Tips, common mistakes in getting survey-ready
Hearing "The Joint Commission is here" doesn't have to send staff into shock. And it shouldn't mean last-minute scrambling to get ready. In upcoming months, Hospital Peer Review will provide perspectives from your peers, health care consultants, and other experts about being survey-ready at any point by looking at mistakes or lapses hospitals make in preparing for their surveys and tips on how to make the process most effective and efficient.
Paul L. Green, RN, MS, CPHQ, is chief quality officer at Memorial Hospital of Gardena (CA) and principal, founder of Greenlight Healthcare Consulting LLC. He says the starting point is a full organization assessment, either by internal staff with sound knowledge of compliance or by an outside consultant. Because he's in California, which has a consolidated survey (a joint survey by The Joint Commission, California's Department of Health, and the Institute for Medical Quality), he looks for an organizational picture along all regulatory body rules — Joint Commission, as well as federal and state governing bodies.
"Once you've got a good sort of organization-wide picture of where your strong points are and where your weak points are, then I think a very detailed action plan with time lines and responsibilities is absolutely critical," he says.
Assigning responsibilities, time lines
It's up to your facility to provide that, he says and therein he sees a lot of organizations falling short. "The most common mistake that they make is that they don't make the responsibility clear and they don't make the due dates clear and they don't hold people accountable to actually getting stuff done," he says, especially when you're in the mindset of thinking, "Oh, the survey is two years from now," and let things slide.
"The standpoint is anyone can come in at any point in time, and some of us who have lived through that experience of having the state descend or having the feds descend or even have Joint Commission descend, it's really critical to stay on top of that stuff and get it done and hold people accountable to getting it done," he adds.
The worst situation is when you've identified a problem and 18 months down the road, you still haven't rectified it. It is critical, he says, to stay on top of things on an ongoing basis, and to do that "you've got to have some kind of regulatory steering committee within the organization that includes senior leadership." It is the executive-level staff that can hold people accountable for getting their part done.
You can assign duties by chapters, by problem areas, or by function, but there's got to be a multidisciplinary team working together. Whoever on the team is responsible for one area must pull in other areas from the organization affected by that standard. For instance, Green says, if you assign your medical record director the information management chapter, he or she must pull from many other areas outside his or her scope. "Information management covers everything from your computer systems to HIPAA issues to unapproved abbreviations to documentation issues. And it crosses a lot of people. I think the common mistake people make is they turn that over to the health information director who then says, 'Well, I can't make sure the doctors get something signed before they do a procedure.' Well, sure you can, if you pull in the people who are involved with that." The assigned staff members must understand what they are responsible for and that they are responsible.
"So you've got this piece where you get the assessment, you get an action plan, you assign people to work on specific portions of the action plan, you've got to set up due dates in relationship to getting particular pieces done, and your steering committee has got to hold people accountable in relation to that," he says.
Another common mistake Green sees is when organizations go through the process, and the person responsible for a specific chapter says, "Yes, I have the policy written. It's done."
Green's response: "Prove it to me, prove it me. . . if you have something, you're going to show it to me." To ensure people were educated about the standard in question, he asks to see the content, the dates education was done, and the sign-in sheets of who was there. "Show me how you evaluated whether people learned anything or not. And I want to see all those documents, and I want to see them together."
And he asks to see where the policy meets the intent of the standard and answers the associated element of performance. When they answer those questions, Green creates a notebook with all the documentation. "If a surveyor should walk in tomorrow and say, 'We've got a question about restraint usage.' Well, right there at my fingertips, I can pull the restraint policy, I can pull the practice logs, I can pull the monitoring data."
Tracers keep you fresh
Once you get your organization up to compliance, Green asks, how do you maintain that? His answer is through ongoing tracer activity and monitoring.
He prefers to organize tracers functionally. "So, for example, you would operate it from the standpoint of the way a surveyor would look at it. A surveyor doesn't look to do a tracer by department; they do a tracer by patient."
So the tracer would take a look at a patient admitted to the emergency department the previous night and, as it follows the patient, look at the components of assessment, planning, and medication administration. Then he does departmental tracers as well to make sure departments are keeping up to speed.
He suggests holding monthly tracers. Mock surveys he does annually.
Where should you focus?
"National Patient Safety Goals is still the big hot button," Green says. And as part of those, what's huge now and will continue to be are:
- hospital-acquired infections;
- medication-related goals, especially anticoagulant management;
- new elements in relationship to leadership, the medical staff, and environment of care.
"The whole environment of care thing got rewritten in 2009, so that's a pretty big touch point," he says.
Focus on any goals that are to be phased in within the current year. He also suggests putting a radar on ongoing practice evaluation for medical staff (OPPE). The Joint Commission, he says, used to call for hospitals every couple of years to review quality data when someone got reappointed and use those data as part of that staff member's reappointment process.
This changed a couple of years ago, he says, with what's now referred to as OPPE and focused professional practice evaluation, or FPPE. With OPPE, you now have to look at the data in each practitioner's performance no less than every nine months "to evaluate the quality of care that is being provided and make a determination about whether this person needs to go into a focused review.
Organizational cooperation
Being survey-ready and compliant is not "a job that belongs to the quality department," Green says. "This is about running your business. And everybody who is a business leader, whether that be a department manager to vice president, runs portions of the business, and they have to run their business according to what legal requirements there are.
"And so the quality department can serve as a consultative resource to you in doing that, but you have to take accountability for running your own business. And that's I think the biggest mistake people make. They still sort of say, 'That's your job. We won't worry about. We'll talk to you in another year.' And it's not that way anymore. Not that it ever really was. But you could sort of fake it if you needed to. You can't fake it anymore."
Hearing "The Joint Commission is here" doesn't have to send staff into shock. And it shouldn't mean last-minute scrambling to get ready.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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