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

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

3. Understanding the process

5. Let’s Get Prepared…

6. Which Do You Prefer? This…

7. Or…. This?

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

9. 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

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

11. notification
Prepare a survey checklist to send in 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

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

13. 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.

14. 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

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

16. 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

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

18. Tracers
Three Types of Tracers:
Individual
Systems
Program specific

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

20. 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

21. 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…

22. 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)

23. 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

24. 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)

25. 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

26. 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

27. Ms chapter outline – 26 standards
Medical Staff Bylaws (MS , MS , MS )
Structure and Role of Medical Staff Executive Committee (MS )
Medical Staff Role in Oversight of Care, Treatment, and Services (MS , MS )
Medical Staff Role in Graduate Education Programs (MS )
Medical Staff Role in Performance Improvement (MS , MS )
Credentialing and Privileging (MS , MS , MS , MS , MS , MS , NS )
Appointment to Medical Staff (MS , MS )
Evaluation of Practitioners (MS , MS )
Acting on Reported Concerns About a Practitioner (MS )
Fair Hearing and Appeal Process (MS )

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

29. 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

31. Thank you! Lynn J Lambert, RN, MPH, CPHQ
Director of Quality Management
Northern Hospital of Surry County