The Surveyors are Here, Now What? Success Strategies for the Survey

1. The Surveyors are Here, Now What?Success Strategies for the Survey

2. Success is an Ongoing Activity • Managing the non-survey years • Managing the onsite survey process • Several roads to onsite survey trouble • After the survey – when to clarify • Top scored problem areas

3. Benefits of Accreditation • Why do we put ourselves through this? • Yes, you really are better than non accredited hospitals • The process involves state of the art, peer developed standards and safety goals • Participation helps create a better, safer environment • The on site survey validates your hard work.

4. Managing the Non-Survey Years • Keep policies simple • Mock Tracers to check compliance • If you are in a whole stop digging (fix it or find another way) • Focus on the top 10 and new things • Avoid the Situational Rules (quick trip to PDA)

5. What You Can Be Scored On • The Elements of Performance/Standards • Situational rules in manual • The Frequently Asked Questions • Information found in Perspectives • Your own policies

6. FIX IT OR FIND ANOTHER WAY • Einstein on insanity – “Doing the same thing over and over again and expecting different results.” • If your self evaluation finds failure with this expectation month after month, it isn’t going to get better before survey • TJC’s specific requirements can become steps in your processes

7. MANAGING THE NON SURVEY YEARS Maintain the momentum Stay in contact with your account rep Access the extranet regularly Read and distribute Perspectives monthly Remember, your next survey may not be in the year due 10/23/2014 7

8. MANAGING THE NON SURVEY YEARS Track the PFI progress and request an extension if needed Make sure ancillary departments have their licenses and fulfill accreditation requirements. Implement the new stuff as soon as published Assume nothing, rely on data to self assess Consider smart phone or tablet applications for tracer teams to capture, photo, fix and track compliance. (iAuditor, AuditBee, Comply Flow Audit) 10/23/2014 8

9. Focus on the Top 10 & NPSGs • The 2012 standards have 1700 EPs that can be scored • The Joint Commission does >90% of its scoring on about 25 standards/NPSGs • Implement the top scored and all NPSGs • Spend you dollar here!

10. Consent Obtained ... Other text … Signed: ____________ MD ... Other text … Consent obtained. Signed: ____________ MD ... I have examined the patient, reviewed the findings of the history and physical and any changes are specified as follows: ______________________________. Signed: ____________ MD • H and P Updated ... Other text … Signed: ____________ MD Identify natural components of the pre-anesthesia evaluation. • Pre-induction assessment conducted. DESIGN FORMS FOR ENHANCED COMPLIANCE Problematic Consider Instead

11. Preparing for Successful Surprise-Free Survey Get all the day 1 and LSC documents together, print draft agenda *1 Read the SAG Look for problems in the unlikely spots, UP in procedure areas not main OR, unlabeled syringes in procedure rooms. Train and practice with staff and escorts on successful survey interview tips 11

12. Success During the SurveyManaging the Onsite Survey

13. GOOD MORNING, WE ARE HERE FROM THE JOINT COMMISSION • Have an action plan *2 • Institute the action plan • Have identified back up staff • Verify ID via extranet • Rolling carts with required information • Optional information shows great things only

14. They’re Here!A Well Planned Calling Tree • Have a call list with back-ups and double back-ups for key roles • Staff invited to system tracers should get notice as to the time and location of these with reminder as to which documents to bring • Have back-up for the 7:30 am TJC web check

15. Have Your Binders Ready • One for the surveyor team • A different/more detailed one for staff • Recommend individual surveyor folders

16. Meet & Greet, They are at the Door • First impressions are important • Have ground crew act as scouts for team arrival, not joking! • Front line staff greet and seat. • Get their IDs, compare to your photo from TJC • Issue IDs • Walk them to their room, • Present them with day one binders • Get leaders ready for opening conference

17. Other Day One Action Items • Reserve conference rooms • One for surveyors, one for staff and all meetings • Get catering • Print and distribute agenda (found on extranet under pre-survey documents) • Invite system tracer attendees • Identify any necessary agenda changes

18. Opening Conference • Slide set or no slide set??? • Have a prepared short slide set • Print and place in each surveyor folder • Be prepared to do the opening with and without the projector, may just want casual talking

