1. Continuous Survey Readiness
Building Leaders – Transforming Hospitals – Improving Care

2. 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

3. 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

4. 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
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
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.

5. Continuous Survey Readiness
Structure
Accountability
Education
Practice
Data
Focus
Networking
Culture

6. STRUCTURE

7. Another meeting? – or Not……….

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. EDUCATION
Can you tell that this is a kindergarten teacher?

15. 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

16. 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

17. 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)

18. 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

19. 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 § (h), Other Environmental Conditions. For facility-wide sanitary practices affecting the quality of care, see § , 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?

20. CAH - State Operations Manual

21. Infection Control Surveyor Worksheet

22. QAPI Surveyor Worksheet

23. Discharge Planning Surveyor Worksheet

24. Long Term Care

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

26. PRACTICE

27. 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

28. 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

29. 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

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

31. DATA

32. 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

33. 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?

34. FOCUS

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

36. Easy Fixes

37. Big Frogs and Hot Topics

38. Look for System Issues

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

41. NETWORKING

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

43. 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

44. CULTURE

45. 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

46. Is your Medical Staff Engaged?

47. 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: management, June 14, 2011

49. If you would like to talk about a mock survey Please contact me
Carolyn St.Charles
Regional Chief Clinical Officer

50.          x
Upcoming Webinars
November 10, 2016: Social Media and the Protection of Residents Click here to register --
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 --
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 --
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 --
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