Continuous Survey Readiness (pre-during-post)
Continuous Survey Readiness(pre-during-post)Accreditation ProfessionalOrientation Certificate Program
Vizient: your accreditation partnerA key element of an organization focused on patient safety andperformance excellence is Continuous Accreditation Compliance andSurvey Management. The previous webinars for the AccreditationProfessional Orientation Certificate Program provided you with afoundation of knowledge.Today, you’ll learn about the fundamentals of survey managementand responding to unannounced surveys. Recommendations includedeveloping a response plan, implementing that plan during survey,and ensuring a solid process for following up post-survey.2Accreditation Professional Orientation Program Confidential Information
FacultyNatalie Webb, MHA, CPHQAccreditation Directornatalie.webb@vizientinc.comMitchell Gesinger, MSN, RN, CJCPAccreditation ion Professional Orientation Program Confidential Information
Disclosure informationNatalie Webb and Mitchell Gesinger do not have any relevant financial ornonfinancial relationships to disclose.4Accreditation Professional Orientation Program Confidential Information
ObjectivesOutline the critical activities of a Continuous PatientReadiness (CPR) model organization undergoingan on-site accreditation surveyDefine the activities that various CPR modelorganization staff perform during an on-siteaccreditation surveyDescribe the appropriate technique for challengingsurveyor findings while surveyors are on-siteOutline the critical activities that must occur immediatelyafter accreditation surveyors have left the organization5Accreditation Professional Orientation Program Confidential Information
Survey Management6Accreditation Professional Orientation Program Confidential Information
Survey success!Organizational CultureFirst impression FeelSurvey ManagementToday’s discussion Engaged Learning Comfortable Law andregulation CMS CoPs Pre-survey Intra-surveyTJC standardsand Eps Post-Survey OSHA Scope of practice MIFU Professionalguidelines Confidence7The RulesThe interworkingof the surveyprocess Clean OrganizedStandards ComplianceAccreditation Professional Orientation Program Confidential Information
Survey managementPre Survey–What do you need thinkabout?8Intra Survey–What do you need thinkabout?Accreditation Professional Orientation Program Confidential InformationPost Survey–What do you need thinkabout?
Pre-surveyWhat needs to happen before the surveyors ever arrive onsite?Planning“If you fail to plan, you are planning to fail” Survey Activity Guide (documents)- SAG Surveyor touchdown Command Center Scribes/escorts Meeting rooms Survey activation Opening presentation Internal Communication9Accreditation Professional Orientation Program Confidential Information
Survey activation guide (SAG)10Accreditation Professional Orientation Program Confidential Information
Preparing for surveyor arrivalStart at the beginning Does security and the front desk know whatto do and who to contact?Front Desk Cheat sheet: Survey ActivationActions to take when surveyor arrivesComments:1) Greet surveyor(s)Hello, welcome to , if I may see your IDto validate your credentials Thank you, if youwould have a seat in the waiting area I willcontact the team and let them know you havearrived 2) Verify identityLook at picture ID to ensure they are from theJoint Commission3) Ask them to waitLocation: Waiting area4) Validate authenticity of surveyContact: (thisindividual has a user ID and password to accessthe organization’s Joint Commission extranet site)Phone number:11Accreditation Professional Orientation Program Confidential Information
Pre-survey planningThe first 30 minutes I just got notified they are here Who is 12 Going to meet the surveyors? Ordering them coffee and pastries? Notifying the c-suite and other stakeholders? Or how are we notifying staff and unit leadership? Downloading the surveyor agenda and reviewing with lead? Downloading census and required documents and delivering them? Sending out surveyor bios? Coordinating lunch and snacks for surveyors, command center andscribes/escorts? Reserving rooms? Clearing calendars? Completing quick environmental sweeps? Notifying Vizient?Accreditation Professional Orientation Program Confidential Information
Sample agenda template13Accreditation Professional Orientation Program Confidential Information
Required documents!14Accreditation Professional Orientation Program Confidential Information
Opening presentation Organization’s 1st big impressionWhat should you be thinking about? Who? Where? How long? What?15Accreditation Professional Orientation Program Confidential Information
SWAT- environment of care (EOC) checksWhat’s the SWAT checklist?16Accreditation Professional Orientation Program Confidential Information
And you are are off The first two hours are over and the actual survey hasbegun Shifting to intra-survey!17Accreditation Professional Orientation Program Confidential Information
Organization and logistics Surveyor conference roomScribe/Escort roomCommand center– Location– Equipment– Supplies18Accreditation Professional Orientation Program Confidential Information
