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Accreditation and compliance issues are constant concerns for quality improvement professionals, with new challenges frequently adding to the burden. The key to addressing the concerns is to take a long-term approach and not focus on upcoming surveys, several experts say.
Even so, it always is useful to keep in mind any current trends in what garners the interest of surveyors. Lately, that seems to be infection control, some data suggest.
The good news is that The Joint Commission (TJC) and other accrediting bodies have been relatively quiet in the past year or so, with few substantial changes to accreditation requirements, says Larry Lacombe, vice president of program development and facilities compliance for Medxcel, a company based in Indianapolis that provides facilities management services for healthcare facilities.
This period of relative calm gives quality professionals a chance to concentrate on their past accreditation experiences and any shortcomings that might need attention, rather than being distracted with new rules and trying to play catch-up before the surveyors arrive, Lacombe says.
“You should be paying attention to a good understanding of what your last results were and that the findings identified were addressed sufficiently before the next survey. The surveyors come into the survey with the results from the last visit and basically start from there to see how you’re doing,” Lacombe says. “Addressing any of those findings should be a top priority when preparing for another survey, and if you’re not scrambling to keep up with changing regulations, that can be a more effective process.”
A common failing in accreditation efforts is not understanding your own organization’s policies and procedures, Lacombe says. Surveyors will notice if leaders in the healthcare organization, as well as frontline employees, do not have an accurate idea of what some policies require, he says.
You also could be dinged for not meeting the more stringent standard you set for yourself, he explains.
“The standard in the industry may be less critical than what you have established as your own minimum, usually because it is what you were already achieving internally within the organization,” Lacombe says.
“So, the surveyors will come in and instead of finding an issue with the standard, they will find an issue with your own policy because you have set a shorter time frame, more intervals of testing or inspections — something more aggressive than what the standard called for. They’re going to hold you accountable to your own policies if they are more aggressive than the standard.”
Inconsistency from facility to facility can be another accreditation pitfall, Lacombe says. This is a particular risk within health systems.
New construction also can create compliance concerns, Lacombe notes. Compliance concerns are often overlooked as the hospital or health system conducts pre-construction risk assessments and begins establishing protocols for the process, he says.
There are many compliance issues involved with construction, including life safety and infection control, Lacombe says. They require the direct involvement of a quality and compliance professional all the way from pre-construction through the close-out.
Compliance and quality leaders should conduct weekly or bi-weekly meetings at the construction site, depending on how much work is being performed, Lacombe says. Conduct a walk-through of the construction area at least weekly, preferably daily, to spot-check for compliance issues, he advises.
Unfortunately, that doesn’t always happen.
“Sometimes, that component is overlooked in the planning process, and sometimes it is recognized as a necessary part of the construction process, but it doesn’t actually happen on a daily basis,” Lacombe says.
“They’re not doing the things they said they need to do based on what they risked out in that pre-construction phase. They’re not doing the life safety rounds, ensuring that there is adequate fire protection, not partitioning the construction areas appropriately.”
Hospital leaders often do not realize the shortcomings until they are pointed out by a surveyor, Lacombe says.
“You think you’re doing it, and all of a sudden, somebody from the state comes in and does a walkabout of your construction site. They will ask how you’re addressing a particular concern, and you know that you had a plan for that, but you realize you’re not actually doing it,” Lacombe says. “In cases like that, agencies will stop the construction — which costs you all kinds of money and time.”
Lacombe’s company keeps a database of survey results from the hospitals it works with, using that information to look for trends in what currently is being targeted by surveyors from CMS, TJC, and other accrediting bodies. Ligatures were a major concern for TJC in 2018, and the most recent data indicate a renewed focus on infection control among all accrediting bodies, Lacombe says.
“That includes not just air relationships and air changes, but also what you’re doing with scopes. Are you cleaning scopes in a room that is dirty and putting clean tools back in the same spot where you cleaned them?” Lacombe explains.
“Air pressurization as it relates from an OR to a corridor is another issue we’re seeing. A lot of times, it’s hard to control that even if you do testing and balancing on an annual basis, because if someone just opens a door during the survey it can throw the whole air pressurization out of whack.”
Healthcare organizations may receive more findings in upcoming surveys from TJC related to infection control, Lacombe says, not because anything is new but because there has not been as much focus on that area in recent years and hospitals may have let their guard down.
“The number of findings you get from The Joint Commission is different now also because of the way they have changed their process, so it could be that the littlest thing now becomes a finding for the overall report,” Lacombe says.
