Imagine hosting a last-minute surprise party at your home for a group of extremely particular individuals. Sound fun? This is similar to what hospital leaders experience when accrediting bodies arrive for a survey.
This content is sponsored by Greeley.
While it is hard to know with certainty the precise day or time a survey will occur, hospitals can be sure accrediting agencies will visit during their survey window or when adverse events are reported. That means the best hosts have created a culture where compliance is a comfortable and natural state of being, according to Bud Pate, a senior consultant and vice president of The Greeley Company who has more than 40 years of experience in survey readiness, response and remediation.
Mr. Pate is a registered environmental health specialist, a past surveyor and a past survey manager. He spoke with Becker's Hospital Review about how hospitals can best prepare and manage a surprise survey, and what to do if your hospital is hit with adverse findings.
How to avoid adverse findings
Hospital leaders' No. 1 objective is to avoid adverse findings completely. The most effective way to do this is by implementing a safety program to identify and address patient safety issues as they arise. "Most significant regulatory findings can be avoided by having a robust safety program that identifies issues quickly and responds to process problems in a sustainable way," Mr. Pate said. The most serious adverse findings typically come after complaints are logged with an external agency or published by local news media. The best way to avoid such findings is to have an effective safety program that takes immediate action to resolve issues that place patients at risk, followed by a credible and comprehensive causal analysis and risk mitigation program. "One rarely knows which event will end up in the newspaper or at the focus of a regulatory encounter," said Mr. Pate. "So a robust safety program that effectively addresses all events causing patient harm is the only way to prepare for the relatively few that get investigated by surveyors."
Luckily, significant errors that undergo regulatory scrutiny are a rare occurrence. However, the organization can effectively prepare for routine inspections. Routine surveys are essentially open book tests, so Mr. Pate offers some tips for performing well.
Mr. Pate advises hospitals to watch the accrediting agencies they work with and identify the topics those agencies tend to emphasize in their surveys. For example, today's accrediting agencies universally look hard at requirements for the physical environment and infection control — things like fire and life safety, extra precautions put in place during construction, high-level disinfection or sterilization, breaks in hand hygiene or adherence to proper surgical attire. For CMS, the most cited issues relate to restraint, according to Mr. Pate. With all of this in mind, hospitals can prioritize their efforts around these "trending" areas of focus.
From there, a hospital needs to craft simple, easy-to-follow policies to ensure those requirements are met consistently. Mr. Pate recommends hospitals keep policies short: about a page and a half, not 20 to 30 pages. This allows staff to know and follow policies. "The intent is not to complicate the situation, but simplify it," Mr. Pate said. "Less is more."
To ensure policies are realistic and understood by staff, hospitals need to monitor processes in action, not merely the documentation. "Documentation measures, well ... documentation," Mr. Pate said. "But documentation alone is often a poor measure of performance."
For example, if a hospital wants to see how well staff members adhere to policies for treating skin breakdowns, it needs to examine how clinicians actually treat patients with bedsores, not simply what's captured in patient charts. To do this, a hospital could find a patient who has skin breakdown and talk to that patient's nurses, assess the patient and the wound, discuss how and when the breakdown was identified, how it is progressing and the patient's plan of care. These questions should touch on the important steps of the hospital's policy. If everything is on track, the reviewer — ideally a clinical educator — can then check how these processes were documented in the medical record. First, correct the practice in real time for the benefit of the patient and the learning of the staff members. Second, correct the documentation in real time for the benefit of the institution, being certain that any late entries are identified as such.
"We find no substitute for engaging the caregiver at the bedside for whatever clinical process we are trying to improve," Mr. Pate said. Such direct communication and engagement can help hospitals create more immediate change in problem-prone processes, usually in one to two weeks.
Who should manage a survey
Hospitals typically have one or more individuals whose job includes responsibility for accreditation and a committee with representatives from nursing, environment of care and other departments who are responsible for identifying and addressing gaps between the regulation or standard and performance. This committee is also responsible for deploying surveyor escorts, manning a survey "war room," and other activities that occur during the stress-filled days (and nights) during a survey.
