Issue link: https://beckershealthcare.uberflip.com/i/717576
44 Executive Briefing The Greeley Company provides innovative consulting, education, outsourcing solutions, interim staffing, and external peer review to healthcare organizations nationwide. We focus on contemporary needs and challenges related to medical staff optimization & physician alignment; accreditation, regulatory compliance & quality, and credentialing & privileging. Headquartered in the greater Boston area, The Greeley Company serves administrative and clinical teams in more than 500 healthcare organizations each year—ranging from the largest healthcare systems and academic medical centers to critical access rural hospitals. Greeley's unique approach and commitment to quality can result in marked improvements in efficiency, quality, compliance, cost reduction, revenue, patient satisfaction, and staff engagement and satisfaction. 2. Be conservative. Do not over-commit to surveyors! Commit only to things your organization can achieve with- in 30 days. Do not implement process changes that cannot be sustained. Note that: • The 30-day commitments must include implementa- tion, performance, and monitoring. • Education and policy change are NOT considered implementation or demonstrated performance/ change in practice. These are actions that must then be monitored to ensure improvement has occurred. • It is perfectly acceptable to have the POC rejected; rejection opens up a communication avenue to allow a discussion about more narrow issues, which will help the hospital to focus improvement actions and inform CMS (via the State Agency) of acceptable hos- pital practice. 3. Focus your POC attention on "The Big Issues" (Hint: The examples in the Statement of Deficiencies are often not "the Big Issues") • Address the process, not the examples • Answer the question, "Why did the process/policy/ practice fail?" • Answer the question, "Was this an isolated incident or is there a broader, underlying issue?" • Have evidence that you've done exactly what you said you would do in your POC 4. Uncover and correct the underlying issues The fact that your organization had a problem during a CMS survey is a strong indicator of underlying issues. Here are five possible culprits: • Poor understanding of CoPs • Failed (and misguided) attempts to comply with the standards (Note: Hospitals most often over-comply with the regulations. As a rule, you should never set an expectation that exceeds federal, state or accred- itation requirements unless the added process im- proves quality, safety, or reimbursement.) • Weak compliance process • Poorly designed policy • Inadequate process training 5. Beware of closely nested standards in the same condition that was cited: • Often, hospitals focus all attention on the specific is- sue cited. This creates two potential challenges: • If you were cited for restraint orders and you correct this challenge by focusing all attention on orders, you may be vulnerable to other restraint-related is- sues such as ongoing monitoring. • Don't lose sight of other standards in the condition cited. You may very well clear the actual standard cit- ed, but on re-survey, be in violation of another stan- dard in the condition, such Restraint and Grievances (both in Patient Rights) and Medication Administra- tion and Care Planning (both in Nursing). n Make sure you're aware of all critical dates. Be conservative. Do not over-commit to surveyors! Focus your POC attention on "The Big Issues." Uncover and correct the underlying issues. Beware of closely nested standards in the same condition. 1 2 3 4 5