Continuous Survey Readiness Building Leaders – Transforming Hospitals – Improving Care

Building Leaders – Transforming Hospitals – Improving Care Speaker Carolyn St. Charles, RN, BSN, MBA Regional Chief Clinical Officer Carolyn began her healthcare career as a staff nurse in Intensive Care.  She has worked in a variety of staff, administrative and consulting roles and has been in her current position as Regional Chief Clinical Officer with HealthTechS3 for the last fifteen years.   In her role as Regional Chief Clinical Officer, Carolyn St.Charles is the lead consultant for development of Community Health Needs Assessments. She also conducts mock surveys for Critical Access Hospitals, Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home Health and Hospice. Building Leaders – Transforming Hospitals – Improving Care

Building Leaders – Transforming Hospitals – Improving Care Who We Are Our Company Our Team Our Mission Formerly known as Brim Healthcare we have a 45 year track record of delivering superior clinical & operating results for our clients Our Executive Team has experience in managing hospitals from multi-billion $ healthcare systems to community hospitals We believe that the combination of People, Process & Technology transforms healthcare & provides the required results Management Consulting Placement Technology Turnaround Strategy Financial Operations Corporate Compliance Board Development Regulatory Compliance and Accreditation Preparation Lean Process Improvement Community Health Needs Assessments Execuitve Recruiting Interim Executive Placements Mid-level and Specialty Placements Gaffey Revenue Cycle Management CrossTX Population Health Platform Optimum Productivity Update Verbiage Building Leaders – Transforming Hospitals – Improving Care

Instructions for Today’s Webinar You may type a question in the text box if you have a question during the presentation We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail You may also send questions after the webinar to Carolyn St.Charles (contact information is included at the end of the presentation) The webinar will be recorded and the recording will be available on the HealthTechS3 web site www.healthtechs3.com HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive.  HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof.  HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.

Continuous Survey Readiness Structure Accountability Education Practice Data Focus Networking Culture

STRUCTURE

Another meeting? – or Not……….

Use Existing Structures Performance Improvement Committee Leadership Council Environment of Care / Safety Committee Disaster Preparedness Infection Control Committee However – it is important to have one group or one committee that oversees Continuous Survey Readiness

Be Ready Survey Documents Ensure there is an up-to-date list Ensure that more than one person knows where the list is kept Ensure documents are in a binder --- or --- they indicate source of information

ACCOUNTABLITY First base: Who Second base: What Third base: I Don't Know Left field: Why Center field: Because Pitcher: Tomorrow Catcher: Today Shortstop: I Don't Give a Darn

Continuous Survey Readiness Leader Assign an individual to stay current with any changes in regulations for each type of service you provide Ideally this would be the program leader for the service – as they should be the most knowledgeable

Multiple Disciplines Many standards are integrated and include more than one discipline….for example Pharmacy & Nursing Medication Dispensing Medication Administration Medication Errors – MERP Swing Bed Nursing Rehab Pharmacy Activities Social Work Dietitian Infection Control Isolation Handwashing Disinfection Sterilization Antibiotic Stewardship Universal Protocol – Time Out Nursing – Surgical and Invasive Procedures Respiratory Therapy – EKG Medical Imaging – Invasive Procedures Cath Lab

Organizational Leaders Assign accountability for oversight and monitoring of key standards to individual(s) and/or a committee Leader Other Leaders Committee Restraints ER Nurse Manager Med-Surg ICU Psych QAPI MERP Pharmacist Infection Control Nursing P&T Hand Washing ALL IC Responsibilities Develop program Develop P&P Collect and/or Analyze data Report data Develop corrective actions if necessary

EDUCATION Can you tell that this is a kindergarten teacher?

Know the Standards Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) State Regulations Health and Safety Code (California) Infection Control MERP OSHA Other accrediting agencies TJC DNV HFAP

CMS Draft and new regulations are published first in the Federal Register and then on the CMS web site under the section on Regulations and Guidance There is usually a lag between when new regulations are incorporated in the State Operations Manual

Medicare State Operations Manuals Appendix A - Hospitals Appendix AA - Psychiatric Hospitals Appendix B - Home Health Appendix C - Laboratories & Laboratory Services Appendix D - Portable X-Ray Services Appendix E - Outpatient Physical Therapy Appendix G - Rural Health Clinics Appendix H - End-Stage Renal Disease Facilities Appendix I - Life Safety Code Appendix J - Intermediate Care Facilities (for persons with mental retardation) Appendix K - Outpatient Rehabilitation Appendix L - Ambulatory Surgical Services Appendix M - Hospice Appendix P – Survey Protocol for Long Term Care Appendix PP - Interpretive Guidelines for Long Term Care Appendix Q - Determining Immediate Jeopardy Appendix R - Resident Assessment Instrument for Long Term Care Appendix T - Swing Beds Appendix U - Responsibilities of Medicare Participating Religious Nonmedical Healthcare Institutions Appendix V - Responsibilities of Medicare Participating Hospitals in Emergency Cases Appendix W - Critical Access Hospitals Appendix Y - Organ Procurement Organization (OPO)

Recent Revisions June 10, 2016 October 16, 2016 November 20, 2015 October 9, 2015 State Operations Manual Certification Process Appendix W – CAH Appendix PP – LTC Appendix A – Hospital Appendix M - Hospice

Long Term Care-State Operations Manual F253 §483.15(h)(2) §483.15(h)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; Intent : §483.15(h)(2) The intent of this requirement is to focus on the facility’s responsibility to provide effective housekeeping and maintenance services. Interpretive Guidelines: §483.15(h)(2) “Sanitary” includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes toothbrushes, dentures, denture cups, glasses and water pitchers, emesis basins, hair brushes and combs, bed pans, urinals, feeding tubes, leg bags and catheter bags, pads and positioning devices. For kitchen sanitation, see § 483.70(h), Other Environmental Conditions. For facility-wide sanitary practices affecting the quality of care, see § 483.65, Infection Control. “Orderly” is defined as an uncluttered physical environment that is neat and well-kept. Procedures: §483.15(h)(2) Balance the resident’s need for a homelike environment and the requirements of having a “sanitary” environment in a congregate living situation. For example, a resident may prefer a cluttered room, but does this clutter result in unsanitary or unsafe conditions? Probes: §483.15(h)(2) Is resident care equipment sanitary? Is the area orderly? Is the area uncluttered and in good repair? Can residents and staff function unimpeded?

