CLARIFICATION AND EVIDENCE OF STANDARDS COMPLIANCE

1. CLARIFICATION AND EVIDENCE OF STANDARDS COMPLIANCE Jennifer Cowel, RN, MHSA Vice President Patton Healthcare Consulting,

2. WHATS THE DIFFERENCE BETWEEN CLARIFICATION AND ESC? • CLARIFICATION – It wasn’t broken at the time of survey. There is nothing we need to fix. • ESC – We agree, it was broken and we have fixed it. • A clarification is not the same as “we fixed it quickly, we fixed it before the survey was over”

3. CLARIFICATION DEADLINES • Begin immediately, use the time after receiving your onsite report to start the analysis. • Should I wait to start in hope that the final report gets cleaned up by TJC? • No, due to continuous flow and if not continuous flow you will need all the time you can get. • You have only 10 days after final posting • You can only submit information reflective of conditions as of the day prior to your survey starting. • Again, no credit for quick fixes after the fact

4. CLARIFICATION, GETTING STARTED • ESC/CLAR Guidelines on Extranet appear to be deleted, contained useful details on preparation • ESC Quick Tips has replaced it, but lacking in details. Account Exec will email you more details if you encounter a problem. • If you are angry, let it go. • Focus on the EP and focus on the surveyor’s written observation • Usually best to discard tangential or background conversations that do not directly relate to the EP and observation cited.

5. CLARIFICATION, GETTING STARTED • If there was a tangential conversation your SIG reviewer is not aware of it. • If it was pertinent you would have to explain it. • Remember to sort your A’s and C’s • Your C’s require audits, not arguments • Don’t give up on your C’s just because the observations are correct.

6. CLARIFICATION – SHOULD I BOTHER? • Direct vs indirect impact RFI’s- See AFS01 and AFS02 2011 • No published screening threshold for 2011 but ADM02 implies it still exists • Consider the workload of an ESC/MOS vs CLAR for the EP. • All RFI’s add to PFP/S3 points • If adverse decision is subsequently reached your last report findings are publically released on the web in layman's terms.

7. CLARIFICATION WILL IT MAKE THEM ANGRY? • No, clarification analysis is an objective analysis – these are the facts • Keep focused on the facts, not your anger, not side conversations • You may need to argue and convince on the more subjective “Condition out” conclusions. • Some clarifications by organizations as written are unidentifiable as to what standard is being addressed. Go back to the EP, and the finding and be specific.

8. CLARIFYING AN A ELEMENT OF PERFORMANCE • We found the policy we could not locate during the survey. • We found the documentation that demonstrates compliance with that issue. • We located the misfiled chart form. • The observation is not correct because… • Its not related to the EP • Its performance and should have been scored at the more appropriate C EP. • Its not a correct statement • Its not supported by any evidence in the text of the observation • Saying it doesn’t exist is not the same as saying the surveyor doesn’t think it is adequate

9. CLARIFYING AN A ELEMENT OF PERFORMANCE • WHO: Wrote or approved the policy? • WHAT: Does the policy say about this specific issue and where does it say this? • WHEN: Was the policy approved and distributed? • HOW: Are policies distributed in your hospital and how are staff trained? • WHY: Was this not shown to the surveyor?

10. CLARIFYING AN A ELEMENT OF PERFORMANCE • You can’t attach or send policies, you must describe – they may ask for a copy prn • You can’t do a lot of special formatting, special fonts, colors in their prescribed clarification format and software. • Lastly, you can’t clarify by saying you fixed it.

11. C Elements of Performance • On site survey technique is 2 observations creates an RFI • Post survey technique allows larger scale auditing to calculate a percentage compliance. • 90% or better clears the EP and RFI • 80%-89% scores the EP 1, partial, but since 2009 this will still result in an RFI

12. CLARIFYING A C ELEMENT OF PERFORMANCE • Don’t argue with them about the observation, prove you are compliant by documenting an audit. (Perspectives) • Strategize your audit design: • Did they see all the observations in one location or more than one? • Did they see observations in both inpatient and outpatient locations? • Do your audit on the applicable population • Design perfectly so you only have to audit once • If your audit fails, STOP!