“An increase of 20% to 40% in findings from the previous survey is probably going to happen because of what we like to call findis-itis. They’re simply noting more findings than they did before.”
(See the related story in this issue for more on TJC’s findings.)
Understanding your own documentation is another important point.
A surveyor typically asks for documentation immediately upon arrival, and that can set the level of expectations for the survey, Lacombe explains.
“In some cases, hospitals are very disorganized. When you’re looking for documentation, it sets the survey off on the wrong foot because if you’re not organized with your documentation, how organized are you going to be out in the facility?” he says.
Lacombe says it also is important to know your own program well and to be comfortable talking about it.
“You only get on the stage once every three years to talk about what you do, so it’s good if you feel comfortable talking about it and can show the surveyor that you understand all the components and processes,” Lacombe says. “Your confidence can go a long way toward demonstrating that this is a comprehensive program to ensure the best care and not simply an effort to meet the minimum requirements laid out by the accrediting organizations.”
One issue looming large in the industry is the continuing requirement for preventive maintenance on medical equipment, says Eric Robinson, vice president of operations at CME Corp., a national healthcare equipment company based in Warwick, RI, that assists healthcare organizations with compliance issues. Clinical engineering professionals are looking for ways to streamline the process because many organizations find compliance to be a costly endeavor, he says.
“They’re looking at alternative maintenance plans and ways to eliminate the requirements for completions on noncritical pieces of equipment so biomedical engineers can spend their time on those critical, life-saving, or life-supporting pieces of equipment that require a lot of time for maintenance,” Robinson says.
The patient experience continues to be a focus of accreditation and compliance activities, and Robinson says many hospitals are trying to improve the electronic medical records in ways that make the patient’s experience more seamless as they move from one area to another.
Financial limitations continue to be a challenge for compliance efforts, Robinson says.
“Hospitals are always trying to find ways to save, and most quality improvement and compliance departments are running very lean already, as are all the other departments they work closely with. They don’t have any FTEs [full-time equivalents] standing in a glass case waiting to be broken out in case of emergency,” Robinson says.
“That makes it a challenge to respond to any upticks in volume.”
Robinson cites the example related to the construction issues Lacombe discussed. Along with all the other issues related to construction, a new hospital wing or department must be outfitted with a great deal of new equipment, most of it brand new.
That influx of equipment creates a spike in demand across many departments, including engineering, IT clinical support, and maintenance, he says.
“That puts a significant demand on them to address all the needs associated with that spike of new equipment coming in to the building, getting it installed and tested so that it’s good to go for the scheduled opening,” Robinson says. “Those departments are getting stressed when these events take place, and that creates the opportunity for things to be missed.”
Robinson urges quality professionals to strive for a steady approach to compliance and accreditation readiness, rather than scrambling in the last months to get everything in order. With a solid compliance program, surveyors should be able to walk into a facility at any time and get an accurate impression of the quality of care provided, he says.
“I think by taking a good look at your processes in an ongoing way, including your maintenance program, you can leave yourself in a better position by the time of your survey than if you went all out with your resources in the buildup to the survey,” Robinson says.
“Part of that should include looking at whether you can risk-rank some of the preventive maintenance processes in order to free up time so that the crucial human resources can devote their time to the critical equipment that needs their attention. That lessens the angst associated with those surveys.”
However, Robinson cautions that any decision to pursue an alternate maintenance program must be supported by research and documentation.
“If you don’t have the documentation to show why you chose to pursue a maintenance program that is not strictly the norm, that is just an unforced error. It is easy to fall into the trap of deciding to alter how you do something without justifying why you’re doing it,” Robinson says.
“If you can show that, the survey team usually will not have any problem with your choice. They will ask why you made those changes, though, and you want to have data to show them that this equipment has shown no failure over the last five years of regular use within our healthcare facility, therefore we made the decision to risk-rank it lower in our regular preventive maintenance needs.”
Much of compliance and accreditation preparation comes down to determining where you should devote limited resources, Robinson says. Be sure to collaborate across departments.
“Tough choices have to be made sometimes, because you can’t do everything to the extreme when you have limited resources,” he says. “You may have to focus on areas that might be deficient and could create a citing event when the survey takes place.”
Behavioral health populations still are on the minds of surveyors and accrediting bodies, notes Diana Scott, senior director of accreditation at Vizient, a healthcare performance improvement company based in Irving, TX. Suicide and ligature risks in particular have been top concerns for CMS, she says.
