accreditation team now uses Smartsheet to streamline Joint Commission survey preparation and management. When conducting a tracer, the accreditation team inspects everything from ceiling tile condition to oxygen storage procedures to clinical equipment maintenance schedules, taking photos on their mobile phones and uploading them directly to Smartsheet using the mobile app. They also talk to clinical staff about their safety procedures and conduct chart reviews to see if documentation supports the care that was provided. Findings are added to Smartsheet in real time, ensuring more accurate and reliable data, with photos mitigating any confusion among the team about where and what an issue is. Automations are used to remind staff of pending due dates or items that have not been resolved within the designated timeframe.

For mock and live Joint Commission surveys, Tanner creates a new survey template in Smartsheet before each survey day. An Accreditation team member accompanies each Joint Commission surveyor to take notes on potential findings. Using the Smartsheet mobile app, they can fill out a form in real-time, attaching relevant photos and notes and submit directly to the tracking sheet to proactively notify stakeholders. At the same time, Shelnutt’s team and organizational leaders monitor submissions from a command center to proactively respond to questions, potential findings, or pull requested documentation.  

Once Tanner receives the survey findings, they have 60 days to resolve issues and submit that information to the Joint Commission. Shelnutt set up several automations in Smartsheet to help streamline that process as well. For example, the form includes a dropdown for the department so that the appropriate stakeholders are automatically notified about findings that need to be evaluated for completeness. Automated emails are then sent out as due dates approach if an issue has not yet been resolved. In addition, she uses row update requests to ensure issues that were not adequately addressed get updated. Stakeholders can respond directly from their email and changes are automatically recorded in Smartsheet.  

The team uses Smartsheet dashboards to view survey summaries including the number of hospital visits, survey findings, and the status of items being addressed. “The dashboards help us validate what we’re doing,” Shelnutt says.

Increased Efficiency – Every Minute Counts

The Tanner accreditation team is now able to conduct tracers more efficiently. Using the Smartsheet mobile app, they can cover more ground in less time. 

“Smartsheet has improved our efficiency by more than 100 percent. We used to only do one tracer a week, but we’ve increased that to three or four a week with Smartsheet,” says Shelnutt. 

In 2024, the accreditation team completed 150 tracers across five hospitals, an increase in tracer volume that helps the organization make sure it is thoroughly prepared for Joint Commission surveys. “We can work smarter with Smartsheet, and it helps us increase our tracer bandwidth,” Shelnutt says. “We can now be out in more departments, covering more ground.”

With Smartsheet, Tanner has digitized its tracer and survey processes, making it easier for the tracer team to inspect hospitals and document their findings. 

“Using Smartsheet, we don’t have to shuffle pieces of paper around anymore or hand over a 5-inch thick binder full of requested documents,” says Shelnutt. “Multiple surveyors can review a document at the same time because it’s all digital.” 

Additionally, because of the automation in Smartsheet, nurses, pharmacists, and other staff members save time in addressing and responding to findings. As soon as findings are submitted, notifications route the information to the right people in real time. “If they’re looking for a specific word, they can quickly search the sheet to find it without looking over different notes in a document,” says Shelnutt. “The entire process is much easier, which is key. Our hospitals are all so busy, so with Smartsheet we can go in and be their resource for everything compliance related.”

Contributing to a Culture of Safety and Better Patient Care

By streamlining this process and increasing the number of tracers they can complete, the accreditation team is able to spend more time engaging with departments, building relationships, and helping to create a culture of safety that is embedded in the day-to-day work of all Tanner staff. “We strive to be survey-ready in every location, and Smartsheet helps us achieve that goal while helping us sustain our accreditation,” says Shelnutt. “As a healthcare organization, accreditations are critical because it means we’re meeting safety standards and improving processes to provide the best care for our patients. Better patient care is really our ultimate goal, every day.”

The accreditation team plans to continue supporting that goal by leveraging insights from Smartsheet. “Smartsheet dashboards are already giving us an accurate snapshot of outstanding tasks and the progress of tracers and surveys,” Shelnutt says. “Now, on top of overviews that show our leadership what we’re doing, we want to start identifying trends from dashboard data. Hopefully this will help us see specific areas we might still need to enhance so we can fix them and continue to deliver excellent care to our patients.”

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