13. SAMPLE SIZE • How many charts do we have to review? • For a population size of less than 30 cases, sample 100% of cases • For a population size up to 100 cases, sample 30 cases • For a population size of 101 to 500 cases, sample 50 cases • For a population size of over 500 cases, sample 70 cases

14. Sample Selection • Draw your sample from the applicable population. • If the standard covers inpatient and outpatient and the surveyor observations cover both populations, then pull from both groups. • If the standard only covers inpatient, or the surveyor observations are only from inpatient, then pull charts only from inpatient • If the standard only covers outpatient, or the surveyor observation only covers outpatient, then pull charts only from outpatient

15. Sample Selection • Drawing your sample from the applicable population. • If the standard covers a small subset of your population, e.g. patients in restraint, then only pull charts for patients that had restraint. • This limited pulling logic may change your required sample size. • E.g. if you only used restraint 5 times in the 30 day period prior to survey then you should audit 100% of those 5 charts.

16. Splitting the Sample • If you want to draw both inpatient and outpatient charts in your sample, you need to calculate how many charts from inpatient and how many charts from outpatient. • Use relative percentage of revenue • Use relative percentage of expense • Just use relative size/volume • Split the sample strategically

17. Timing • You should review records and services provided in the 30 day period prior to survey for clinical RFI’s. Use 12 month data for EC issues. • Request IT provide you a list of patients admitted and discharged in that 30 day timeframe, either house wide or unit specific based on RFI. • This prevents any cross over to post survey effect or changes induced as a result of the survey.

18. Calculating your Sample Size • Our ADC = 200 • In the 30 day period prior to survey we admitted and discharged 900 patients. • Sample size then = 70 • In the 30 day period prior to survey we served 600 unique outpatients • For an outpatient only issue your sample size = 70 • For inpatient plus outpatient issue you must split your sample, but still only need 70 cases.

19. Identify your Audit Team • Nurses, medical records staff or other unique content experts for specific standards. • Two techniques can be used. • All auditors analyze same charts for multiple issues • Specific auditors go through charts and pass the charts along to other auditors. • You can and should use the same charts for multiple audits if the applicable population is covered.

20. Randomizing your Sample • How do you select 70 charts if you have 700 names on a list? • Pull every 10th chart (EASY! RECOMMENDED) • Use statistical @Rand feature to randomly select 70 charts (COMPLEX) • =RANDBETWEEN(1,xxx) • Do highlight the names selected and retain the lists to show Joint Commission if ever asked. No cherry picking.

21. SPLITTING THE SAMPLE • We admitted and discharged 700 inpatients in the 30 day period prior to survey. • We served 300 unique individuals in outpatient the month before survey. • Inpatient services are responsible for 80% of total revenues. • Pull 56 inpatient records and 14 outpatient to obtain a total of 70.

22. Saving your Results • Save your lists of patients where you highlighted the names of patients. • Save your recording worksheets where your auditors noted results. • TJC might choose to validate the clarification so verify that everything was legitimate. • Do not risk falsification repercussions • If a consultant helps you, make sure the language the consultant uses is 100% accurate and reflective of conditions prior to your survey, no matter how well it reads.

23. GOOD NEWS • You can draft your clarifying evidence in Word, email around to your team, revise, edit, etc, then clip and paste into the extranet. • Remember no special fonts, colors, formatting, no attachments, just text.

24. BAD NEWS • TJC clarification extranet tool does not permit uploading of your Excel spreadsheets • Your spreadsheets must be built in the extranet and the data re-entered. • Don’t wait until the 10th day. Start the data entry process as early as possible because this data entry task is time consuming.

25. CLARIFICATION PREPARATION • Print all applicable policies – all those cited, referenced by surveyors or otherwise pertinent to the clarification. • Change nothing immediately. Wait and see if you can clarify before changing a practice. Once changed it is harder to clarify. • Debrief all escorts and scribes and gather their notes.

26. CLARIFICATION EXAMPLE, A ELEMENT • MS.03.01.01, EP, EP 17, A, indirect: The medical staff approves the nuclear medicine directors specifications for the qualifications, training, functions and responsibilities for the nuclear medicine staff. • Observation: “During the tracer in nuclear medicine the nuclear medicine technician indicated that this approval had not been done”.

27. YES, CLARIFY IF IT WAS DONE • WHO: The nuclear medicine director… • WHAT: Took the job descriptions and the required competencies to the MEC… • WHEN: December 12, 2009 and approval is documented in the minutes • HOW: Copies of job descriptions and competencies had been distributed to the MEC for discussion and approval. • WHY: The surveyor received a response from staff that were not aware of and not responsible for this process. The nuclear medicine director and the medical staff office who were both aware were not interviewed about this issue.