Essential functions- scribe/escortEscort: Person who is comfortable and knowledgeable about your organization,operations, locations, and provision of patient care.Job functions: Build a relationship with the surveyor Serve as the liaison to aid the surveyor in traveling the hospital.Scribe: Person who is detail-oriented, eager to learn and has the time to participate.Job Functions: Communicate with the command center (never bypass) Take notes of surveyor questions Track medical record numbers of records reviewed Track staff and medical staff personnel for competency filesDon’t forget- Train the escorts and scribes in advance!19Accreditation Professional Orientation Program Confidential Information
Essential functions- command centerYou are the heart of survey management!Job functions: Track and complete objectives Mitigate/manage findings Track surveyors Communicate to the organization Coordinate needs Notify operations of arrivalKey stakeholders: Infection prevention Clinical Informatics Accreditation/Quality/Risk Central support departments PolicyPositions: Lead 1st assist Logistics Informatics IP Objective coordinators20Accreditation Professional Orientation Program Confidential Information
Onsite: Utilize team leadInteracting with team leadMaintain ongoing dialogue withteam lead; be direct, professionaland assertive when necessaryDiscuss results and potentialdeficienciesAddress conflicts with surveyorsASAP with the team leadAccreditation staff – knowstandards and your organization’sdata so as to be able to facilitatereal time clarifications of findingswith the team lead21Accreditation Professional Orientation Program Confidential Information
Life safetyLife safety engineerSurvey processPart of full survey teamBegin to rectify any serious issuesimmediatelyTJC provides agenda anddocument listIf there are disagreements onissues, involve team lead, callhome office, ensure issue is fullyclarified before life safety engineerleavesLife safety exit conference may beheld separately from full surveyexit conferenceBy exit conference, organizationshould know what the issues are22Accreditation Professional Orientation Program Confidential Information
Tracer methodologyFocus areas: Patient care processes: admission to discharge Critical operational processesTypes of Tracers: Individual Tracer– Specific patient population Risk Area Tracer– High level disinfection– Sedation/Anesthesia– Ligature risk– Hemodialysis System Tracer– Tissue management Patient Flow Tracer– ED and OR / boarding / bed placement23Accreditation Professional Orientation Program Confidential Information
Tracer methodologyIndividual tracerRisk area tracerTaken from patient lists providedDrill into particular organization-widehigh risk processFollow patient through their stay:may focus on complex patients10% of average daily census or 30medical recordsWill review consents, care plans,orders, medicationsMay review policies and proceduresrelated to care, treatment andservicesInterviews of staff and patientsIdentify synergies and collaborationbetween departments andmultidisciplinary team24Accreditation Professional Orientation Program Confidential InformationReview of processes that may havea significant impact on patient if gapsexist or errors occurExamples: Cleaning, disinfecting, &sanitization Patient Flow process continuum Contractual agreements Diagnostic Imaging OPPE & FPPE Therapeutic radiation Clinical & Health Information
Tracer methodologySystem tracerPatient flow tracerExploration of one specific system orprocessReview of patient flow fromadmission to dischargeSurveyor evaluates integration ofsystem or processIdentification of potential treatmentdelays, unsafe practices duringperiods of patient congestion (highcensus)Interactive interview sessionProcess flow, identification of riskpoints, integration of key informationCommunication among teamBaseline assessment of standardscomplianceExamples: Tissue management25Accreditation Professional Orientation Program Confidential InformationExamples: Emergency departmentthroughput – use of hallway beds Initiation of care Post-operative recovery unitthroughput Time from discharge to clean bed Discharge process
A tag review sheet26Accreditation Professional Orientation Program Confidential Information
Tracer sessions (system tracers) 27Competency (HR)Competency (credentialing/ privileging)Infection preventionMedication managementDataLeadershipAccreditation Professional Orientation Program Confidential Information
Role of accreditation professional in tracermethodologyDaily census, surgical and procedure schedules Provide list of active patients Names, current locations, diagnosis & conditionsSurveyors may request staff to help in selecting appropriate tracerpatientsCoach your staff as to the appropriate type of patient to chooseAs surveyor navigates your hospital: They will interview staff involved in patient’s care Questions are focused on what those staff have experience in doingevery day Keep track of patients (for HIPAA purposes) and staff (for personnel filereview) who are interviewed28Accreditation Professional Orientation Program Confidential Information