19. Opening Presentation • Basics of who you are, size, services • Mission, vision, goals • Bragging Rights - Special awards, certifications • Sob stories - how do you address a potential big risk area? • Community you serve • Some PI or patient satisfaction data

20. Day One Binders • There are two TJC day one lists • The list from the Survey Activity Guide (SAG) • The surveyor list, PRN items • Have the Day One SAG list ready – give to surveyor • Have the PRN list in your hands, give only what is requested specifically

21. Tips • Avoid showcasing dirty laundry • Have fresh eyes look through every thing in the day one material and other material given to surveyors

22. Send “Checklist” to All Unit Managers • Each manager to print or pull punch list from their TJC folder, give location specific list to staff to review: *3 • Medication room • Hallways and nurses station • Clean utility • Dirty utility • Each list is specific to their area, check everything, initial, call in work orders

23. Escorts, the Power Player! • Assign escort and note taker *4 • Never leave the surveyor alone • Eyes and ears for your leadership • You are the early warning system; text the next unit when the surveyor is on the way • Be adept at the computer

24. Role of the Escort/Note Taker • With an electronic system consider a buddy system, have someone other than the nurse search the record for requested information • Gently coach • Record offers to present support and record surveyor’s response • Record the “he said” “she said” • Record MR numbers

25. On the Unit, all Hands on Deck • When surveyor is on the way, assemble your team • Meet the surveyor at the entrance to unit, escort them • Find a clean room for them to review charts • Get your team, include pharmacy, nurse educator, Respiratory Therapy, case workers, (have them up and “working” on unit

26. Institute the Action Plan, Everyone in Position

27. When They Are on the Unit • Know where to find your policies & “fast facts” or other tip tool *5 • Have two people in the patient record, a second person as back up looking for stuff • Offer policies, describe education • Use your resources, you don’t need to memorize • Call on experts around you

28. When They Leave Your Unit • After the team leaves, find all “IOUs” • Find the order • Find the anesthesia record, the consent, etc • Copy it, highlight the part the surveyor couldn’t find • Find the surveyor, show them AND/OR • Bring a copy to the surveyor room during special issue resolution, escort should record this

29. Help Staff by Conducting Internal Tracers: • Train staff on what to expect during the survey • Ask yourself, ask your staff: • Do we do this? • Where is it written we do this? • How well, or how often do we do this? • Show me the evidence that we do this • Validate the “doing” with high risk and high priority standards

30. Tracer Tips For Staff • Be enthusiastic about how good we are • Focus on the excellent service and care we provide • Find a quiet room, out of main traffic path to review the medical record for the patient tracer • Before answering a question: • Take a deep breath • Make sure you understand the question • Or ask “Could you please rephrase that question…” • Stop talking once you have answered • Know where policies are kept & how to access them

31. Tracer Tips For Staff • Training – practice tracers • Never, never “fix” a chart to avoid an RFI • Don’t allow yourself to be intimidated by surveyors, or by your own management. Stay calm if possible. • If you do not know the answer to a question, describe how you would find the answer, who has the answer, and/or offer to provide the answer later in the day

32. Tracer Tips For Staff • Take advantage of surveyor suggestions • Never “make up” answers to please the surveyor • Do not argue with the surveyor • Know what improvements in patient care came from PI (performance improvement) activities • Describe your continuous compliance in an environment of improvement • Don’t affirm the leading question…” this isn’t a very good process, is it?”

33. Immediate Threat “Situational” Decision Rules Direct Impact Indirect Impact Trouble OnsiteImmediate Threat to Life • It is the Joint Commission equivalent of the “go directly to jail” card! • Joint Commission believes there is substantial noncompliance issues that have caused or could cause harm/death to patients or staff. • ITL called, your accreditation status changes to Preliminary Denial of Accreditation (PDA) overnight!