CAH - State Operations Manual

Infection Control Surveyor Worksheet https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-1.pdf

QAPI Surveyor Worksheet https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-2.pdf

Discharge Planning Surveyor Worksheet https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-3.pdf

Long Term Care https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/QIS-Survey-Forms.html

If you are accredited by an organization with deemed status (TJC, DNV, etc.) ---- their standards MAY NOT BE CURRENT with CMS standards!

PRACTICE

Practice – Patient Tracers Follow course of care, treatment, or services provided from pre-admission to post-discharge Assess interrelationships between disciplines, departments, program, series or units, and the important functions in the care, treatment or services provided Identify issues that will lead to further exploration in the system tracers or other survey activities

Practice - Patient Tracers ICU patients Patients admitted from the ED Patient in L&D Swing Bed (CAH) Patients in Restraints Patient who received sedation and anesthesia 23-hour admit (observation) Dialysis patient Psychiatric patient Pediatric patient Patient receiving Radiology or Nuclear Medicine services Patient receiving Rehabilitation Patient who is a potential organ donor Patient receiving waived laboratory services A deceased or terminal patient

Practice - Program Tracers Laboratory - Waive Tests / Blood Administration Patient Flow Infection Control Medication Management Leadership Data Management Medical Staff Credentialing and Privileging Staff Competency Life Safety Environment of Care Emergency Management

It’s What’s Documented It’s What Staff Say It’s an Opportunity for Real-Time Education

DATA

Electronic Data Advantages Disadvantages Reduces time collecting data – if – it can be extracted electronically Provides external comparisons (if externally reported data) Complex data can be aggregated and displayed more easily Disadvantages May not be real time Feedback MAY be too late to make a difference in outcomes ------- It’s So Yesterday

Don’t Underestimate the Power of Pencil and Paper How many falls did we have yesterday? Why did they happen? What are we going to do today?

FOCUS

Sources of Information Regulatory Standards (of course) Most recent accreditation survey QAPI – “What are you already working on”? Mock Survey and Tracers

Easy Fixes

Big Frogs and Hot Topics

Look for System Issues

Too Big Too Much Too Little Not Enough Just Right Just Right

NETWORKING

Sources List Serves Professional Organizations Professional Publications Peers Facebook ---- probably not!

CHECK THE REGULATION BEFORE YOU ACT When they were at our hospital they told us, “………………………………”, so you need to “…………………….”. CHECK THE REGULATION BEFORE YOU ACT You may not be getting the whole story – or – a misinterpretation of the story

CULTURE

Is your Board Engaged? Regular reports on “how you’re doing” Regular reports on new standards and what they mean to the organization Resources that may be needed to implement new standards

Is your Medical Staff Engaged?

Are you Staff Engaged? Does your staff know what your goals and expectations are relative to continuous survey readiness? Do you share information about how you’re doing? Do you encourage staff to tell their own stories about what worked and what didn’t work? Do you encourage innovation – better way of doing things? Do you encourage a strong team environment – working together? Does feedback focus on the “positive” or just the “negative”? Do you provide “immediate feedback” or once a month or once a quarter? Do you celebrate achievements? Adapted from: https://www.torbenrick.eu/blog/category/performance management, June 14, 2011

If you would like to talk about a mock survey Please contact me Carolyn St.Charles Regional Chief Clinical Officer carolyn.stcharles@healthtechS3.com 360-584-9868

         x Upcoming Webinars November 10, 2016: Social Media and the Protection of Residents Click here to register -- http://bit.ly/2eKLkBr Helping your long-term care residents’ successfully return home requires planning, goal development and follow-up services. Additionally you must consider community and care giver resources as well as equipment and medication management. This webinar will include a discussion on patient-centered discharge planning that will help your residents achieve their goals. 12:00 – 1:00 p.m. CDT Hosted By: Cheri Benander, MSN, RN, NHA, CHC, NHCE-C November 21, 2016: Clinical Integration and Care Coordination: A Means to Reducing Fragmentation Click here to register -- http://bit.ly/2eKIWdV Organizations actively pursuing population health management must focus their energy on providing efficient and effective care delivery in the best possible setting. This is accomplished through the development of a clinically integrated network. Clinical integration is only achieved by understanding the connection between data analytics and technology. Hosted By: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA Regional Chief Clinical Officer x December 2, 2016: Community Health Needs Assessment: Developing an Action Plan Click here to register -- http://bit.ly/2eKJTDb Hospitals have 4 ½ months after completion of the Community Health Needs Assessment to develop an action plan in collaboration with community partners. Join us and learn about how to develop a realistic, actionable plan. 12:00 – 1:00 p.m. CDT Hosted By: Carolyn St.Charles, MBA, BSN Regional Chief Clinical Officer December 12, 2016: Leading Change: Shifting to Population Health Management Click here to register -- http://bit.ly/2eKM8Gk With the rapidly changing health care landscape, the goals for organizations are to assure better outcomes and lower costs. The challenge of shifting to a population health management model can be a daunting effort. Hosted By: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA