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© HTS3 2018
CONTINUOUS SURVEY READINESS
IS IT POSSIBLE?
February 2, 2018
BUILDING LEADERS – TRANSFORMING HOSPITALS – IMPROVING CARE
© HTS3 2018
1I HOPE YOU’RE WARM AND DRY
© HTS3 2018
245 YEARS OF DELIVERING RESULTS 2
HealthTechS3 is a 45 year old, award-winning
healthcare consulting and strategic hospital services
firm based in Brentwood, Tennessee with clients across
the United States.
We are dedicated to the goal of improving
performance, achieving compliance, reducing costs,
and ultimately improving patient care. Leveraging
consultants with deep healthcare industry experience,
HealthTechS3 provides actionable insights and
guidance that supports informed decision making and
drives efficiency in operational performance.
Our consultants are former hospital leaders and
executives. HealthTechS3 has the right mix of
experienced professionals that service hospital clients
across the nation. HealthTechS3 offers flexible and
affordable services, consulting, and technology as we
focus on delivering solutions that can be implemented
and provide a positive, measurable impact.
2
© HTS3 2018
3STRATEGY – SOLUTIONS – SUPPORT
GOVERNANCE & STRATEGY FINANCECLINICAL CARE
& OPERATIONSRECRUITMENT
• Affiliation Consulting
• Executive & Management
Leadership Development
• Strategic Planning & Market
share Analysis
• Community Health Needs
Assessment
• Compliance Consulting
Services
• Performance Optimization /
Margin Improvement
• Revenue Cycle & Business
Office Operations
• Productivity & Staffing
Consulting
• Continuous Survey Readiness
• Quality Assurance
Performance Improvement
• Lean Culture
• Customer Experience
• Clinical Resource
Management
• Care Coordination – Primary
Care Practice
• Physician Practice & Clinic
Assessment
• Long Term Care Consulting
• Swing Bed Consulting
• Perioperative Services
Consulting
• Executive Recruitment
• Manager and Clinical
Positions
• Physician / Provider
Recruitment
• Information Technology
Professionals
• Interim Placement
© HTS3 2018
41ST QUARTER 2018 WEBINARS
Office of Inspector General Work Plan: Change towards Transparency
Host: Cheri Benander MSN, RN, NHA, CHC, NHCE-C
Health Services Consultant, HealthTechS3
Date: February 8th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2mLbR9I
Strategies to Maximize Service Lines and Improve AccountabilityHost: Diane Bradley, PhD, RN, NEA-
BC, CPHQ, FACHE, FACHCA, Regional Chief Clinical Officer
Date: February 16th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2hGBBP9
Funding Diversification Takes Planning: Do you have a Grant Plan?
Hosts: Faith M Jones, MSN, RN, NEABC, HealthTechS3 Director of Care
Coordination and Lean Consulting; and
Bianca Policastro, Vice-President, The Policastro Group
Date: February 22nd, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2hR1ZtH
Community Health Needs Assessment –Your Partner in Population Health
Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical Officer
Date: March 2nd, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2B84kFn
Strategic Alignment of Practice Measures in Care
Coordination: Making it Meaningful
Hosts: Faith M Jones, MSN, RN, NEA-BC HealthTechS3 Director of Care
Coordination and Lean Consulting;
Deb Anderson, Business Relationship Manager, Health Technology Services
Date: March 22nd, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2B7AVLc
Cost Effective Care Models That Improve Outcomes
Host: Diane Bradley, PhD, RN, NEA-
BC, CPHQ, FACHE, FACHCA, Regional Chief Clinical Officer
Date: March 23rd, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2je44w2
Recruitment Tips: Get It Right The First Time
Host: Peter Goodspeed, Vice President Executive Placement
Date: March 26th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2izSpsg
© HTS3 2018
5TODAY’S SPEAKER
Carolyn
St.Charles
Regional Chief
Clinical Officer
Carolyn began her healthcare career as a staff nurse in
Intensive Care. She has worked in a variety of staff,
administrative and consulting roles and has been in her
current position as Regional Chief Clinical Officer with
HealthTechS3 for the last fifteen years.
In her role as Regional Chief Clinical Officer, Carolyn
St.Charles conducts mock surveys for Critical Access
Hospitals, Acute Care Hospitals, Long Term Care and
Rural Health Clinics.
She also provides consulting services for facilities with
Swing Bed services.
360-584-9868
© HTS3 2018
6
HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this
information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such
information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding
policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or
their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of
this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare
reimbursement and regulatory matters.
