1. Prepared for GAMES Spring 2014 Attendees By Mary Nicholas, MHA President / CEO HQAA, Inc.

2. Planning & Preparation

3. Failure is not a desired outcome with accreditation No one proceeds with accreditation with the goal of failure What then are some of the pitfalls you run in to preventing your planning and preparing?

4. Planning & Preparation Day to day responsibilities often take priority over maintaining accreditation compliance

5. Planning & Preparation Why important? Our data indicates that in the past 8 months for renewal surveys: An average of 58% of all surveys had repeated deficiencies Lowest percentage in a month = 40% Highest percentage in a month = 77%

6. Planning & Preparation Where to begin?

7. Execution Let’s look at the areas with the highest frequencies of cited deficiencies: Human Resources area claims three of the top 5 cited deficiency areas: Lack of demonstrated compliance to maintaining a Competency Program = # 1 Maintaining Personnel Files = # 2 Maintaining Annual Educational Programs = #3

8. Execution Employee Competency Create a process – assign responsibility  Start at the time of hire: observe person completing tasks they were hired to perform  Annually ensure the same checklist is evaluated; update it as tasks & skill levels change  Create opportunities for staff to observe each other; provide feedback and discussion  Ensure opportunities for learning are included in annual education calendar

9. Execution Personnel Files Use the standard(s) as your guide for what is required Ensure someone is responsible for upkeep  Maintain all files in consistent manner  Place a checklist in each file and note when components required are filed, updated, added  Ensure secure storage

10. Execution Annual Education Program Again, use the standard as your guide (mandatory vs. non) Designate someone to schedule, manage and implement  If using a 3 rd Party Education Program, assign specific courses to each employee; track progress  Ask employees what types of courses interest them  Bring experts in for all staff meetings  Use sign in sheets for validation

11. Execution The next two highest cited deficiencies are: Infection Control = 34% of surveys Quality Management = 34% of surveys

12. Execution Infection Control Thoroughly review expectations of the standard Maintaining a Clean, Safe & Organized Work Environment is where we’ve found the deficiencies  Know what your policy states you comply with  Educate all on safety issues with the chemicals they encounter  Separation of clean & dirty items  Involve several employees in maintaining items  Complete a checklist daily/weekly/monthly – turn in

13. Execution Quality Monitoring The general concept of having, implementing, maintaining a QI program is inconsistent  Generally placing one person in charge to manage helps to keep it running  Break down requirements based upon standard Define how each performance measurement is managed Integrate actions across staff positions; include EVERYONE Create a structure to keep on task

16. For QI Quarterly Reports: Bring all P*D*S*A projects to meetings or offer written reports to central person Speak to the progress being made How was the planning done? What happened when implemented? Improve? No improvement? When analyzing, was it apparent what went wrong? What went right? In implementing, has the process improved to your satisfaction?

17. For QI Quarterly Reports: Use a specific format to the meetings / for the meeting minutes Bring issues relating to processes Talk through what goes on before and what goes on after each process: Input – Throughput – Output Report progress and recommendations if less than expected Document * Document * Document Who was at meeting ID the date / time Outline discussion items and action items File the “minutes” in same place always

18. Discussion What areas are you experiencing the most difficulty? What ideas can you share to help others? Resource Handout – FREE access to aids to help organize

19. Thank you very much! Mary Nicholas, MHA President / CEO Healthcare Quality Association on Accreditation 866.690.9851