Transcript Conducting Your Own Mock Survey

Mythbusters! Accreditation
Myths and Legends
MedTrade
Wednesday, October 3, 2007
Mary Ellen Conway, President
Capital Healthcare Group
Accreditation Myths and Legends
Learning Objectives:
• What is the format of a survey?
• How can you prepare?
• What is reality and what is a myth?
• The top 10 problems found and how you
can avoid them
Where Do We Begin?
• What is the typical format of
the survey?
– Now all are unannounced
– Formats
• JCAHO Tracer Methodology
• Review of Patient Lists, Personnel
Lists, Patients Scheduled for Visits
Two-Day Survey
Day One
Entrance Conference
Interview of Leadership
Review of Survey Schedule
Review of Patient Census
Selection of Patients to Visit (Close to the Office)
Review of Patient Charts (Include those being visiting)
Selection of Employee Charts (or Tracers to Determine)
Patient Visits and/or Chart Review
End of Day Wrap up and Plan for Tomorrow
May take Policy/Procedure Manuals, PI Program info
to review overnight
More on a Two-Day Survey
Day Two
Review of Day One or items reviewed overnight
Continue Patient Chart, Personnel Chart review
Continue Visits, Staff Meetings
Telephone Interviews
Can Include Referral Sources, Discharged Patients
Review PI program
Review minutes of Board Meetings, planning sessions, staff
meetings
Exit Conference
Required to mention all recommendations/concerns
Main Reasons Organization Fail
• Lack of Preparedness
• Few Staff Aware of
Process/Requirements
• Lack of Focus and Follow-through
• Main items:
– Physician Orders
– Infection Control
– Incomplete HR Files
Before We Begin
• Ensure that you have worked through your
accreditor’s standards
– Make sure your policies and procedures are
aligned with the accreditation company’s
standards
– You have completed all requirements
CMS Final Quality Standards
• Were released on 8-14-06
• 14 pages—as compared to 104
• Found on the CMS website at: (http://www.)
cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_Standards.asp
• Compliance with these standards is enforced
through the accreditation provider you select
#10 Psychotic Surveyors
Myth or Reality?
Is it Myth or Reality?
Fact:
– You are the accreditor’s
customer
– You have ways to appeal
– You need to be
prepared!
In Preparation,
Create Your Checklist
• Develop your own or purchase one
• Check to make sure you have everything
you need on your list
– Review your standards/guidelines
– Make sure each aspect of your services and
ALL types of services you provide are
addressed (retail, delivery, on-line?)
Creating Your Checklist
• Warehouse/layout
• Educational Calendar
• Staff and Patient
Interviews
• Infection Control and
Surveillance
• Performance
Improvement/QI
• Personnel Files
• Patient Records
• HIPAA
• Home Visits
Keep in mind any other compliance
that might be assessed, such as HIPAA
Review your entire operation for HIPAA
compliance especially:
– Customer areas
– Staff areas
– Security of files, billing, patient records, delivery logs, items
patients sign
– Shredding?
– Process for sending patient information and receiving
referrals and orders
• Example: What’s at your fax machine? Cover Sheet Text?
#9 Everyone Doesn’t Need to Know
This Stuff
Myth or Reality?
Is it Myth or Reality?
Fact:
– Everyone needs to know
what’s going on
– You can not do things in
a vacuum
– Everyone needs to be
prepared!
#8 PI, QI What’s the Difference?
It’s all over my head
and I don’t know
anything about it!
Myth or Reality?
P.I./Q.I Programs
Performance or Quality Improvement
• Usually the one area that organizations have
not had in place prior to the pursuit of
accreditation
• Can be done internally without outside
assistance---but may require benchmarking
• Focuses on item/area that can be monitored
and improved (Customer Satisfaction)
P.I./Q.I Programs
• Are Written
• Show involvement of staff (as many as
appropriate)
• Program is presented, approved and reported on
quarterly
• Generally need to show at least 3 months of data
when you submit your application.