INSTRUCTIONS FOR TODAY’S WEBINAR
You may type a question in the text box if you have a question
during the presentation
We will try to cover all of your questions – but if we don’t get to
them during the webinar we will follow-up with you by e-mail
You may also send questions after the webinar to our team
(contact information is included at the end of the presentation)
The webinar will be recorded and the recording will be
available on the HealthTechS3 web site:
www.healthtechs3.com
www.healthtechs3.com
© HTS3 2018
7CONTINUOUS SURVEY READINESS
1. Stay Current
2. Understand the Standards
3. Prepare for Surveyors
4. Plan for Survey Readiness
– Accountability
– Assess
– Focus
– Improve
5. Tracer Methodology
6. EOC and Safety Rounds
7. Data
8. Culture
© HTS3 2018
81. STAY CURRENT WITH STANDARDS
• Centers for Medicare and Medicaid Services (CMS) Conditions of
Participation (CoPs)
• State Operations Manual
• State Regulations – Department of Health and/or Licensing
• Health and Safety Code (California)
• Accrediting agencies with deemed status
© HTS3 2018
9CMS STATE OPERATIONS MANUALS
• Appendix A - Hospitals
• Appendix AA - Psychiatric Hospitals
• Appendix B - Home Health
• Appendix C - Laboratories & Laboratory Services
• Appendix D - Portable X-Ray Services
• Appendix E - Outpatient Physical Therapy
• Appendix G - Rural Health Clinics
• Appendix H - End-Stage Renal Disease Facilities
• Appendix I - Life Safety Code
• Appendix J - Intermediate Care Facilities (for persons
with mental retardation)
• Appendix K - Outpatient Rehabilitation
• Appendix L - Ambulatory Surgical Services
• Appendix M - Hospice
• Appendix P – Survey Protocol for Long Term Care
• Appendix PP - Interpretive Guidelines for Long
Term Care
• Appendix Q - Determining Immediate Jeopardy
• Appendix R - Resident Assessment Instrument for
Long Term Care
• Appendix T - Swing Beds
• Appendix U - Responsibilities of Medicare
Participating Religious Nonmedical
Healthcare Institutions
• Appendix V - Responsibilities of Medicare Participating
Hospitals in Emergency Cases
• Appendix W - Critical Access Hospitals
• Appendix Y - Organ Procurement Organization (OPO)
© HTS3 2018
10STATE OPERATIONS MANUAL UPDATES
• State Operations Manual Certification Process
• Appendix P – LTC
• Appendix PP – LTC
• Appendix W – CAH
• Appendix A - Hospital
• 11/4/16
• 12/8/17
• 11/22/17
• 12/16/16
• 12/29/17
© HTS3 2018
11UPDATES
• Draft and new CMS regulations are published first in the Federal Register and then on the CMS web site under the section on Regulations and Guidance
• Memos are issued from Center for Clinical Standards and Quality/Survey & Certification Group
• There is usually a lag between when new regulations are approved and when they are incorporated in the State Operations Manual (SOM)
• Deemed status organization standards may not include the most updated CMS standards
© HTS3 2018
12
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850
Center for Clinical Standards and Quality/Survey & Certification Group
Ref: S&C: 17-36-NH
DATE: June 30, 2017
TO: State Survey Agency Directors
FROM: Director Survey and Certification Group
SUBJECT: Revision to State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag Revisions, and Related Issues
© HTS3 2018
13
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850
Center for Clinical Standards and Quality/Survey & Certification Group
Ref: S&C 17-30-Hospitals/CAHs/NHs
REVISED 06.09.2017
DATE: June 02, 2017
TO: State Survey Agency Directors
FROM: Director Survey and Certification Group
SUBJECT: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)
• ***Revised to Clarify Provider Types Affected***
13
© HTS3 2018
14ORGANIZATIONS WITH DEEMED STATUS
• Ambulatory Care
– Accreditation Association for Ambulatory Health Care
– American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
– American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP)
– Institute for Medical Quality (IMQ)
– The Joint Commission (TJC)
• Home Health and Hospice
– Accreditation Commission for Health Care, Inc (ACHC)
– Community Health Accreditation Partner (CHAP)
– The Joint Commission (TJC)
• Critical Access Hospital and Hospital
– American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP)
– Center for Improvement in Healthcare Quality (CIHQ)
– DNV GL – Healthcare (DNV GL)
– The Joint Commission (TJC)
• Psychiatric Hospital
– The Joint Commission (TJC)
• Rural Health Center
– The Compliance Team (TCT)
© HTS3 2018
15TIPS
1. Assign someone in the organization – or – a team to stay current with
standards
– Consider assigning by topic area (Life Safety, Infection Control, etc.)
2. Include a Standing Agenda Item on your Continuous Survey Readiness
Team – or – another committee such as Performance Improvement
3. Assign responsibility for implementation of new standards including
development of an action plan with timelines and metrics (monitors) of
compliance
© HTS3 2018
16ONE MORE TIP: DON’T BE CLUELESS – EDUCATE!
© HTS3 2018
172. UNDERSTAND HOW TO READ THE STANDARDS
CMS State Operations Manual
• Standard
– General statement
• Interpretative Guidelines
– How to implement the standard
• Survey Procedures
– How the surveyors will review the standard
Don’t rely on just the standard to determine compliance
Some standards are more prescriptive than othersSurveyors will review YOUR policies
Good Audit Tool
© HTS3 2018
18STANDARD EXAMPLE - CMS
C-0202 §485.618(b) Standard: Equipment, Supplies, and Medication
Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following
(C-0203 b1 / C-0204 b2)
Interpretive Guidance §485.618(b)
In addition to these items, the CAH must maintain the types, quality and numbers of supplies, drugs and biologicals, blood and blood products, and equipment required by State and local law and in accordance with accepted standards of practice.
Survey Procedures §485.618(b)
• How does the CAH ensure that the required equipment, supplies and medications are always readily available in the CAH?
• Interview staff and tour the ER to ascertain compliance and ability to provide emergency services.
© HTS3 2018
19STANDARD EXAMPLE - CMS
C-0203
§485.618(b)(1) Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions.
Survey Procedures §485.618(b)(1)
• How does the CAH ensure that staff knows where drugs and biologicals are kept?