Our first finding Don’t panic- it is going to happen Do Investigate Ask Is it a finding? Can you find supporting documentation? Can you provide clarity? Evaluate against the source of truth?29Accreditation Professional Orientation Program Confidential Information
Source of truthHierarchy: Law or regulation (state law, OSHA) CMS (CoP of CfC) Manufacturer’s Information for Use (MIFU) Evidence based guidelines Consensus documents Policy30Accreditation Professional Orientation Program Confidential Information
Our first disagreement on a finding Special issue resolution 31Accreditation Professional Orientation Program Confidential Information
Communicating themes and trends SAFER to keep to the left32Accreditation Professional Orientation Program Confidential Information
Morning (daily) debriefing 33Accreditation Professional Orientation Program Confidential Information
Morning (daily) debriefing During surveyPost surveyDaily briefing – highlight ofsignificant issuesBegin to rectify any serious issuesimmediatelyOpportunity to identify issuesthat need to be clarified orresolvedTJC scoring process Surveyors score elements ofperformance Likelihood to harm and scope Score performance andcompliance track recordAccreditation decision process Based on criticality model – RISK 60 days to respond to arequirement for improvementPresent IOUs from previous day’ssurvey activitiesBy exit conference, organizationshould know what the issues are34Accreditation Professional Orientation Program Confidential Information
Exit briefing - executive leadershipSurveyors defer to organization leadership as to whether andhow this briefing occursWho attends: CEO, COO, CMO, CNO, CFO – Board members arewelcome Accreditation staff should be present to assist with anyclarification leaders need from surveyorsSession follows preparation of preliminary survey reportSurvey team reviews summary of findings35Accreditation Professional Orientation Program Confidential Information
Organizational exit conferenceLeadershipStaffOrganizational leaders determine: Who attends What is shared Whether it occursLeaders should consider sharinginformation with staff at the end ofsurveyTJC – preliminary report posted tothe organizational extranet prior toexit conferenceTJC – final report is posted to theorganizational extranet within 10business days36Accreditation Professional Orientation Program Confidential InformationStaff have:Worked hardExperienced anxiety during surveySome organizations hold a separateorganizational exit conference orconference call to share results
Tools37Accreditation Professional Orientation Program Confidential Information
Document request formDateDocumentSurveyorEscortLocationCopiesCopies Commentprovided made byY/NLog all documents requested / given to survey team– assists in tracking issued reviewed38Accreditation Professional Orientation Program Confidential Information
Human resource employee request formDateLocationEmployeenameEmployeetitle(e.g.: ommentLog all employees interviewed each day – helps begin tobuild potential list of employee files to be reviewed39Accreditation Professional Orientation Program Confidential Information
Medical records request formDateLocationPatientnameMR tTrack all records reviewed for HIPAA purposes – recordwill also be valuable in following up on issues, findings,clarifications (as applicable)40Accreditation Professional Orientation Program Confidential Information
Following the survey41Accreditation Professional Orientation Program Confidential Information
Immediately post-surveyCelebrate42Accreditation Professional Orientation Program Confidential Information
Following the surveyReview preliminary report Determine impact of findings Begin to frame responses before receipt of the final report Specific attention should be devoted to those findings that have adirect impact on patients or are scored at the condition-level Determine if there are findings that need to be discussed with youraccount representative (hopefully you will have addressed allissues during survey!) Develop a timeline for addressing and correcting findingsAccreditation Professional Orientation Program Confidential Information43
Following the surveyAccreditation staff: Support, monitor, and coordinate response to survey findings Ensure consensus on and approval of the responses and actionplans Work with operational partners to develop and implementcorrective action plans and evidence of standards compliance Submit corrective action plan / evidence of standards compliancetimely (per voluntary accrediting body or CMS instruction) Monitor development of action plans, data collection andmonitoring to validate compliance Update leadership on progressAccreditation Professional Orientation Program Confidential Information44
Following the surveyMonitoring action plans: Select appropriate sample sizes for tracking compliance– Population size than 30, 100% of cases– 30 – 100 cases, 30 cases– 101 – 500 cases, 50 cases– than 500, 70 cases What is considered compliant?– Shoot for 90% or greater– Think about the patient – the higher the better Based on risk and compliance – determine duration of monitoringAccreditation Professional Orientation Program Confidential Information45
