NCAMSS Fall Meeting November 3, 2017 Survey Readiness NCAMSS Fall Meeting November 3, 2017

Objectives Understanding “continuous survey readiness” How to implement practices to minimize survey stress How to manage the survey process – start to finish

Understanding the process

Let’s Get Prepared…

Which Do You Prefer? This…

Or…. This?

Survey Readiness tools Prepare information for first point of contact Prepare overhead announcements Prepare email notice for department leaders Prepare email notice for all email users Prepare a survey readiness box Prepare a tentative agenda

Contact information for first point of contact Identify where first point of contact will be for the survey team Have a plan to call security to wait with surveyors while you wait for escorts to arrive Verify identity of the survey team Provide a script or quick check list for staff in that location Remember…a smooth start sets the tone for your survey

Let everyone know…quickly Prepare an overhead announcement to welcome surveyors This will serve as an alert for all staff, physicians and visitors

Email notification Prepare a survey checklist to send in email for department leaders This will serve as a reminder to department leaders to make a quick walk though of their areas This will allow time for leaders to alert their staff and give last minute reminders Prepare an announcement to go our to all staff

Almost ready… Gather typically requested documents or the source for the information Keep it readily available

Organize normally requested documents Create a ‘Table of Contents’ to organize your documents Add a sheet of paper as a place holder to identify the go-to person for: Current census OR schedule Recent discharges Minutes BOT, MEC, Patient Safety, Quality, Infection Control, Utilization Review, etc.

Introducing your facility Key Points to Cover: Mission Statement Vision Statement Values High-level organizational chart Service areas Patient demographics Service lines Providers and staff Facility capacity Special awards

Other Documents Map of your facility List of off-site locations to be included Senior/Department leader contact information Survey coordinator

Elements of continuous survey readiness Effective communication Review the survey readiness files with your team Effective teamwork Identify team members Determine who will accompany the surveyors during visit Identify who is best able to navigate the open and closed EHR Talk to department leaders regarding the survey process They should be prepared to meet surveyor when they arrive on unit They should stay with the surveyor until the surveyor leaves the unit If issues are identified work to resolve them as quickly as possible Safety culture Address concerns of staff prior to survey

Continuous survey readiness Engage your staff Identify opportunities for improvement Provide tools to staff Communicate changes to rules, by-laws, processes, etc.

Tracers Three Types of Tracers: Individual Systems Program specific

Policies Are they current? Do they reflect the most stringent rule? How are staff educated?

During the survey Stay calm – your attitude is contagious Debrief with your team everyday Keep a list of all staff the surveyors interact with and share this with Medical Staff Office and HR Keep a list of policies reviewed

After the survey…debrief What went well? What didn’t go well? Compare notes Gather and compile a list of all scribes notes List issues found and prioritize and assign Get started on action items All ESCs are due in 60 days Develop a timeline for 60 days out…

Cms surveys Three general categories: Certification/Recertification Complaint/Allegation Validation CMS maintains oversight for compliance for all organizations serving Medicare/Medicaid beneficiaries Surveys are completed by state agencies (DHHS)

Cms validation surveys Random selection No more than 60 days after the conclusion of an accreditation survey Unannounced Used to ensure accrediting organizations are enforcing Medicare standards adequately Surveyors are NOT informed of previous survey findings Extremely rigorous No incentive to be customer focused Assume you will be chosen

Jc medical staff(ms) Responsibilities of self-governing organized medical staff: approve and amend medical staff bylaws provide oversight for the quality of care, treatment and services provided by practitioners with privileges ongoing evaluation of competency of practitioners delineating the scope of privileges that are granted providing leadership in performance improvement activities credentialing and granting privileges (note: governing board has the ultimate authority and responsibility)

Ms must be structured using these guiding principles: Designated members of the organized medical staff who have independent privileges provide oversight of care, treatment, and services provided by practitioners with privileges The organized medical staff is responsible for structuring itself to provide a uniform standard of quality patient care, treatment, and services The organized medical staff is accountable to the governing body Applicants for privileges need not necessarily be members of the medical staff

Self-governance is outlined in the bylaws and includes the following: Initiating, developing, and approving medical staff bylaws and rules and regulations Approving or disapproving amendments to the medical staff bylaws and rules and regulations Selecting and removing medical staff officers Determining the mechanism for establishing and enforcing criteria for and standards for medical staff membership Determining the mechanism for establishing and enforcing criteria for delegating oversight responsibilities to practitioners with independent privileges Determining the mechanism for establishing and maintaining patient care standards and credentialing and delineation of clinical privileges Engaging in performance improvement activities

Ms chapter outline – 26 standards Medical Staff Bylaws (MS.01.01.01, MS.01.01.03, MS.01.01.05) Structure and Role of Medical Staff Executive Committee (MS.02.01.01) Medical Staff Role in Oversight of Care, Treatment, and Services (MS.03.01.01, MS.03.01.03) Medical Staff Role in Graduate Education Programs (MS.04.01.01) Medical Staff Role in Performance Improvement (MS.05.01.01, MS.05.01.03) Credentialing and Privileging (MS.06.01.01, MS.06.01.03, MS.06.01.05, MS.06.01.07, MS.06.01.09, MS.06.01.11, NS.06.01.13) Appointment to Medical Staff (MS.07.01.01, MS.07.01.03) Evaluation of Practitioners (MS.08.01.01, MS.08.01.03) Acting on Reported Concerns About a Practitioner (MS.09.01.01) Fair Hearing and Appeal Process (MS.10.01.01)

Ms chapter outline, cont. Licensed Independent Practitioner Health (MS.11.01.01) Continuing Education for Practitioners (MS.12.01.01) Medical Staff Role in Telemedicine (MS.13.01.01, MS.13.01.03)

Lessons learned Be sure staff are knowledgeable and familiar with your policies, procedures and bylaws Be familiar with the JC most frequently cited and most problematic standards How do hospital staff verify and know MS members are credentialed and what their privileges are Know your hospital’s quality and performance data—what are your weak and strong points and what have you done about it Be sure MS knows how to report concerns Be sure you have copies of primary source verification and that the print date is before the expiration At time of re-credentialing be sure the reviewer is verifying the OOPE, current licensure and competency with privileges, review case logs

Thank you! Lynn J Lambert, RN, MPH, CPHQ Director of Quality Management Northern Hospital of Surry County 336-783-8023 llambert@nhsc.org