• How is the inventory maintained?
• Who is responsible for monitoring drugs and biologicals?
• How are drugs and biologicals replaced?
© HTS3 2018
20STANDARD EXAMPLE - CMS
C-0204
§485.618(b)(2) Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters.
Survey Procedures §485.618(b)(2)
• How does the CAH ensure that required equipment and supplies are readily available to staff?
• How does the CAH ensure that staff knows where emergency equipment and supplies are kept?
• How is the supply inventory maintained?
• Who is responsible for monitoring supplies?
• How are supplies replaced?
• When was the last time emergency supplies were used?
• Is there an equipment maintenance schedule (e.g., for the defibrillator)?
• Ask staff if equipment has ever failed to work when needed.
• Examine sterilized equipment (e.g., tracheostomy sets) for expiration dates when applicable.
• Examine the oxygen supply system to determine functional capabilities.
• Check the force of the vacuum (suction) equipment to see that it is in operating condition.
© HTS3 2018
21STANDARD EXAMPLE - TJC
IC.01.02.01: Critical access hospital leaders allocate needed resources for the infection prevention and control program.
Rationale: Not applicable.
Introduction: Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning
For any infection prevention and control program to be effective, it needs to be well managed. Toward that end, critical access hospital leadership assigns one or more people to be responsible for development of the program and its management. Depending on the size of the critical access hospital and its resources, this person can be an employee, a contractor, or a consultant. After this person is in place, the work of planning the infection prevention and control program can begin by gathering staff with expertise in infection control, building management, and other key team members who can perform a risk assessment and put in place infection prevention and control activities. The infection prevention and control team may want to consult with community leaders and other outside infection control experts who can provide important information about the critical access hospital’s population and associated health risks.
The results of the critical access hospital’s infection risk assessment should be prioritized, ideally in order of level of probability and potential for harm. The critical access hospital can then set goals for reducing the risks of the infections that pose the greatest threat to patients and the community. These goals should lead to focused activities, based on relevant professional guidelines and sound scientific
practices.
Elements of Performance
1. The critical access hospital identifies risks for acquiring and transmitting infections based on the following: Its geographic location, community, and population served. (See also NPSG.07.03.01, EP 1)
2. The critical access hospital identifies risks for acquiring and transmitting infections based on the following: The care, treatment, and services it provides. (See also NPSG.07.03.01, EP 1)
© HTS3 2018
22STANDARD EXAMPLE - DNV
NS.3 ASSESSMENT AND PLAN OF CARE
SR.1 Nursing staff shall develop and maintain a plan of care for each patient within 24 hours of admission that reflects the findings of a completed nursing assessment and input of other disciplines, as appropriate.
SR.2 Nursing staff shall complete an assessment of a patient’s condition within twenty four hours of admission to an inpatient setting.
SR.2a The nursing assessment will include but not be limited to:
• Allergies
• Admitting problem
• History of pain and current status
• Preexisting or other conditions (i.e. Pregnancy, COPD, Diabetes)
• Current medications (what time last dose, including any illicit drugs)
• ADL needs
• Dietary Requirements
• All other requirements per hospital nursing policies
SR.2b Nursing staff will complete an assessment according to the hospital nursing policies in all other areas of the organization. (Outpatient, clinics, surgical centers etc.).
SR.3 Nursing staff will reassess the patient at regular time defined intervals and if the patient’s condition changes
SR.3a The patients plan of care is reviewed and revised, as necessary, when the patient’s condition has changed.
Interpretive Guidelines:
A nursing assessment will be completed within 24 hours of admission to an inpatient setting and according to hospital policies in other areas of the organization such as clinics, outpatient surgery etc. While the list of requirements to be included in the initial nursing assessment is specific, the complete nursing assessment should reflect the philosophy of the nursing department on patient care. The use of nursing diagnosis, pathways or clinical guidelines are allowed and encouraged if they meet the minimum requirements. All nursing assessments should collect enough data for the nurse to be able to develop a plan of care to keep the patient safe and address the presenting and relevant concomitant conditions.
© HTS3 2018
23STANDARD EXAMPLE - DNV CONT.
NS.3 ASSESSMENT AND PLAN OF CARE
Surveyor Guidance:
Select a sample of nursing care plans. This should be a part of the review for each inpatient area visited. In evaluation of the plan of care, the following will be
reviewed.
• Are the plans initiated as soon as possible after admission for each patient?
• Does the plan reflect findings of the assessments and outlines the patient goals and as appropriate includes both, physiological and psychosocial factors;
• Has the discharge planning process been initiated?;
• Is the plan consistent with the attending practitioner’s plan for medical care?
• Does the plan includes appropriate interdisciplinary assessments and documentation of findings (as applicable); and,
• Has the plan been revised as necessary to meet the needs of the patient changes?
• Are the plans implemented?
Verify that nursing assignments include consideration of the complexity of the patient’s care needs and that the staff caring for the patients are competent and
have the required qualifications.
Review the process for determining how nursing assignments and staffing is applied in the patient care setting. This process should encompass the following:
– Patient needs
– Acuity of patients
– Special needs of individual patients
– Competence and qualifications of nursing personnel.