• Data should be collected, analyzed and acted upon
(all of this is written in the PI Report)
Second Quarter
Washington, Division
FY 2006
Patient
Satisfaction
Benchmarks
S Office
Mean
D Office
Mean
V Office
Mean
Overall Mean
Overall Mean
Last Quarter
All Offices
(including B)
National
Mean
Region 3
Mean
Overall Mean
Agency
95.2
87.6
88.6
90.46
88.7
90.0
91.1
Nurses Taught
Self Care
95.7
91.3
95.9
94.3
92.3
91.8
92.8
Family Involved
in Planning
88.8
89.3
91.7
89.93
85.3
87.2
87.8
Arranging
Home Health
89.9
84.8
83.0
85.9
88.1
88.9
89.9
2nd Q Data
Overall Mean Agency
100
95
90
85
80
S
D
V
Overall Last Q Nat'l Region
Performance Management
1. Beneficiary satisfaction surveys
2. Patient complaint log
3. After hours (on call) log to prove
timeliness of response to questions,
problems and concerns
4. Log that documents frequency of billing
and/or coding errors
5. Log documenting adverse events (as
defined by your P & P manual)
Most accrediting organizations require at
least three months of surveys collected
and summarized with plans for
improvement or you will have to provide
written follow-up and possible a re-visit
#7 No Ride Alongs?
Tell them your
insurance carrier
prohibits it!
Reality
Fact:
– There is no insurance issue
– If questions are not asked
during the ride, they will be
asked at other times
– Practice interviews, safety
issues
– Examples
#6 Inventory Management
I do it all in my head!
Final Supplier Quality Standards
2 Sections
First Section: Business Services
–
–
–
–
–
–
–
Administration
Financial Management
Human Resource Management
Consumer Services
Performance Management
Product Safety
Information Management
CMS Final Quality Standards
Financial Management
1. Implement financial management practices that
ensure accurate accounting and billing.
2. Accurate, complete and current financial records
3. Cash or accrual based accounting
4. Link equipment to client
5. Manage revenues and expenses on an ongoing basis:
• Reconcile charges with invoices, receipts and deposits
• Operating budget
• Mechanism to track actual revenues and expenses
CMS Final Quality Standards
Product Safety
Equipment management program that promotes the
safe use of equipment and minimizes safety risks
and hazards including:
1. Plan for identifying, monitoring and reporting failures,
repair and preventive maintenance
2. Investigate any accident or injury (within 72 hours or
24 hours if results in hospitalization or death)
3. Contingency plan for response to emergencies and
disasters
Requirements
Must Comply With:
– CMS Final Quality
Standards
– Your Accreditor’s
Requirements
#5 “Red Tape” on the Floor
Myth or Reality?
Is it Myth or Reality?
It’s an Urban Legend!
– You are held
accountable for
following your own
Policies and Procedures
#4 Preventive Maintenance
What Do I
Need to Have
Available?
Reality
Fact:
– You need to be able to
explain your program
for Preventive
Maintenance on
appropriate items
• How to identify items in
the field that need it
• How to show that it’s
been performed
appropriately and timely
# 3 Policies and Procedures
A “MUST HAVE” in
order to become
accredited
My P&P ListPolicies you need to review
• Policy and Procedure Manual—At a Minimum:
– Patient Admission, Transfer, Discharge
– Compliance with all Local/State Requirements
• Supporting evidence attached
–
–
–
–
–
Handling of Equipment
Storage of Equipment
Inventory Control and Management
OSHA and Infection Control
Performance Improvement (P.I.) and Data Collection
***Review the requirements of the company you select**
More of My List
• Employment and Personnel Policies
– Include Written Job Descriptions and Org Chart
• Competency Assessment Program
• Sample Contracts-if you use them
• Personnel File for Each Staff Member
– Files organized and kept in locked, secure area
– Health information, DOB kept separately
Personnel Files
• Personnel File for Each Staff Member
–
–
–
–
–
–
–
Date of Hire
Evidence of Interview
Background checks
Driver’s License/Driving Record
Signed Job Description and Annual Evals
Signed Orientation Checklist
Competency Evals- on hire and annually
• See the specific requirements for the accreditation
program you choose
Complete Policy and Procedure
Manual
•Must meet the needs and
requirements of the accreditation
provider you select
•Not worth trying to create on
your own at this point
•Price Range $400 - $4000
Common Items Found Deficit
• HR Charts
–
–
–
–
Incomplete
Annual Evaluations not done
incomplete Hep B documentation
Medical/Health Info not separated
• Patient Charts
– Incomplete documentation of receipt of
paperwork
– Forms not witnessed, dated, completed as
indicated
Reality
Fact:
– Your P&P should have
everything you need to
meet accreditation
guidelines
– You need to AUDIT
your files and make sure
they are complete
LONG BEFORE your
survey
#2 Infection Control
What Happens?