28. CLARIFICATION, C ELEMENT • IM.02.02.01, EP 3 unapproved abbrevs. • Observation: “ During the tracer in ICU orders were written for sliding scale insulin using U instead of units. During the tracer in the family practice clinic, two charts were noted to contain medication orders for qd. During the tracer in the inpatient psychiatry unit 3 charts were noted to contain medication orders with trailing zero.

29. COMMON MISPERCEPTION • Darn, the surveyors observations are entirely correct, we can’t do anything with this except fix it going forward. • NO! • You can clarify and this is an easy audit to pass. • Remember, this is not pass fail at the chart level. • This sounds like a lot of work, but compare to doing MOS X 4 months

30. ABBREVIATIONS AUDIT • Get your patient lists, 30 day period prior to survey. Inpatients served and outpatients. • Identify sample size • Split sample between inpatient and outpatient • Randomize chart selection • Identify and train staff to look at all medication related documentation.

31. ABBREVIATIONS AUDIT • Create tally sheets to identify all correct uses and all incorrect uses in your sample charts. • All daily, morphine, lack of trailing zero, leading zero, magnesium, units, etc are correct uses. • The count of correct uses will dwarf the count of incorrect uses. You should be 95%+ compliant.

32. ABBREVIATIONS AUDIT • Recommend converting paper tally sheets to Excel to compute final percentage. • Identify the records and results in your spreadsheet. Calculate a final percentage compliance. • Validate your results. • Re-enter data into TJC extranet tool.

33. OTHER C AUDITS • Timing of medical record entries • Authentication of verbal orders • Pain reassessments per policy • PRN medication orders are qualified • Medication storage is appropriate • H+P’s are done correctly per policy

34. CAN WE USE THIS TECHNIQUE FOR MEDICARE CONDITION OUT? Sometimes: If one TJC standard lead to condition out and you can clarify If multiple standards in the same chapter were scored out all aligned with same COP and you can clarify one or more. If COP issue isn’t properly aligned with what your surveyor saw. Will need to clarify EP’s and embed request to delete COP out status.

35. CORRECTIVE ACTION ESC • Adhere to TJC 45 day and 60 day deadlines • Be on target, precise and concise • Use their mandatory format, who, what, when, how. • Language should be past tense, it has been done, not; it will be done. • During the ESC phase its too late to clarify. Don’t start arguing the appropriateness of the RFI at this point. • Distribute ESC format to responsible departments for their buy in, ownership and expertise.

36. CORRECTIVE ACTION ESC • Be on target and focused: IC.01.04.01, EP 1: The infection control plan did not address or identify prioritized risks. • ESC: We sent our infection control practitioner to a seminar on how to write a plan. NOT ACCEPTABLE • ESC: Our infection control practitioner has drafted a list of priorities and this will go before our infection control committee and MEC at their next quarterly meetings. STILL NOT ACCEPTABLE

37. CORRECTIVE ACTION ESC • Say instead: Our infection control committee met on xx/xx/xx (prior to ESC submission date) to review and prioritize a list of risks appropriate to our hospital our community and our services.

38. CORRECTIVE ACTION ESC • All C elements of performance are going to require an evaluation methodology. • Select a measurement strategy that is realistic, targeted on the problem noted in the finding and you know you can pass. • Use sampling techniques like discussed for clarification. • Keep your data, make it real, potentially subject to validation by TJC.

39. CONSIDER EVIDENCE BOOKS OR FILES • Either for clarification or corrective action ESC, or MOS, it is suggested that you keep an evidence, data binder, that multiple leaders know how to interpret, read, and access. • If you are ever subjected to a validation, you won’t have to start searching. • You need month 1 of your MOS to be fairly good so start your preparation early.

40. DON’T FORGET ABOUT YOUR MOS • Only set a goal of 90% • Clarification and ESC time give you some time to improve the process • When the official 4 month period begins, you want your initial data to be at or close to 90% • Can’t average to 90% if your first month is 50-60% • AFS11, follow up survey, public disclosure if you fail

41. QUESTIONS? • Contact information: • Kurt@Pattonhc.com • JenCowel@Pattonhc.com • JohnRosing@Pattonhc.com • ExpertAdvice@Pattonhc.com