© HTS3 2018
24TIPS
1. Review ALL the information
– CMS Standard / Interpretative Guidelines / Survey Procedure
– TJC Introduction / Element of Performance
– DNV Standard / Interpretative Guidelines / Surveyor Guidance
– Other Accrediting Organizations are similar
2. Use the Survey Procedure / Surveyor Guidance as a source to develop
internal audit and tracer tool(s)
© HTS3 2018
253. PREPARE FOR SURVEYOR ARRIVAL
Develop script for front desk staff – or other staff that may be at point of entry
(nursing staff after-hours) - and what they should do when surveyors arrive.
1. Ask for Identification
2. Escort to meeting room
3. Notify Administrator or Supervisor
TRAIN STAFF
TEST YOUR SYSTEM
© HTS3 2018
26TIPS
1. Ask for surveyor identification. If there is any doubt as to identification – call accrediting agency for validation before allowing
surveyors access to documents or patient records
2. Develop specific process for notifying the organization and/or key organization members that surveyors are on-site. Identify
WHO is responsible for notification – and content of notification
– Don’t forget physicians
– Don’t forget the governing board
3. Identify WHO will accompany surveyors and act as scribes. Identify back-up if designated individual(s) are not available
4. If necessary, call in additional staff so that there are sufficient staff to accompany surveyors
5. Post notices at public entrances of survey in progress – if required by accrediting organization. Identify WHO will do this –
and content of notice in advance.
6. Provide adequate space for surveyors to work and provide for any needs they may have (access to computers, phone, etc.)
7. Establish a single point of contact – WHO the organization can call if they have questions about the survey
© HTS3 2018
27HAVE DOCUMENTS READY
EXAMPLE
1. Hospital license
2. CLIA certificates
3. Organizational Chart
4. Name of key contact person(s) with phone numbers
5. Map of organization
6. List of departments / units / areas / programs / services within the organization
7. List of sites where deep or moderate sedation is used
8. List of sites where high-level disinfection and sterilization is in use
9. List of patients
10. List of scheduled surgeries and special procedures
11. List of unapproved abbreviations
12. List of contracted services
13. Organ Procurement Organization agreement
14. Tissue and Eye Procurement Organization agreement and policies
15. Performance Improvement data for last 12 months including externally reported data
16. Documentation of performance improvement projects
17. Patient flow documentation
18. Environment of Care data
19. Environment of Care Management Plans and annual evaluation
20. Environment of Care multidisciplinary team meeting minutes for prior 12 months
© HTS3 2018
28SURVEYOR DOCUMENTS CONT.21. Emergency Operations Plan and annual
evaluation
22. Hazard Vulnerability Analysis
23. Emergency management drill records and after action reports
24. Written fire response plan
25. Interim Life Safety Measure policy
26. Fire drill evaluations
27. Infection Control Plan
28. Infection Control surveillance data for past 12 months
29. Medical Staff Bylaws and Rules & Regulations
30. Medical Record delinquency data
31. Medical Executive Committee meeting minutes for the past 12 months
32. Governing Body minutes for the past 12 months
33. Autopsy policy
34. Blood transfusion policy
35. Complaint / grievance policy
36. Restraint and seclusion policy
37. Medication management policy
38. Abuse and neglect policy
39. Fall risk assessment and policy
40. Discharge Planning policy
© HTS3 2018
29TIPS
1. Develop list of State or Accrediting Organization required documents
2. Consider Survey Notebook that is kept updated
– Assign responsibility for keeping notebook up to date
3. For items that can’t be kept in a notebook – assign position (not individual) to gather information
4. If you decide NOT to have a notebook – develop a document that clearly states where information can be found – and who is responsible for obtaining the information when surveyors arrive
© HTS3 2018
304. MAINTAIN COMPLIANCE WITH STANDARDS
A. Accountability – Who’s on first?
B. Assess – How are you doing?
C. Focus – What to work on?
D. Improve – Do you have a plan to improve?
© HTS3 2018
31A. ACCOUNTABILITY: WHO’S ON FIRST
First Base WhoSecond Base WhatThird Base I Don't KnowLeft Field WhyCenter Field BecausePitcher TomorrowCatcher TodayShortstop I Don't Give a Darn
© HTS3 2018
32CONTINUOUS SURVEY READINESS TEAM
1. Identify one group or committee that oversees / coordinates Continuous Survey Readiness
• Performance Improvement Committee
• Leadership Council
• Continuous Survey Readiness
2. Delegate responsibility for sections / chapters / topics • Environment of Care
• Infection Control
• P&T
• Nursing
© HTS3 2018
33ASSIGN RESPONSIBILITY
Page 33
Standards Potential Leader(s)
Ethics, Rights and Responsibilities (RI) Ethics Committee ChairDirector of Social Work
Provision of Care, Treatment and Services (PC) Chief Nursing Officer
Medication Management (MM) Pharmacy Director
Performance Improvement (PI) Chair of Quality CouncilQuality Director
Leadership (LD) CEO or COO
Environment of Care (EC) Director Plant / Maintenance
Human Resources (HR) VP or Director of HR
Information Management (IM) CIO
Infection Control (IC) Chair of IC CommitteeIC Practitioner
Medical Staff (MS) Chief of Medical StaffMedical DirectorMedical Staff Coordinator
Nursing (NR) Chief Nursing Officer
Example is forTJC – but you can assign responsibility by topic area for other accrediting agencies including CMS
© HTS3 2018
34
ASSIGN TOPIC LEADERS
IT’S NOT JUST ABOUT NURSING
Page 34
Standards Topic Leader Other Disciplines / Departments
Medical Imaging Radiation Safety Medical Imaging Director • Plant / Maintenance• Biomedical
Advance Directives Social Work • Admitting• Nursing
Falls Director of Med-Surg • Pharmacy
Restraints Day Shift Supervisor • Engineering• Security
Universal Protocol Surgery Manager • Surgery• Medical Imaging• Respiratory Therapy• Cath Lab
Hand Washing Infection Control Practitioner • ALL Depts.
