POST SURVEY EVIDENCE OF STANDARDS COMPLIANCE AND CLARIFICATION

1. POST SURVEY EVIDENCE OF STANDARDS COMPLIANCE AND CLARIFICATION • UNIVERSITY HEALTH CONSORTIUM • Kurt A. Patton, Patton Healthcare Consulting, former Executive Director Hospital Accreditation Program, Joint Commission • October 2013

2. POST SURVEY ACTIVITIES • In past years: Celebrate departure of the survey team, take a few days off to recover. • Today: Scan the preliminary report left onsite to look for clarification opportunities. • Talk with escorts and scribes • Talk with area managers and staff • Compare survey findings with your own internal monitoring data

3. GETTING STARTED • Access, print and review 3 TJC documents from extranet • Evidence of standards compliance navigation instructions • Overview of navigation instructions contains important content requirements for all key dates and “sustainability” of corrective action. • Clarification instructions • ESC instructions

4. FINDING CLARIFICATION OPPORTUNITIES • The issue documented by the surveyor in the observation does not seem related to the EP. • The issue documented by the surveyor does have a policy. • Staff answered this question incorrectly • We do have a risk assessment, staff just did not know this • While the observations are correct, I know our data is better than 90% compliant.

5. REMEMBER YOU’RE A’s and C’s • A elements of performance, yes there is a policy or we do have that process or the performance was perfect and compliant. • C elements of performance, yes the surveyor was correct, but after we conduct a large scale audit we can demonstrate greater than 90% compliant. • No option to avoid an audit, no matter how bizarre the finding or how much you disagree

6. CLARIFICATION WINDOW • You only have 10 business days to submit • You have to e-sign the clarification agreement attesting that this information demonstrates compliance at the time of the survey. • After 10 days the window closes • If you are trying to clarify findings that relate to a COP issue, simultaneously consider preparation for onsite follow up survey. • 10 business days plus time for SIG review can run dangerously close to repeat visit timeframe.

7. UNDERSTANDING A CLARIFICATION • OCO doesn’t avoid the RFI • Fixing it quickly doesn’t allow for clarification • A frightened department head who fears repercussions is dangerous. Verify that all evidence was actually prior to survey. • If you use consultants to interview department heads, verify the evidence before submitting to TJC.

8. IF WE DISAGREE WHILE THE SURVEYORS ARE STILL HERE…. • Should we argue, should we flag, should we surrender and do OCO? • If you argue, things might get worse • If you flag SIG will review that finding and may review others and things may get worse • If you do OCO, you just plead guilty and clarification is no longer an option

9. HOW SHOULD WE HANDLE DISAGREEMENTS? • Allow your report to flow through the TJC continuous flow process and be posted to your extranet. • Clarify those few issues where there was disagreement or evidence of compliance. • The clarification opens up that EP to SIG review

10. WHEN, IF EVER SHOULD WE USE OCO? • If the surveyor mentions that the issue they plan to score is so critical that it will result in a COP level finding. • “The OR airflow was negative instead of positive”. • Get engineering in STAT to fix it, get your vendor in STAT to retest and validate compliance. • You may be able to avoid a COP resurvey

11. COMPONENT REQUIREMENTS OF THE CLARIFICATION • Who – approved existing policy • What – does the policy state, what did the surveyor take issue with that really is compliant • When – was the policy approved, updated and staff trained • How – do policies get disseminated • Why – did the surveyor not see this

12. REMEMBER IF IT’S A C, YOU MUST AUDIT • You can’t just argue, even if you think the surveyor was completely wrong. • Your audit must demonstrate 90% or better compliance with your policy and the EP. • Data entering the clarification audit is tedious and time consuming. Leave at least 2 or more days from your 10 business days to do this!

13. KEEP ALL THE EVIDENCE ORGANIZED • The clarification you submit is potentially subject to an onsite examination by TJC. • Does not happen often, but it can • Keep all the policies you referenced • Keep track of the patient lists you sample from • Make sure your randomization is fair no cherry picking • Keep track of your paper tally sheets • TJC would need to reach the same conclusion you did during a re-audit review

14. WHAT DO I AUDIT? • Medical records • HR records • EC documentation • Records of inspections done

15. AUDIT TIMEFRAME • Medical records audits must be 30 days prior to the survey begin date, thus no post survey effect, no changes • Recommend a list of patients admitted and discharged in that 30 day period. ( screens out any post survey effect) • EC audits must be 12 months, e.g. generator testing, fire extinguisher testing, etc

16. AUDITS AND SAMPLE SIZE • POPULATION • Less than 30, audit all records • 31-100, audit 30 • 101- 500, audit 50 • >500, audit 70

17. RANDOMIZING THE AUDIT • Easy way: If the population is 700 total patients divide 700 by required sample size of 70 and identify every tenth record to review. • More complex way: use @Rand from excel or let IT do it. • Either way, keep the total list, highlight those reviewed, keep it honest

18. FOCUSING THE AUDIT • If the observations are just from the ICU, limit the audit to just the ICU • If the observations are from 2 or more inpatient locations, use the entire inpatient population • If the observations are from inpatient and outpatient locations, use both populations but split the sample. Easy way % of revenue or % of total names. • Describe how you identified the population, split the sample and randomized in your HOW section.