Infection Control and Surveillance
• Manner in which items
are cleaned, serviced,
stored (clean – dirty)-logs
• Decontamination, OSHA issues,
safety equipment and training
• Reporting of infections: patient or staff
• Personal protective equipment
• Visits/patient contact- handwashing
• Retail- customer rest rooms
What Other Problems with Infection
Control/Safety Issues Are Found?
• Infection Control:
– Clean vs. Dirty- Warehouse, trucks
– Handwashing
•
•
•
•
•
•
Chemicals scattered throughout
Labeling/placarding
Fire drills not conducted annually
Fire extinguishers not current
Stacks of forms/trash
Trucks not clean, up to date on maintenance
Reality
Fact:
– Infection Control is one
of the main tenants of
accreditation
– You can not review
enough
– A revisit is really the
only way to observe if
infection control
practices are being
observed
#1 Lack of Physician Orders
What are the
Most Common
Problems?
Problems
• Oxygen
• CPAP
• Hospice
P.O. Box 346
Beattyville, KY 41311
Phone (606) 464-9100 Fax (606) 464-9191
Patient Name:
PHYSICIAN ORDERS
Start of Service Date
Please provide the above named patient of Hospice Care Plus with any or all of the following items as needed:
Bedside Commode
BIPAP
CPAP
Feeding Pump
Hoyer Lift
IV Pole
Nebulizer
All related supplies
Over the Bed Table
Oxygen Concentrator with humidification
Portable Suction Machine
Semi-electric Hospital Bed with surfaces as requested
Trapeze Bar
Walker
Wheelchair
For transport outside the home:
Pre-filled oxygen tanks,
Oxygen conserving device if needed
Oxygen is ordered up to 5 L/min via nasal cannula as needed for comfort
If indicated by weight, provide equipment sized for bariatric use.
Other Equipment or Additional Orders:
Physician:
Signature:
Date:
Reality
Fact:
– HUGE issue
– EASILY addressed
• Prescriptions
• Discharge Orders
• Hospice Standing Orders
Solutions
•
•
•
•
PLENTY of staff training
Chart audits
Creation of your own order forms if needed
Conduct your own mock survey
Home Visits
GO OUT AND SEE WHAT’S HAPPENING!!!
Surveyors will interview patients, asking how
they were oriented, how to reach the office,
how the services has been, any problems…
Time Issues
• Current accreditation programs suggest that
organizations should have at least a 3-month
history of performance improvement data
collected and be implementing systems prior
to an accreditation visit
• Small organizations often take at least 3-4
months to complete a “self-study”
• CMS Deadlines
• Most surveys are scheduled at least 1- 2
months in advance
Is this your future
if you’re not accredited?
All Videos
• Available exclusively from VGM
– Accreditation for HME
– Infection Control for HME
– Many more titles available
The Most Effective Way to
Survive and Thrive in Your
Business is to
Be Prepared
Your Questions…
Thank You!
Mary Ellen Conway
President
Capital Healthcare Group, LLC
Bethesda, MD
301-896-0193
www.capitalhealthcaregroup.com