Clinical Alarms Biomedical • ICU Manager • Plant / Maintenance• Biomedical• Information Technology
Medication Administration Director Nursing Education • Pharmacy• Medical Imaging• Respiratory Therapy Cath Lab• Physical Therapy
© HTS3 2018
35B. ASSESS: HOW ARE YOU DOING?1. Internal review of standard compliance
2. Quality / Performance data
3. Department dashboards / metrics
4. Infection Control data
5. Environment of Care / Safety Rounds
6. Externally reported data
7. Prior survey(s)
8. Frequently cited standards
9. Tracer data
10. External Survey
Surveyor Worksheets – 2015
11. QAPI Surveyor Worksheet
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-2.pdf
12. Discharge Planning Surveyor Worksheet
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-3.pdf
13. Infection Control Surveyor Worksheet
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-1.pdf
14. Infection Control Surveyor Worksheet
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-1.pdf
© HTS3 2018
36DRILL DOWN
Averages may mask where to focus
95%100%
95%
65%
89%90% 90% 90% 90% 90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med-Surg ICU OB Step Down Nursing
Fall Assessment
Compliance Target
© HTS3 2018
37
TIPS
1. Assign standards for review to individuals and/or teams and/or committees
2. When you are reviewing compliance – don’t guess! Look for evidence that you are in compliance
3. Review internal documents such as – Quality Plan, Infection Control Plan, EOC Plans, Emergency
Management Plan, Policies & Procedures, Medical Staff Bylaws etc.
4. Some standards require that they are measured – for example TJC National Patient Safety Goals
5. When you are looking at data (metrics) -- you don’t have to measure everything all the time ----
random sampling is OK
6. Drill down to understand where to focus
Pag
e
© HTS3 2018
38C. FOCUS: SO MANY STANDARDS – SO LITTLE TIME
The 80/20 Rule means that in any situation, 20 percent of the inputs or activities are responsible for 80 percent of the outcomes or results. In Pareto's case, it meant 20 percent of the people owned 80 percent of the wealth.
In Juran's initial work applying the 80/20 rule to quality studies, he identified 20 percent of the defects causing 80 percent of the problems.
Project Managers know that 20 percent of the work (the first 10 percent and the last 10 percent) consume 80 percent of the time and resources.
© HTS3 2018
39
MEASUREMENT AND IMPROVEMENT
ARE NOT THE SAME
You measure a lot of things (for example National Patient Safety Goals or Dishwasher temperatures or Handwashing)
If you are meeting your internal or external benchmark it doesn’t need to be an area of focus for improvement
Drill down to identify where to focus!
Measure Improvement Needed
YES NODishwasher temperatures Within range 99% of the time
Open Food in dietary refrigerator labeled with date / time opened
50% compliance
Hand Washing Not meeting target of 90% in Lab,Respiratory, ICU
Restraint Documentation Missing documentation elements in 54% of records
Pain assessment documented with vital signs, prior to medication administration for pain, 30 – 60 minutes after medication administration for pain
50% compliance in ER 98% compliance in Med-Surg and ICU
Drill Down
Drill Down
© HTS3 2018
40YOUR 20%1. What were the deficiencies from your last
survey? – Life Safety – Fire Drills
– Unsecured medications
– Outdated medications
– Outdated / unlabeled food
2. What are the new standards / focus areas?– Antibiotic Stewardship
– Legionella
– Sterilization and Disinfection
3. What are the most frequently cited standards?– EOC
– Life Safety
– Unsecured medications
5. What is your performance improvement data / tracers / audits telling you about potential problems?– Restraint documentation
– Signing / Dating Verbal orders
– Timeliness of H&P
– Medication Reconciliation
– Handwashing
6. What did the internal review of standards identify as potential vulnerabilities? – Hand Off Communication
– Medication Reconciliation
– Legionella
6. Are there any potential “immediate jeopardy” findings?– Suicide precautions
– Alarm fatigue
– Humidity not in range
© HTS3 2018
4120% OF THE 20%
Are there any potential “immediate jeopardy” findings?
– Suicide precautions
– Alarm fatigue
– Humidity
State Operations Manual: Appendix Q - Guidelines for Determining Immediate Jeopardy
“Immediate Jeopardy is interpreted as a crisis situation in which the health and safety of individual(s) are at risk.”
“These guidelines apply to all certified Medicare/Medicaid entities (excluding CLIA) and to all types of surveys and investigations: certifications, recertifications, revisits, and complaint investigations.”
Example: Failure to protect from undue adverse medication consequences and/or failure to provide medications as prescribed.