CMS 2567Form: wnloads/cms2567.pdf46Accreditation Professional Orientation Program Confidential Information
CMS plan of correction A-Tag and primary issue: Each corrective action should be crosswalked to the applicable deficiency Corrective action: High level statement outlining what will be done tocorrect issue, mitigate/prevent future issues (Potential Root CauseAnalysis) Policy/Procedure: Is the issue in any way linked to a policy /procedure? If so, list it and delineate whether it will be modified in anyway as part of the corrective action Training/Communication: If training is part of the action, who will betrained, how will they be trained, and when will training be completed? QAPI Measurement/Monitoring: Will there be quality measurement ofmonitoring to ensure corrective action is sustained? Who will it bereported to and at what frequency? Responsible Party: One person who is ultimately accountable for theaction Completion Date: Date it will be completed47Accreditation Professional Orientation Program Confidential Information
Summary 48Develop a response plan.Be confident in your knowledge of organizational compliance so thatyou are able to communicate to the survey team and assistorganizational staff in conveying compliance.Stay connected to team lead during survey to understand issues asthey are identified.At the end of survey, celebrate your success.Ensure your survey report is accurate.Assist operational partners in building a valid corrective action planwith appropriate monitoring to validate ongoing compliance.Accreditation Professional Orientation Program Confidential Information
Questions49Accreditation Professional Orientation Program Confidential Information
Next steps1. Complete evaluation2. Stay connected – Network Members - register for Fundamental and Advancedwebinar series and encourage operational partners to listen in topertinent webinars Attend Vizient conferences to stay up to date with trends andrequirements Connect with the colleagues during the course Connect with your Vizient faculty50Accreditation Professional Orientation Program Confidential Information
Contact:Diana Scott, Associate VP, Accreditation Advisory Services, Diana.Scott@vizientinc.comNatalie Webb, Accreditation Director, Natalie.Webb@vizientinc.comThis information is proprietary and highly confidential. Any unauthorized dissemination,distribution or copying is strictly prohibited. Any violation of this prohibition may be subjectto penalties and recourse under the law. Copyright 2018 Vizient, Inc. All rights reserved.
Survey success! Organizational Culture First impression Feel Clean Organized Engaged Learning Comfortable Confidence Survey Management Today's discussion The interworking of the survey process Pre-survey Intra-survey Post-Survey 7 Accreditation Professional Orientation Program Confidential Information
Answer Key Question Number Reporting Category Readiness or Supporting Content Expectation Correct Answer Reading Selection 1 - Black Holes 1 1 Supporting 3.4C C 2 3 Readiness 3.13 Figure 19(E) A 3 3 Readiness 3.13B D 4 3 Readiness 3.13A C 5 3 Readiness 3.13C A 6 1 Readiness 3.4B D 7 3 Supporting 3.16 A
Table 15: DOE Technology Readiness Levels (2011) 135 . Table 16: DOD Manufacturing Readiness Levels 137 . Table 17: Integration Readiness Levels 140 . Table 18: System Readiness Levels 141 . Figures
tem readiness are not yet implemented in any formal way Department of Defense (DoD)-wide. This article explains a method to combine Technology Readiness Level (TRL) (See Appendix, Table A-1), Integration Readiness Level (IRL), and Manufacturing Readiness Level (MRL) (See Appendix, Table A-2) into aCited by: 2Page Count: 29File Size: 1MB
Ministry of Education to consider enhancing children's readiness to learn. The three policy recommendations are social change and preparation policies, government leadership for school readiness policies and school readiness funding policies. KEYWORDS: children's school readiness, C. W. Mills, bell hooks Hongliang Hu, M.A. Candidate
A2 Transition Readiness Seminar Student Guide CAREER READINESS STANDARDS Career Readiness Standards you will be expected to meet Attend Pre-Separation Counseling Complete Pre-Sepa
Expeditionary Skills for Readiness/Readiness Currency - Combat Specialty Knowledge - Individual skills specific to operating in an expeditionary environment. Category 2 Readiness Criteria ensures transference of Category 1 skills to the expeditionary environment, including patient care during combat operations. Category 2 Readiness
Agile and Continuous Delivery Oracle Confidential – Restricted Continuous Delivery: frequent releases of new software through the use of automated testing and continuous integration. Continuous integration continuous delivery continuous deployment code label branch(es) p
Why the AMC’s are Trivial Brandon Jiang January 24, 2016 1 How to Use this Document This could possibly be used as a sort of study guide, but its main intent is to of- fer students some direction to prepare for this contest other than just doing past problems. Note that it is assumed that the reader is mathematically capable of understanding the standard curriculum at school. If not, the .
