The best accreditation experience comes from a steady approach to standards and compliance rather than focusing on surveys, says … everyone on the other side of the clipboard.
While that may be true, hospital quality leaders still have to worry about the surveys and prepare for them, and there are ways to make that process better.
Accrediting bodies would rather have healthcare organizations strive for optimal compliance every day and not try to put on a good face when surveyors show up, but the reality is that everyone wants to look their best for surveyors, says Patrick Horine, president of DNV GL Healthcare in Milford, OH, the second-largest hospital accrediting body in the U.S. behind The Joint Commission, accrediting more than 500 hospitals in 49 states. DNV has been expanding rapidly in recent years.
With that in mind, Horine says the first word of advice is to thoroughly understand the standards.
“Not everyone needs to be an expert on the standards, but everyone should know what the standard is and how your hospital is applying it. This can be especially important for validation or complaint surveys when the state comes in,” he says.
“A lot of hospitals concentrate more on the accreditor and less on CMS, but so much of what surveyors are looking for has to do with the CMS Conditions of Participation. It’s odd how some hospitals don’t even know they’re responsible for that as well.” It is particularly important to understand the standards when your method of compliance is unusual in any way, Horine notes.
DNV conducts annual surveys, as opposed to TJC’s surveys every three years, and the facility’s internal audits are always a major focus. The internal audits should demonstrate that the hospital has a methodology for continually assessing its compliance and progress in addressing deficiencies identified in the previous survey, Horine says.
Show Your Work
Hospital leaders sometimes misdirect their resources when it comes to accreditation, he says.
A hospital that is generally doing well with accreditation will sometimes continue devoting resources to compliance areas that do not need so much attention, he says. It is important to not neglect areas in which compliance is good, lest those areas go awry, but the bulk of a hospital’s attention and resources should be devoted to the accreditation issues that are not as solid, he says.
That applies to the actual survey as well, he adds.
“If you have areas in which you have a lot of variation from what should be happening ideally, that’s where your attention should be. If you’re focusing on areas that are working well because that’s easier and more pleasant to deal with, change that and focus on areas where you’re not,” he says.
“People want to show off their good work and demonstrate what they’re doing well, but we want to see stuff that is not working well and how you’re focusing your improvements there. It’s nice to see your successes, but we want to see how you’re addressing your problem areas.”
Showing off your good work, with little attention to what you’re trying to improve, could backfire with surveyors, Horine cautions. He compares it to the trend in education in which so much emphasis is put on standardized test scores that the teachers “teach to the test” by drilling students in how to get the best score rather than truly educating them in the topic. Hospitals that focus too much on getting the highest points for compliance are missing the point of the accreditation process, he says.
“They’re trying to pass the test and not looking at all they do every day to improve quality of care,” Horine says.
“We don’t want to see what you look like when you’re all dressed up for the party, but rather what you look like day to day,” he adds. “When you have issues that you’re dealing with, we want to see how you’ve written the standards into your policies and procedures, and how you’re following those.”
That is another common problem: having policies and procedures that look good on paper, but not actually following them on a day-to-day basis.
“A lot of noncompliance is associated with things they say they’re going to do but don’t, or the opposite in which they’re doing great in practice, but it’s not reflected in the policy,” Horine says.
“They sometimes focus a lot on writing a policy that is perfectly in line with the standard, but they don’t spend much time making sure people are actually following that policy. We’re going to look for both.”
Congress Looks at Accreditors
Horine notes that healthcare accrediting organizations (AOs) are under scrutiny themselves, with the House and Energy Commerce Committee recently sending letters to CMS and four hospital accreditation organizations, including DNV GL and TJC, asking for more information on how they conduct surveys. In particular, the committee said it is interested in why their survey results often are different from state survey findings. (The letters are available online at: https://bit.ly/2J5VVtm.)
The committee was prompted by a 2017 Wall Street Journal story about how 350 Joint Commission-accredited hospitals were found in violation of Medicare requirements in 2014, but less than 1% had an accreditation violation. (The story is available online at: https://on.wsj.com/2jaIpYY. Hospital Peer Review’s coverage of that issue is available online at: https://bit.ly/2so9YQW.) Some retained their “Gold Seal of Approval” from TJC despite serious patient safety issues.
Committee members Reps. Greg Walden, R-Ore.; Gregg Harper, R-Miss.; and Michael Burgess, MD, R-Texas, questioned whether the survey results accurately reflect quality and patient safety.
“Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the AO survey process,” they wrote. “For example, according to CMS’ most recent annual report to Congress, in (fiscal year) 2015, AOs conducting hospital surveys did not report 39% of ‘condition level’ deficiencies that were subsequently reported following validation surveys conducted by State Survey Agencies no later than 60 days following the AO survey.”
Physical Environment Can Be at Issue
The committee is seeking assurance that the survey process is a valid way to assess compliance with accreditation standards, Horine says, and that depends on hospitals respecting the survey process. Looking at accreditation surveys as an annual or every-three-years test to pass is the wrong approach, Horine says.
When hospitals focus too much on putting their best foot forward for the few days the surveyors are in house, that’s when the survey results can end up being a poor reflection of the hospital’s true performance, he says.
“Congress is looking into the disparity between what the AOs are finding and what the state agencies are finding. Where that seems to be an issue most is in the physical environment. We and the other AOs are looking at a bigger scope of safety and security, whereas state surveyors are looking more directly at Life Safety Code and NFPA requirements,” Horine says.