1. Administration of medication to an individual with a known history of allergic reaction to that medication;
2. Lack of monitoring and identification of potential serious drug interaction, side effects, and adverse reactions;
3. Administration of contraindicated medications;
4. Pattern of repeated medication errors without intervention;
5. Lack of diabetic monitoring resulting or likely to result in serious hypoglycemic or hyperglycemic reaction; or
6. Lack of timely and appropriate monitoring required for drug titration.
© HTS3 2018
42D. IMPROVE – DEVELOP A PLAN FOR THE 20%
Page 42
Focus Area Current Data / PerformanceExpected Performance
Root Cause / Why Action PlanWhat / Who / When
Fire Drills Current: 75% of required fire drills completed quarterly per policy
Goal: 100% of fire drills completed quarterly per policy
Fire Drill information is on paper and difficult to determine when drills should occur
What: Convert to Excel with alerts
Who: IT - Celia
When: January 29
Unsecured medications
Current: Ongoing unsecured medications identified in ICU as part of EOC rounds
Goal: 100% of medications will be secured
Lock broken on cabinet What: Repair cabinet
Who: Maintenance - John
When: January 29
© HTS3 2018
435. TOOLS FOR IMPROVEMENT - TRACERS
© HTS3 2018
44INDIVIDUAL TRACERS
These tracers are designed to “trace” the care experiences that a patient had
while at an organization. It is a way to analyze the organization’s system of
providing care, treatment or services using actual patients as the framework for
assessing standards compliance. Patients selected for these tracers will likely
be those in high-risk areas or whose diagnosis, age or type of services received
may enable the best in-depth evaluation of the organization’s processes and
practices.
Source: TJC Feb 10, 2017
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45SYSTEM TRACERS
Includes an interactive session with a surveyor and relevant staff members in tracing one specific “system” or process within the organization, based on information from individual tracers.
While individual tracers follow a patient through his or her course of care, the system tracer evaluates the system or process, including the integration of related processes, and the coordination and communication among disciplines and departments in those processes.
The three topics evaluated by system tracers are data management, infection control and medication management. Whether all system tracers are conducted varies, but the data use system tracer is performed on every survey.
Source: TJC Feb 10, 2017
© HTS3 2018
46ABOUT TRACERS
PROS
1. Method surveyors use
2. Real-Time Feedback to Staff
3. May NOT be representative (small
sample size)
CONS
1. It takes time
2. No perfect tool
3. Individuals doing tracers MAY
have variable skill level --- some
are better than others
© HTS3 2018
47THINK ABOUT THE KIND OF TRACERS YOU WANT TO DO
General – Just pull the string and see
where it takes you
Focused on a specific area
• Medication Management
• Operative and High Risk
Procedures
• Assessment and Patient Care
• Rights & Ethics
© HTS3 2018
48EXAMPLE - INDIVIDUAL TRACER
Start with general questions
Tell me about your patient.
1. Why were they admitted?
2. When were they admitted?
3. Did they come thru the ER or were they a direct admit?
4. How did the hand-off between ER and Med-Surg occur – or between ER and ICU –or between ICU and Med-Surg?
5. Does the patient have any chronic conditions?
6. What is their medical history?
7. When do you expect them to be discharged?
8. Who is responsible for discharge planning?
© HTS3 2018
49EXAMPLE - INDIVIDUAL TRACER
1. Medication: So the patient was admitted for CHF. Can you tell me what medications they were on at home? Are they getting the same medications in the hospital? Why or why not? Can you walk me thru the medications and the indications for each one of them.
2. Medication: Are you weighing the patient? Has the patient’s weight changed? How much of a weight change would require that you notify the physician? Is that a policy? An order? Or just your judgement?
3. Fall: I see the patient has been identified as a fall risk. Can you walk me thru your assessment. Have all the interventions been implemented? (Can you check please). Is fall risk on the Care Plan? Why or why not?
4. Nutrition: Is the patient at nutrition risk? If YES – have they been seen by the Dietitian? What did the dietitian recommend? Are the dietitian’s recommendations being followed? Why or why not?
5. Nutrition: The patient was not assessed as nutrition risk but it looks like they have been losing weight. At one point would you request a dietitian assessment? Can you show me your policy.
6. Discharge: I see the patient has been admitted 4 times in the last 12 months. Can you tell me what you are doing to make sure the patient isn’t readmitted after they are discharged?
© HTS3 2018
50EXAMPLE - PLAN OF CARE TRACER
• Are the plans initiated as soon as possible after admission for each patient?
• Does the plan reflect findings of the assessments and outlines the patient goals and as appropriate includes both, physiological and psychosocial factors
• Has the discharge planning process been initiated?
• Is the plan consistent with the attending practitioner’s plan for medical care?
• Does the plan includes appropriate interdisciplinary assessments and documentation of findings (as applicable)
• Has the plan been revised as necessary to meet the needs of the patient changes?
• Are the plans implemented?
Verify that nursing assignments include consideration of the complexity of the patient’s care needs and that the staff caring for the patients are competent and have the required qualifications.
Review the process for determining how nursing assignments and staffing is applied in the patient care setting. This process should encompass the following:
– Patient needs
– Acuity of patients
– Special needs of individual patients
– Competence and qualifications of nursing personnel.
DNV
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51EXAMPLE - MEDICATION TRACER
1. What medications was the patient taking at home?
2. Do you use medication reconciliation? Can you explain the process to me. What is the physician responsibility in the process?
3. Is the patient receiving the same medications in the Hospital that they were taking at home? Why or Why Not? Review medication reconciliation document.
