Send expensive consultants packing
Here’s how to run your own mock survey
With reimbursement declining and regulatory requirements increasing, finding the money to spend on an outside consultant to do a mock survey may seem prohibitive. But there are ways you can take advantage of internal resources to make sure you are prepared for surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) when they come.
Barbara January, RN, clinical services specialist at In Home Health in Minnetonka, MN, runs a mock survey program internally for the agency, which has 29 branches in 14 states. Initially part of the agency’s internal compliance program, January’s Branch Assessment program evolved as Joint Commission accreditation started becoming more important. "We have an ongoing evaluation and monitoring system for each branch’s compliance with and adherence to applicable federal, state, and local laws and regulations, as well as JCAHO standards, company policies, and standards of practice," she says.
The plan has not only ensured that branches are prepared for their surveys and know what to expect, but it also highlighted problem areas in those branches and enabled managers to take corrective action before the surveyor’s find them.
January says each mock survey consists of several elements, all of which parallel what will happen in a real JCAHO survey. The surveys take two to three days each, depending on the size of the branch and the services it offers. For instance, a branch that has hospice will take longer. "If you want to adequately evaluate a branch, you have to do home visits. You can’t do that in less time," she adds. (For more on what her mock surveys include, see related story, p. 43.)
After each mock survey, the branch is given a written assessment report of the findings. Branch managers are then required to create a plan of correction and action plan for any areas deemed non-compliant. This plan is reviewed and approved by the corporate office, says January, and remains "open" until the plan is completed.
Better compliance, better information
The impact of the mock surveys has been significant, January says. Among the key benefits have been improved infection control practices, equipment management procedures and documentation. "This just makes staff more aware of things beyond hand washing," she says. "They ask themselves if they are packing wounds correctly, and if they are using sterile equipment when they should."
In the documentation area, one area that branches failed was keeping glucometer logs current. "We implemented a very formal program that includes a quarterly report on that topic alone," says January. "There isn’t a problem any more."
Another benefit to the program is that managers and supervisors who are new to the job have an easy-to-follow audit tool at their disposal that helps them to quickly identify problem areas at a branch even before they are totally familiar with company policies and procedures. "They can also review the most recent Branch Assessment Report to identify any areas of noncompliance."
While In Home Health is a large organization with resources at its disposal for a formal program, January says smaller organizations can still put their own mock survey programs in place with minimal effort and existing resources.
"With tightening budgets, it is increasingly difficult for home health agencies to hire outside help to do this kind of assessment," she says. "But you can do this by using your present tools. For instance, if you are a Medicare certified agency, you already do quarterly record reviews. Just make sure that your record review tools include the criteria surveyors will be looking for when they review your charts."
When you go with staff on home visits, adds January, look for what surveyors look for, such as breaks in infection control practice or confidentiality. Interview patients about what they have been told about patient rights, hotline numbers, and advance directives.
Periodically, you can use staff meetings to practice survey interview questions. Check to see if your staff understands policies and procedures by quizzing them, says January.
Take advantage of other resources
If you are a hospital-owned agency, or if you have close ties with a hospital, you can also use their resources as a boost to your own. Meadville (PA) Medical Center has a VNA operating its home health agency. Marie Pears, CPHQ, quality and survey coordinator for the hospital, says the hospital joined forces with VNA for a mock survey.
A year prior to its first survey, the hospital and home health agency formed committees to review policies and procedures to make sure they were ready. They did find some problem areas during what Pears calls a "dress rehearsal for the real thing," and were able to correct them before the actual JCAHO survey.
When the real surveyors came in, the answers to the questions they asked came more easily to staff, Pears adds. The results were remarkable at the hospital and home health agency. "Our grid score was 100, and I think that is attributable to the mock survey," Pears says.
At the very least, says January, any agency can take the JCAHO standards manual and go over it to see whether it will pass muster during a survey. The best way, she says, is to devote a month to each of the 11 chapters of the manual, taking December off for the holidays.
"Once the survey is over, keep the process going," advises January. "If you conduct regularly scheduled branch assessments, you can catch areas of noncompliance before they become troublesome."
Sources
• Barbara January, RN, Clinical Services Specialist, In Home Health, Inc., 601 Lakeshore Parkway, Suite 500, Minnetonka, MN 55305-5214. Telephone: (612) 449-7500.
• Marie Pears, RRA, CPHQ, Quality Coordinator/Survey Coordinator, Meadville Medical Center Home Health, 751 Liberty St., Meadville, PA 16335. Telephone: (814) 333-5583.
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