“They will open up numerous doors and ceiling tiles looking at fire safety, whereas that is only a component of everything we look at in terms of safety — how you incorporate the Life Safety Code and fire protection in your rounds, how you educate people, how you handle drills, and what people’s roles are. We want to see how that is part of your daily operations rather than just a focus of the survey.”
Don’t Focus on Survey
It is not uncommon for the accreditation process and compliance to rest on the shoulders of one or two people within a hospital, Horine says, and that is a mistake.
Those people most likely are overworked, which encourages an attitude of looking at the survey as just an ordeal to get through and preserve your job, he says.
“We wanted to do annual surveys because a lot happens in 36 months between surveys,” Horine says.
“You can identify an issue and then not really start addressing it for 18 months if you know your survey isn’t coming again for three years,” he adds. “We want to encourage people to address corrective action plans immediately and have a good monitoring system in place to make it sustainable.”
Hospitals tend to fall short by not understanding why they’re missing a standard, Horine says.
“It’s one thing to recognize or be told that you’re not in compliance with a standard, but the response needs to be more than simply fixing it so you pass the next survey. You have to understand why you fell short. Are you not communicating standards and policies well?” he says.
“There should be more than a checklist that you checked off to show you met the standard. What did you learn about why you missed it in the first place, and how does that information apply to other accreditation issues?”
Strive for Constant Readiness
Readiness for accreditation surveys should be ingrained in your everyday activities, says Thomas J. Linhares, a consultant with ECG Management Consultants in Boston, who previously worked in hospitals. That’s how you prevent problems during the actual surveys, he says.
While accreditation and compliance should involve many hospital leaders and frontline staff, Linhares says there should be one person who owns the readiness piece of it.
“Their entire job should be watching for issues that will cause problems with the accrediting body. It’s no secret what they’re looking for, so this person should be focusing on those issues all the time,” Linhares says.
“If you build this into your day-to-day operations, it’s not going to be as big a deal when the surveyors come,” he adds.
A key goal for this person should be making the entire staff familiar and comfortable with the survey process so that when that event happens it is not a new or intimidating process, he says. This is best accomplished with mock reviews, Linhares says.
Mock reviews can be conducted in-house by the accreditation and compliance leaders, or by others within the hospital to give the staff a better sense of someone looking at accreditation issues with different eyes, he says.
Department managers might conduct their own mock surveys, and outside consultants also can conduct mock reviews. “I worked with one hospital where we hired actual Joint Commission surveyors on their own time to conduct mock reviews every year,” he says.
“A lot of things they found were things that the facility just overlooked, simple things like making sure oxygen tanks are dated and timed, that code carts are reviewed every day. Humidity and temperature gauges are a huge thing now with The Joint Commission, so making sure those are set to correct levels and working properly [is important].”
Hospitals also build accreditation issues into their routine rounding, Linhares notes.
These questions can address the common questions surveyors pose to staff members, such as the procedures for fire evacuations or a missing infant, during daily or weekly rounds by hospital leaders.
Policies, Competencies Targeted
Like DNV GL, TJC also dings hospitals for not following their own policies and procedures, Linhares says. “In many situations, they don’t care as much what your routine is as long you actually do what you say your routine is. That often is where you’ll be caught by the reviewer,” he says.
“How often you review policies is another issue where they don’t tell you exactly when or how to do it, but whatever you say you do, you’d better do. If you say you review policies every three years, there’d better be evidence dated and signed showing that you reviewed them every three years.”
Employee competencies are another big issue for TJC surveyors, Linhares cautions. Whatever your policy is on how you confirm credentials and how often you review employee competency, the records must reflect that you are following that policy, he says.
“They will go through employee files for hours, making sure that all the registered nurses were cleared before they were hired. That is one of the biggest things that hospitals are hit with during surveys,” Linhares says.
“The credentialing is supposed to happen before the employee is hired, and a lot of times they find that the review date is after the nurse has already started working. That’s an automatic ding.”
Other common problems include cluttered hallways and dated materials. Surveyors often home in on practices that staff use to make their jobs more convenient and efficient, but which violate health and safety standards.
“An example is in the emergency room where staff are in the habit of connecting the suction tube and having it ready for use, rather than the sealed package there waiting to be opened. Once it’s open it’s no longer sterile,” Linhares says.
“A lot of these things get lost in the internal reviews because it’s routine for the staff and nobody notes it as a deviation from protocols. But surveyors are looking for those things.”
Open and undated medications are another common citation, as well as IV bags that are not labeled quickly enough. Isolation protocols are another common source of citations, Linhares says.
“They’ll stand in the hallway and watch people going in and out of an isolation room, taking notes on how people follow protocols,” he says.
“Another huge one is when they see inconsistent washing of hands. If the majority of people are washing their hands and they see one or two that don’t, you’re fine, but if they see a majority of people consistently not washing their hands when they walk in and out of rooms, that will be a huge problem.”
Hospital leaders and staff should get in the habit of looking at their surroundings in the same way a surveyor does, Linhares says, and that means looking for small, seemingly insignificant problems like a frayed call light cord.
Staff should understand how to interact with surveyors, he notes. They need to understand that during a survey, the shortest answer usually is the best.
“They should simply answer the question that was asked of them. Don’t elaborate,” he says.
“The surveyor won’t want to hear just ‘yes’ or ‘no,’ but employees should keep their answers simple and direct. Answer the question that is asked, but don’t go into other issues.”
- Patrick Horine, President, DNV GL Healthcare, Milford, OH. Phone: (866) 523-6842.
- Thomas J. Linhares, ECG Management Consultants, Boston. Email: email@example.com.