4. Let’s look at each of the medications the patient is receiving.– Timeliness
• Ask to see policy for what constitutes “on-time” medication”
• Review each medication – time ordered and time administered. Determine if any were not “on-time” per policy
– PRN Medications
• Is there an indication as part of the order for each PRN medication?
• Is the indication documented when the PRN medication is administered?
• Is there follow-up documentation to determine if the medication was effective? (Temperature / Pain level / Blood Pressure, etc.)
– Non-Formulary
• I see that the patient was on an anti-psychotic medication at home but it hasn’t been administered in the Hospital even though it was ordered. Can you explain?
– Not available on our formulary --- Review process for obtaining non-formulary medications
– Is physician aware that the medication is not being administered?
– Has the patient exhibited any symptoms?
– Pharmacist Review
• I see the order for an antibiotic was written after the pharmacy closed. Can you explain how the order was verified before the drug was given?
Watch a Medication Pass
© HTS3 2018
52EXAMPLE - FALL RISK ASSESSMENT TRACER
1. Is the patient at risk for falls? Why or Why Not?
2. What is your policy for fall assessment? (Frequency / Elements). Can you show me your policy.
3. Can you tell me if the risk assessment in the policy is the same as the risk assessment in your EMR? If they are not the same – WHY NOT?
4. Based on our review of the chart it looks like the patient IS AT RISK for falls. Your policy says the patient will have a “falling star” on their door. Can you check and see if this patient has a star on their door. Your policy says the patient will have an arm band. Can you check and see if this patient has a star on their door.
5. Can you show me the patient’s plan of care. Does it include Risk for Falls? Why or Why Not.
Other Potential Questions
1. Based on our review of the record it looks like the patient was on multiple medications which should have placed them at Fall Risk. Can you explain WHY they weren’t identified as a Fall Risk?
2. What kind of education did you receive regarding assessing fall risk? (Follow-Up with HR to ensure education is documented.)
3. What is the fall rate on your unit? Do you have any quality initiatives to decrease the rate of falls? If so, what are they and how are you involved?
© HTS3 2018
53EXAMPLE - INFECTION CONTROL TRACER
1. I see the patient was admitted for the flu and pneumonia. When was the flu diagnosed?
2. It looks like the flu was diagnosed in the ED about 60 minutes after the patient arrived – and the patient was in the ED about 5 hours. Were there any precautions taken in the ER before or after the patient was diagnosed? (Go to ER and talk to staff if appropriate.)
3. Was the patient transported to Med-Surg with any type of isolation precautions in place (mask, etc.)?
4. Is the patient in isolation now? What type? Why?
5. What is your policy for isolating someone with the flu? Were all those precautions implemented?
6. What kind of education do you receive regarding patients who are contagious and isolation? (Review HR or IC records to validate.)
© HTS3 2018
54EXAMPLE - ACCESS TO PHARMACY TRACER
Yes No Compliance Comment
Do non-pharmacy staff ONLY have access to a limited to a set of medications that has been approved by the hospital. These medications can be stored in a night cabinet, automated storage and distribution device, or a limited section of the pharmacy.
Has the Hospital approved the medications that are available and can be removed when the pharmacist is not available?
Is there a policy identifying who is designated to remove drugs and biologicals?
Are ALL staff who access drugs when a pharmacist is not present ORIENTED / TRAINED before they are allowed to remove drugs?
Percent Compliance
If policy requires annual orientation of staff who remove drugs – is annual orientation in place for ALL staff? Percent Compliance
Are Quality control procedures (such as an independent second check by another individual or a secondary verification built into the system, such as bar coding) in place to prevent medication retrieval errors?
Are Quality Control procedures DOCUMENTED whenever a medication is removed? Percent Compliance
Is there a policy identifying the amount of drugs a non-pharmacist can remove in the absence of a pharmacist
Are amounts removed from pharmacy only in amounts sufficient for immediate therapeutic needs. Percent Compliance
Are all drugs removed from the pharmacy documented including type and quantity? Percent Compliance
Does a pharmacist review all medication removal activity and correlates the removal with current medication orders within the timeframe specified in Hospital policy?
Percent Compliance
Does the pharmacist review the contents of the after-hours supply to determine if it is adequate to meet the after-hour needs? How frequently is this done?
© HTS3 2018
55PULL THE THREAD AND SEE WHERE IT TAKES YOU
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56
IT’S WHAT’S DOCUMENTED
IT’S WHAT STAFF SAY
IT’S AN OPPORTUNITY FOR REAL-TIME EDUCATION
© HTS3 2018
576. TOOLS FOR IMPROVEMENT – EOC / SAFETY ROUNDS
© HTS3 2018
58EXAMPLE - ENVIRONMENT OF CARE ROUNDS
Patient Exam / Treatment Rooms Hallways
Floors and walls clean Floors and walls clean
Cubicle curtains clean and free of tears, etc. Free of obstruction and equipment
Furniture clean and in good condition Waiting and Reception Areas
Sink clean Carpeting clean
Soap & Paper Towel Dispensers are stocked and working Furniture clean and in good condition
Alcohol Hand sanitizers are available Empty cups and food items placed in trash
Gloves, PPE available as per policy Food only in designated areas
No supplies stored under sinks Equipment and Non-Critical Items
No food or drink in Patient Care Areas Equipment in patient use clean
Blood spill kits available Equipment stored is clean
Vent grills clean Equipment handled as per policy
High-level dusting performed Soiled Utility Rooms
Utility and Storage Rooms Floors and walls clean
Adequate separation of clean and soiled Free of patient supplies and sterilized trays
Floors and walls clean Soiled linen is bagged and appropriately placed for transport
No supplies stored on the floor Waste Management
Supplies stored 6" from floor. Bottom shelf is solid. Waste containers clean, operational, and in good condition
Supplies stored 18" from ceiling Waste containers covered and labeled as required
No supplies stored under sinks Red bag available in each regulated medical waste container
No supplies stored in bathrooms, soiled utility rooms Regulated medical waste discarded appropriately Items in regulated medical waste containers are appropriate
Are any outer warehouse or shipping boxes present? Sharps containers available and secured appropriately
Patient supplies within expiration dates Sharps containers not overfilled
Sterilized instruments and trays unopened, free of dust, tears No capped syringes in containers
© HTS3 2018
59EXAMPLE - ENVIRONMENT OF CARE ROUNDS CONT.