34. How Bad Can It Be?Immediate Threat to Life • The surveyors survey protocol guide for immediate threat states: "Failure to follow pertinent guidelines from APIC, CDC, WHO, etc." • Requires the surveyor to consult with the Joint Commission field director, who consult with VP’s and EVP’s • Can only be approved by President of Joint Commission

35. Immediate Threat “Situational” Decision Rules 2 Direct Impact 3 Indirect Impact Immediate Threat to Life • EC & LS examples from Perspectives, conferences, other communications: • One single issue or a combination of observations: • Inoperable fire alarm system • Inoperable or unreliable fire pump • Inoperable Medical Gas System or alarms • Negative pressure rooms not working • Generator tests failed, not fixed

36. Immediate Threat “Situational” Decision Rules 2 Direct Impact 3 Indirect Impact Immediate Threat to Life • EC & LS examples cont: • Utility system: main circuit breaker not tested or maintained • Raw sewage leaking from pipes in basement • No way to transmit fire alarm signal to local fire department • No emergency exit and no ILSM to compensate

37. If You SuspectImmediate Threat May Be Called.. • Leadership action plan: • All hands on deck quickly! • Get the facts, copies • Involve your leadership • Clarify with the surveyor • The phone call from Joint Commission leadership is your best time to prevent ITL… be prepared to coherently explain why patients were not in jeopardy if you get “the call” 37

38. After the Survey

39. Post Survey • Clarify everything even if you are not adverse • Random Unannounced Validation (RUV) surveys - 5% • RUVs will review ESC and MOS onsite • RFIs add to S3 point total, may be used to shorten time until next full survey • Keep records of ESC & MOS (RUV)

40. Clarification • Evidence that the organization was compliant with the element of performance at the time of survey • We found it, here it is • We audited and are compliant 90% of the time • Corrective actions do not count in your favor

41. MANAGING THE POST SURVEY PROCESS Understand you’re A,+ C’s Use audits for C’s and look for the documentation about missed A’s. The performance observation may be totally correct, but you still have audit opportunities. Remember 2 observations is very sensitive compared to 90%. 10/23/2014 41

42. Lessons Learned from Recent TJC Surveys

43. Strategies for SuccessPreparing Clinical Areas • Rollout the Clinical Area Checklists • Email them out, assign, implement, collect them back, analyze compliance • Involve/educate clinical & frontline staff • Everyone knows who to call to get fixed • Identify areas to improve, fix it, then reassess • Make LS an every day expectation!

44. Environment of Care10 easy fixes • No equipment blocking • fire alarm pull boxes, • fire extinguishers, • electric breaker panels, • medical gas shut-off valve boxes. • No blocking fire doors, • No storage in stair wells

45. Environment of Care10 easy fixes • Keep hallways clear of clutter • Fix broken locks and hardware • Fix large gaps under doors or at door closures • Fire rating label on doors should be visible • Doors that don’t self close properly, door wedges!

46. Environment of Care10 easy fixes • Unclear, or missing or unmarked fire exits, exit lights that are burnt out • Fire extinguisher checks, safely stored • Label and secure hazardous areas • 18 inch rule for sprinklers • Sprinkler pipes can not support other items like cables or wires • Sprinkler head clean and free of obstruction, collar flush • Remove or repair nasty things: Ripped mattresses, cracked ceiling tile, mold, broken wheel chair

47. Environment of Care10 easy fixes • Medical Gas shut off valves must be labeled with rooms they shut off. Staff must know who can shut these off and when. Alarms working • No unsecured O2 tanks, no storing too many

48. H&P and Update • An H&P is done no more than 30 days prior to admission or within 24 hours of admission. • If the H&P is done anytime in the 30 days prior to admission you update it within 24 hours of admission, or prior to an invasive procedure on the day of the procedure, whichever comes first. • Must document: the patient was examined, and the H&P was reviewed - CMS mandate • In EMR – use a SmartText: e.g., .no changes or .changes

49. Document Operative & High Risk Procedures (RC.02.01.03) • H&P in record before procedure (EP 3) • Post op/post procedure report is dictated before transfer to next level (EP 5) • (Unless a post op/post procedure note is entered immediately [see EP 7], if so, report may be written or dictated per policy) • The post operative/procedure report includes: name of LIPs, procedure name and description, findings, EBL, specimens, post op diagnosis (EP 6 - Top Scorer)

50. Document Operative & High Risk Procedures (RC.02.01.03) • If report is delayed, an immediate post procedure note is entered and includes LIP, assistants, procedure(s) performed and finding(s), ANY EBL, ANY specimens, Post op diagnosis (EP 7 top scorer). Check your policy. • Medical record includes the LIP release order or approved DC criteria (EP 9) • Medical record includes the use of DC criteria/pt readiness (EP10)