19. POTENTIAL AUDITS • 2 Unapproved abbreviations (very easy to pass) • Failure to have 2 up to date competencies • Failure to inspect 2 fire extinguishers • Failure to check a medication room refrigerator on two dates • Failure of 2 fire doors to latch

20. AUDIT WORKLOAD • The Joint Commission just left, the audit requires a lot of work, the narrative requires a lot of work and I only have 10 business days. • Check to see if there is an MOS which would require a similar audit every month for 4 months • Failure to time record entries may not be worth the work effort. • Consider avoidance of PFP “points”, and future minimal risk of public disclosure

21. INABILITY TO AUDIT DUE TO LACK OF PRESURVEY DATA • 2 fire doors fail to latch in our 500 bed hospital • 2 expired drugs or medical supplies are noted • 2 dusty air vents • 2 areas violating the 18 inch rule • We think we do pretty well on these issues, but there is nothing we can audit like a medical record

22. DESIGNING FOR AUDIT PROTECTION • Rumors have floated around for a while that TJC and CMS disagree on the viability of C elements. • 2013 EB did not announce any elimination of C elements • Could we better design a paper trail that gives us something to audit? YES!

23. DESIGNING FOR AUDITS • Someone inspects fire doors routinely • Someone inspects for expired medications and supplies routinely • EC/IC conduct unit inspections routinely • Drill down through the data, or develop data that is more granular than today.

24. DESIGNING FOR AUDITS • Did you inspect the fire doors for proper latching this month? • Yes boss, I did (worthless) • Yes boss. Here is the documentation. Each fire door is identified on the inventory, each inspection pass or fail is noted, and when one failed I corrected it immediately. The percentage that passed first time through was 98.5%

25. DESIGNING FOR AUDITS • Did you inspect the medical supply closet for expired medical supplies? • Yes boss, I did ( worthless) • Yes, we have an automated inventory and par level worksheet with 227 line items. I found 4 line items expired and removed them from inventory.

26. DESIGNING FOR AUDITS • Without any real extra work it may be possible to design documentation that provides you numerator/denominator data that could be used in audits. • Almost all will easily provide evidence of greater than 90% compliance • If CMS orders TJC to stop C elements this will all go away.

27. CLARIFICATION EVIDENCE • Can I attach policies and memo’s to the clarification? • NO! Describe what the policy says that proves your point. • Can I indent, use bullets, use bold code, underlining, color fonts to make my point? • NO! The extranet will wipe out the effort. Use text and whole sentences in a narrative format to explain.

28. CLARIFICATION EVIDENCE • Can I send them my Excel spreadsheet's which demonstrate greater than 90% compliance? • NO! You must create a spreadsheet within the extranet by defining how many rows, how many columns and re-enter all the data. • This takes a lot of time so don’t wait until the 10th business day to start.

29. WHAT HAS TO BE ON THE AUDIT SPREADSHEET? • Record number or employee ID, or door number • Number of observations where compliance can be evaluated • Number of compliant observations • Ending percentage compliance • E.g. 70 records, 1000 correct uses of abbreviations, 1004 total abbreviations, 4 of which are prohibited for a 99.6% compliance rate

30. WHY WAS THAT ABBREVIATIONS AUDIT DATA SO GOOD? • Its not pass/fail at the record level. • Each record may have 10-20 correct uses and likely 0-1 incorrect • Morphine, 4 mg PO daily for pain. • Morphine instead of MS is 1 correct use • 4 mg instead of 4.0 mg is the second • Daily instead of qd is the third • No body fails this audit!

31. EVIDENCE OF STANDARDS COMPLIANCE • Today there are two timeframes or deadlines, 45 days and 60 days • Remember that if you are scored at a condition level the resurvey may occur before you even submit your ESC for fix things quickly • Process is similar to clarification

32. ESC HEADERS • Who: “one individual with ultimate responsibility”. Similar language to the CMS 2567. • More TJC fussiness seen 2013 • Not a team, not a partnership, not joint/shared responsibility.

33. ESC HEADERS • What: did you do to fix the problem? • Created a policy • Trained staff on the new policy • Never use future tense for this header. Always use past tense. • “we trained all staff, we wrote the policy, we distributed the policy, we had it approved” • Not we will complete training next month.

34. ESC HEADERS • When: Document the deadline(s) in which corrective actions took place. • We approved the new policy Oct 1 • We distributed the new policy Oct 2 • We conducted unit training on the new policy Oct 3 and 4. • Again, more fussiness seen in detailed the steps than in past years.

35. ESC HEADERS • How: How will compliance be sustained? Not just how do you distribute policies to staff? • Conceptually this runs right into Evaluation Method for C elements • Your going to do audits, just like described for clarification including appropriate sample size, randomization and locations of the audits.

36. MEASURE OF SUCCESS • 90% is the minimum expectation, don’t pick any other number • Design a measurement strategy you know is going to work • Start test measurement before you are required to ensure success • Official measurement does not start until ESC is accepted by TJC.

37. MEASURE OF SUCCESS • If the outcome isn’t reaching 90% or even close or if the work effort is so severe the audit may not get done, try to create a new strategy.