TETAF Maternal Level IV Survey Gwendolyn Janssen, BSN, RN Director Labor and Delivery & Antepartum Methodist Women’s Hospital

Our experience Informative and engaged collaboration Supportive/responsive team Thorough review of all aspects of the rules Right from the beginning we felt that we had a supportive and open relationship with TETAF after we submitted our application. We were able to ask clarification questions, fine tune some of our responses, and much better prepare for the on-site survey with the help and support of Carla. It was evident to us that the team wanted us to succeed and they did everything they could to help get us ready for their arrival in advance, and were collaborative during the preparation process. Once on-site the surveyors were detail oriented through and through, asking in depth questions that directly aligned with the rules of level IV designation. We went over some elements multiple times so they could ensure we could speak confidently and thoroughly about our program. They definitely kept us on our toes for the two days that they were here.

Pros Preparation Alignment with rules Process improvements QAPI program Education/Competencies We really felt well prepared by the time that the surveyors arrived which was helpful. There was so much work that went into getting ready to be surveyed and it was a good feeling to have a lot to be proud of that we were able to present to the team. We put together an extensive amount of binders with every possible policy, protocol, initiative, meeting minutes, education check-offs, etc that we anticipated having to share with them and that made the process much smoother when they were looking for reference or supportive data. We were diligent about making sure that we aligned with the rules and that we were able to demonstrate that clearly to the surveyors. That being said, in areas where we knew that chart audits would demonstrate poor compliance with a rule, we made sure that we already had action plans initiated prior to their arrival so we could speak to what we are doing to improve and they seemed pleased to see all the areas we were focused on related to clinical excellence. The QAPI program was a huge win for us and we felt that the team was very impressed with this aspect of our maternity operations. We made sure to include key stakeholders from leadership, front line staff, quality, and education to make this a really robust initiative. They also positively commented on how focused we are on on-going education and competency as well as initial competency check-offs with our staff.

Cons Missing rule aspect Anxiety Our biggest disappointment with the survey was the realization that we had not addressed one aspect of one of the rules. It was a process that none of us had been used to previously in our clinical practice and so it was overlooked and that came to light during the survey. Even though our entire survey team, and the team from the state were all kind and supportive, it was still an extremely nerve wracking process and a stressful couple of days.

Pearls of Wisdom Know the rules thoroughly, completely, inside & out Preparation QAPI Deep breaths! The biggest piece of advice of course is to truly have an intimate knowledge of what it is that you are being surveyed on. Have every single member of the team that is leading the preparation for the survey read them multiple times in order to avoid missing anything. No matter how small it still counts Extensive preparation is key. Every detail should be taken care of ahead of time, from the presentation & immediate availability of information (the binders worked well for us), the competence of the navigators that will be doing chart reviews with the surveyors, and the availability of key team members from all departments/services that are a part of the leveling preparation. The right people should be readily accessible to answer questions or clarify anything that is unclear. Really polish the QAPI program prior to the survey dates. Highlight all the work being done through the QAPI meetings and what the follow up is and how that leads to continuous process improvement Lastly- try not to be nervous! The survey team was supportive and constructive throughout and if you’ve prepared in alignment with the rules the survey will go smoothly.