“It’s a group of patients that have in the past not had a lot of resources. It’s a challenging population, and the efforts to improve care for them, particularly as it relates to preventing suicide, are drawing a lot of resources,” Scott says.
“We know that evidence-based tools are the right way to approach this, but that means educating our staff on the right way to use these tools to identify these patients at risk and save lives through minimizing the environmental opportunity.”
Other hot issues this year are infection prevention, specifically the reprocessing of medical devices and sterilization of instruments, Scott says. Hemodialysis also is getting attention as it relates to infection prevention, she says.
“We’re also seeing heightened awareness of radiation safety because of some changes that are occurring with anticoagulation therapy and the protocols specifically associated with anticoagulants and episodes of bleeding,” Scott says. “The Joint Commission is focusing on these areas because they have seen evidence of organizations having challenges with complying. Some of the issues, like requirements around sterile compounding, are a little newer only in the sense that there has not been much light shone on them in the past. A lot of organizations had been outsourcing compounding, and now, we’re seeing more a trend of bringing that back in-house.”
TJC released a new National Patient Safety Goal (NPSG) for anticoagulation therapy that becomes effective July 1, 2019. (For more information on the NPSG, see the related story in this issue.) USP also is updating its guidelines for sterile compounding. (More information on the sterile compounding update is available online at: https://bit.ly/2EV0JuR.)
“There’s a lot of new content and much more rigorous reviewing of sterile compounding,” Scott says. “Dialysis is similar in the way they are shining a brighter light in that area. Because that is a very immunosuppressed population, there is a great emphasis on the risk points for infection.”
Focusing on the survey process itself is a common mistake, says Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, senior director of accreditation education programs at Vizient. The much better approach is to build a program that leaves you confident every day of the year so that no matter who walks in the door, you can be sure your hospital is doing the right thing, she says.
Even if you are worried about surveys, Eisenberg notes, much of the emphasis now in surveys and compliance is on the basics. “We’re seeing findings on appropriate cleanliness, maintenance, and staff competency; product preparation; [and] adherence to manufacturer guidelines,” Eisenberg says. “We’re seeing gaps in those basic compliance pieces, and when you don’t meet those basic requirements, that often [causes] bigger issues.”
For instance, Scott says, sterile compounding requires an extremely clean environment, yet there are frequent findings regarding failure to garb appropriately, aseptic technique, and monitoring the environment.
Failing to meet those basic requirements is bad enough, but it could lead to more serious findings, Eisenberg explains. “One inadequacy may not seem like that much, but the more you fail to meet those basic requirements, the more that gap is widening so that you have the potential for errors in your sterile compounding to reach the patient and do real harm,” Eisenberg says. “In disinfection and sterilization, if you have a gap in how you’re processing an endoscope, you can miss a step, and the risk of impacting the patient rises.”
Scott cautions that quality and compliance leaders can easily become overconfident about the knowledge and skill level of employees after providing education on guidelines and best practices. Hospitals have moved to computer-based education, she notes, and that can offer substantial benefits in terms of volume and efficiency when there are many employees to train. But it also can bring risks.
“One of the pieces that we’re missing now that we’ve gone to computer-based education is that we don’t see a lot of hands-on verification — actual execution of the new learning,” Scott says. “I think there is a need for reinforcement there because we all know from our quality education that the things you measure are the things that have a better likelihood of sustainability. Organizations can’t monitor absolutely everything, so there has to be some prioritization to monitor areas where you have not been compliant in the past.”
Eisenberg also stresses the need to educate employees about the reason for best practices and required procedures. “Make sure they know why you’re telling them to do it this way, and also how to escalate or elevate when there is an issue that makes it difficult for them to complete the process in the way you expect,” she says. “There can be competing priorities, and you need to be sure people know when and how to take that conflict to another level for resolution.”
Staff also must deal with real-world practicalities that might not have been addressed in training. In high-level disinfection, for instance, employees might be taught to follow a specific protocol that includes the directions from a product manufacturer. However, employees may find that similar products have manufacturers’ guidelines that are significantly different.
“If we’re using multiple products, we have to follow different manufacturers’ guidelines. Even though the products might be very similar, the guidelines might not be,” she explains. “The complexities add to the need for vigilance because they increase the chances of steps being missed or handled inappropriately.”
Hospitals also are encouraging employees and patients to speak up when they have questions or suggestions for improving processes, Scott says. “One of the things we’re seeing is an effort to make every individual under that roof feel confident and free to bring things forward to improve those system processes,” she says.
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Jill Winkler, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.