Refrigerators / Freezers Disinfection/Sterilization
Daily Checklist completed for temperatures Appropriate solutions available for soaking
Separate refrigerator designed for medications, specimens, food/drink Appropriate containers available
Correct temp observed: Medications, 36-46° F. Connected to Red Plug. Workflow proceeds from soiled to clean
Correct temp observed: Frozen Medications/Vaccines, < 3- 5° F Instruments/devices being processed according to manufacturer’s guidelines
Correct temp observed: Specimens, 36-46° F Written procedures available for each device reprocessed
Medications Sterilizers clean and functioning properly
No outdated IV solutions or medications Sterilizer preventive maintenance available
Open vials dated and timed as per policy Chemical/Biological monitors used as per policy
Vaccines stored appropriately Sterilization records/documentation complete
Are medications disposed of as required by Pharmaceutical Disposal regulations? Staff Competency-based Education/Training Program documented
Safe Injection Practices being followed as per Policy
Miscellaneous
Specimens being bagged,
© HTS3 2018
607. A WORD ABOUT DATA & MAKING IMPROVEMENTS
© HTS3 2018
61ELECTRONIC DATA
• Advantages
– Reduces time collecting data – if – it can be extracted electronically
– Provides external comparisons (if externally reported data)
– Complex data can be aggregated and displayed more easily
• Disadvantages• May not be real time
• Feedback MAY be too late to make a difference in outcomes ------- It’s So Yesterday
© HTS3 2018
62
DON’T UNDERESTIMATE THE
POWER OF PENCIL AND PAPER
How many falls did we have yesterday?Why did they happen?What are we going to do different today?
© HTS3 2018
63DRILL DOWN
Averages may mask where to focus
95%100%
95%
65%
89%90% 90% 90% 90% 90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med-Surg ICU OB Step Down Nursing
Fall Assessment
Compliance Target
© HTS3 2018
64DEVELOP PLAN FOR FOLLOW-UP
ReviewArea
Compliant Non-Compliant Follow-Up ActionWhat
Follow-Up ActionWho
Follow-Up ActionWhen
It’s a waste of time if there isn’t follow-up
© HTS3 2018
65TAKE ADVANTAGE OF EASY FIXES
© HTS3 2018
66LOOK FOR SYSTEM ISSUES
© HTS3 2018
678. EXAMINE YOUR READINESS CULTURE?
© HTS3 2018
68IS THE C-SUITE ENGAGED?
CFO?
CNO?
CEO?
Medical Director?
COO?
CIO?
© HTS3 2018
69IS THE BOARD ENGAGED?
1. Regular reports on “how you’re doing”
2. Regular reports on new standards and what they mean to the organization
3. Resources that may be needed to implement new standards
© HTS3 2018
70IS THE MEDICAL STAFF ENGAGED?
© HTS3 2018
71IS THE STAFF ENGAGED?
1. Does your staff know what your goals and expectations are relative to continuous survey readiness?
2. Do you share information about how you’re doing?
3. Do you encourage staff to tell their own stories about what worked and what didn’t work?
4. Do you encourage innovation – better way of doing things?
5. Do you encourage a strong team environment – working together?
6. Does feedback focus on the “positive” or just the “negative”?
7. Do you provide “immediate feedback” or once a month or once a quarter?
8. Do you celebrate achievements?
Adapted from: https://www.torbenrick.eu/blog/category/performance management, June 14, 2011
© HTS3 2018
72FINAL THOUGHTS72
© HTS3 2018
73
PLEASE CONTACT ME IF YOU WOULD LIKE TO TALK ABOUT
SCHEDULING A SURVEY AT YOUR FACILITY – OR –
IF YOU HAVE QUESTIONS ABOUT CONTINUOUS SURVEY READINESS
WE CONDUCT MOCK SURVEYS FOR ALL ACCREDITING ORGANIZATIONS
Carolyn St.Charles
Regional Chief Clinical Officer
360-584-9868
73
© HTS3 2018
74
Dallas Office2745 North Dallas Parkway,
Suite 100, Plano, TX 75093
Brentwood Office5110 Maryland Way, Suite 200
Brentwood, TN 37027
Our PhoneMain Office: 615.309.6053
Executive Placement: 972.265.4549
Carolyn St.Charles
Office: 360-584-9868
Cell: 206-605-3748
Diane Bradley
Office: 585-671-2212Cell: 585-455-3652
74
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