Becker's Hospital Review

22 Executive Briefing Sponsored by: I magine hosting a last-minute surprise party at your home for a group of extremely particular individuals. Sound fun? This is similar to what hospital leaders experience when accrediting bodies arrive for a survey. While it is hard to know with certainty the precise day or time a survey will occur, hospitals can be sure accrediting agencies will visit during their survey window or when adverse events are reported. That means the best hosts have created a culture where compliance is a comfortable and natural state of being, according to Bud Pate, a senior consultant and vice president of The Greeley Company who has more than 40 years of experience in survey readiness, response and remediation. Mr. Pate is a registered environmental health specialist, a past surveyor and a past survey manager. He spoke with Becker's Hospital Review about how hospitals can best prepare and manage a surprise survey, and what to do if your hospital is hit with adverse findings. How to avoid adverse findings Hospital leaders' No. 1 objective is to avoid adverse findings completely. The most effective way to do this is by implementing a safety program to identify and address patient safety issues as they arise. "Most significant regulatory findings can be avoided by having a robust safety program that identifies issues quickly and responds to process problems in a sustainable way," Mr. Pate said. The most serious adverse findings typically come after complaints are logged with an external agency or published by local news media. The best way to avoid such findings is to have an effective safety program that takes immediate action to resolve issues that place patients at risk, followed by a credible and comprehensive causal analysis and risk mitigation program. "One rarely knows which event will end up in the newspaper or at the focus of a regulatory encounter," said Mr. Pate. "So a robust safety program that effectively addresses all events causing patient harm is the only way to prepare for the relatively few that get investigated by surveyors." Luckily, significant errors that undergo regulatory scrutiny are a rare occurrence. However, the organization can effectively prepare for routine inspections. Routine surveys are essentially open book tests, so Mr. Pate offers some tips for performing well. Mr. Pate advises hospitals to watch the accrediting agencies they work with and identify the topics those agencies tend to emphasize in their surveys. For example, today's accrediting agencies universally look hard at requirements for the physical environment and infection control — things like fire and life safety, extra precautions put in place during construction, high-level disinfection or sterilization, breaks in hand hygiene or adherence to proper surgical attire. For CMS, the most cited issues relate to restraint, according to Mr. Pate. With all of this in mind, hospitals can prioritize their efforts around these "trending" areas of focus. From there, a hospital needs to craft simple, easy-to-follow policies to ensure those requirements are met consistently. Mr. Pate recommends hospitals keep policies short: about a page and a half, not 20 to 30 pages. This allows staff to know and follow policies. "The intent is not to complicate the situation, but simplify it," Mr. Pate said. "Less is more." To ensure policies are realistic and understood by staff, hospitals need to monitor processes in action, not merely the documentation. "Documentation measures, well ... documentation," Mr. Pate said. "But documentation alone is often a poor measure of performance." For example, if a hospital wants to see how well staff members adhere to policies for treating skin breakdowns, it needs to examine how clinicians actually treat patients with bedsores, not simply what's captured in patient charts. To do this, a hospital could find a patient who has skin breakdown and talk to that patient's nurses, assess the patient and the wound, discuss how and when the breakdown was identified, how it is progressing and the patient's plan of care. These questions should touch on the important steps of the hospital's policy. If everything is on track, the reviewer — ideally a clinical educator — can then check how these processes were documented in the medical record. First, correct the practice in real time for the benefit of the patient and the learning of the staff members. Second, correct the documentation in real time for the benefit of the institution, being certain that any late entries are identified as such. "We find no substitute for engaging the caregiver at the bedside for whatever clinical process we are trying to improve," Mr. Pate said. Such direct communication and engagement can help hospitals create more immediate change in problem-prone processes, usually in one to two weeks. Survey readiness 101: A guide for safety and success A few things that rarely work and should be avoided: adding a check box to the medical record, adding provisions to an already too-long policy, adding a "hard stop" in the electronic record and piling competency upon competency.

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