"Get ready to host a survey just like you would host a party. These are guests in your home. You want them to be comfortable, get the information they need quickly and not make them ask twice for something," Mr. Pate said. The committee should help hospital staff members be ready to answer questions in full, without volunteering extraneous information that could lead to unwanted lines of additional inquiry. They should also oversee a process to quickly gather requested information. All documents should be reviewed to assure that they are complete and responsive before being given to the surveyor. Ask: Is it the right document? Is it the current version? Is it complete?
According to Mr. Pate, a little hospitality can go a long way. "Surveyors are human beings, and humans make up their minds about an institution in the first half day of a survey. The rest of the time during a survey is occupied by validating that first impression, good or bad," he said.
Even beyond the teams specifically designated to manage the survey, a big part of preparation is making regulatory compliance important to staff at all levels of an organization, from the C-suite to the frontlines. If this appears to be lacking, it is a symptom of one of two likely problems, according to Mr. Pate. The first: A missing connection between compliance and quality, safety or efficiency. The second: Compliance is harder than it needs to be.
"Don't ask clinical people to do silly things or you will lose credibility," Mr. Pate said. "Whatever you ask them needs to make sense in terms of quality and safety, and it needs to actually be doable and efficient." The point is not to be a disciplinarian or even a manager — the role of teams, committees and individuals leading survey readiness is to solve, not add, to problems. "You will know you are successful if front-line employees are glad to see you," he said.
What to do if things go wrong
If surveyors do cite the hospital, the first thing the survey-readiness designee(s) should do is check each finding for accuracy. If a hospital believes a finding is inaccurate, they should document everything carefully and handle the situation with care. "Regulators don't like to be challenged," Mr. Pate said. However, surveyors are human beings and there are usually findings in any survey report that are based either on the surveyor's misunderstanding of the requirement or the surveyor's misunderstanding of the situation. "But you can't respond to findings that are inaccurate," he said. "Trying to fix something that is not broken only makes matters worse." The organization will only increase its vulnerability.
Once any false positives have been rooted out, hospitals need to look at what is left and identify one-off issues versus systemic problems. Maybe one or two staff members didn't display proper hand hygiene. That may represent a one-off problem. The organization will merely remind staff of the requirement and continue to monitor for the "one offs." But in the case of a true systems issue there needs to be an organized, systematic response. Maybe the two breaks in hand hygiene observed by the surveyor indicated an overall failure to implement safety practices at the bedside. Mr. Pate said distinguishing findings that indicate a system in need of overhaul from those that result from an isolated occurrence due to human error is a difficult but essential step.
When fundamental process change is indicated, an interim solution — one that can be put in place quickly, but that may not be sustainable over time — should be implemented. These interim fixes are intended to protect patients during process redesign, enabling the organization to take the time necessary to fix the system rather than apply a Band-Aid. The interim response will demonstrate compliance with the requirement and satisfy the survey agency. But the interim response should be followed by the design and implementation of a long-term, sustainable, efficient change to the process. This kind of change takes a lot of effort and cannot be done quickly. That is why these efforts should only be reserved for real issues, not "one offs" or inaccurate findings. That is also why the hospital needs an interim way of protecting patients.
"Interim fixes can generally satisfy survey agencies, but they can't be sustained for a long time," Mr. Pate said, adding that most hospitals have the bandwidth to truly fix one or two systems at a time. And the best way to actually fix problem-prone processes is to make them easier for staff to implement. The right thing to do should be the easy thing to do. A few things that rarely work and should be avoided: adding a check box to the medical record, adding provisions to an already too-long policy, adding a "hard stop" in the electronic record and pilling competency upon competency.
Another thing to understand is many times internal teams are too close to a problem to get to the root causes and identify a solutions effectively, said Mr. Pate. Greeley works with hospitals all over the country every day to see through unnecessary complexity to the practical simplicity at the center of a successful compliance program and culture of survey readiness.
Conclusion
With a little planning and organization, hospitals can meet the scrutiny of accrediting surveys at any time. By implementing a safety program focused on effective oversight and prioritizing efforts to make compliance part of a hospital's culture, hospital leaders can ensure their organizations are fully prepared for a survey. Additionally, having a specific response plan in place should a citation occur will create a framework for high-reliability within the organization.
"Our simple, practical approach is something we want hospitals to live and breathe," Mr. Pate said.