New process is like night and day’ compared with previous surveys
Expect a lot of interaction with unit staff — but no control over where surveyors go or who they talk to. That’s what quality managers who participated in the pilot surveys for the Joint Commission on Accreditation of Healthcare Organizations’ Shared Visions — New Pathways process are saying. "We have actually experienced it. So now we know what it feels like, looks like, and walks like," says Helena Feather, vice president of compliance and health information at Trident Health System in Charleston, SC.
A total of 24 organizations participated in the pilot test surveys, which were conducted from June to November 2003. "I have been involved in surveys for approximately 30 years, and this was like night and day. It is very, very interactive," she reports.
Overall, the new survey process is more customized, so the questions surveyors ask will differ depending on the facility, says Debra Anthony Larson, director of quality management at Mercy Hospital Grayling (MI), a 90-bed facility which was pilot surveyed in June 2003. "However, everything they surveyed had a patient safety focus, including medical record reviews, conversations with physicians and staff, and the leadership interview."
The new process scored points with unit staff, who felt that it was more patient-focused, Feather says.
Since surveys are customized, you can’t do as much gearing up as you used to, says Larson, who treated the pilot as an unannounced survey. "I don’t anticipate as much preparation as what I did previously. If you continue to focus on quality and patient safety on a daily basis, you really don’t need to do a lot over and above. The staff did great. They did not feel intimidated and could readily answer the questions because it’s what they do every day."
To prepare for your upcoming Joint Commission survey, consider the following lessons learned from the pilot survey process:
• Don’t be surprised if outlier patients are traced.
Each surveyor did three or four traces per day, but to Larson’s surprise, they often selected patients with an extended length of stay. "That was one aspect of the survey that we didn’t expect. For most organizations, patients with increased utilization of services tend to be your outliers. At the time, it felt as though they weren’t looking at the patients that we routinely take care of," she says.
However, Larson acknowledges that outliers often are low-volume, high-risk patients, so selecting these patients to trace is consistent with the emphasis on patient safety. "That was something we learned from the pilot. Your top DRGs may be acute myocardial infarction and pneumonia, but those are not necessarily the patients they are going to trace."
In addition, the outliers were more amenable to being traced because they had multiple utilizations, so surveyors were able to assess processes in many units and across the continuum, she notes.
• There is much less emphasis on document review.
In past surveys, document review was always very time-consuming, and that burden has lessened considerably, Larson adds. "However, surveyors can always ask to review a specific policy, so you always need to remain up to date."
The traditional document review on the first morning of the first day has been eliminated, she says. "Prior to their visit, they did indicate to us specific policies they wanted to review, but they spent very little time reviewing policies throughout the survey. They would ask a question, and if we were able to give information and demonstrate compliance, they didn’t delve further into policies and procedures."
The surveyors were looking for clear, concurrent documentation in patient records, Feather explains. "Everything needs to be on the chart by all the caregivers, so anyone can pick that record up and know what to do with that patient. They are only going to look at your retrospective, closed records if there is an issue, such as a chart missing a history and physical."
Surveyors wanted to see how staff went back and forth between paper and electronic records, and legibility was a significant issue, she says. "While tracing, if the surveyors picked up a medical record and were unable to read the order, the surveyor would hand it to a member of our staff. If the staff could read it, that was fine. If not, it was noted."
• Surveys will zero in on your priority-focused areas.
Surveyors identified communication, patient safety, and physical environment as priority-focused areas for Mercy Hospital Grayling. "This information was based on data gathered from our past surveys, our self-assessment, and our core measures," Larson points out.
She says that certain clinical groups identified were confusing at first, such as neurosurgery. "We are a small rural community hospital and don’t provide that service here." However, surveyors explained that procedures such as ear, nose, and throat surgery fell under the DRG of neurology. "Once the surveyors explained to us how service groupings were selected, then it made sense," she adds.
During the opening conference, surveyors presented a one-page report identifying the clinical service areas of trauma, cardiology, general medicine, and general surgery as priorities, Feather says.
"The surveyors asked us if we would agree that those were our priority-focused areas. We know that those are priorities for us, so we acknowledged they were correct," she says.
The survey team will come in knowing what clinical service areas they are going to look at, adds Feather. "Priority-focused areas appear to be selected from areas you identify as not totally compliant, as they evaluate your periodic performance review [PPR]."
Likewise, Feather says, the patients selected for tracing involved areas that were identified as partially or not compliant in the PPR.
"They didn’t tell us how they were selecting the patients, but it is clear that they were identifying themes from our PPR," she explains. "They selected more than one trauma patient and several cardiovascular patients, and that was the majority of what they looked at."
Helpful tool for prioritizing improvements
According to Larson, the PPR allows you to determine in advance if you are compliant, not compliant, or partially compliant. "The PPR was an extremely helpful tool to assist us in prioritizing improvements," she says, adding that the feedback received from surveyors also was useful. "In some cases, we found that we had evaluated our compliance harsher than the actual intent of that element of performance."
Similarly, Feather says her organization was "very hard on ourselves" when completing the PPR. "There were some areas that the Joint Commission thought we were compliant in, when we said we were only partially compliant," she notes.
• Surveyors will visit some units more than once.
Overall, surveyors selected about 15 patients to trace during the five-day survey, Feather says. "They went to every unit at least once and sometimes three or four times. They spent 1½ hours on one of the units."
Some units were visited multiple times by more than one surveyor, she adds. "A surveyor may go to the same department two or three times on one medical record, and then another surveyor may also go to that same department with the same or another tracer."
On one occasion, Feather was entering the special testing area with one surveyor and passed another surveyor who was leaving.
"The surveyors were looking at different medical records, and it just happened to be the same department," she says.
In addition, patient tracer rounds may bring surveyors to departments that normally aren’t visited during surveys, such as the laboratory, which is accredited by the College of American Pathologists, Feather adds.
"Surveyors were tracing a patient who received several blood transfusions, so they stopped by the lab to talk to staff about their process of obtaining informed consent for blood and how the blood was transported to the OR," she recalls.
• Staff may be confused about the lack of a survey score.
Surprisingly, the absence of a survey score didn’t sit well with staff, Feather says. "As I presented results back to our departments, it was hard for everybody to understand that we had no score, and we don’t get anything we can brag about or share with staff.
"That will need to be explained more than once, that this is a continuous ongoing process in preparation for the unannounced surveys," she continues.
However, Larson says that not having a score may remove some of the pressure, especially since survey results will be published. "I think that knowing we don’t have scores will diminish the anxiety associated with getting a bad score," she says.
• Information gleaned from patient tracers will determine system tracers.
The information surveyors discover during the patient tracer rounds will determine which system tracers will be conducted. At Larson’s facility, these were medication management, infection control, and use of data.
"When we developed our agenda with Joint Commission, they identified a day and time that the surveyor would do the system tracers," says Larson. "However, we did not know specifically what system tracer would be conducted and only had a brief period of time to bring staff together for the interview."
The lack of advance notice made it difficult to have staff involved in the various aspects of care available to interact with surveyors, she notes.
• Staff spent far more time with surveyors than in the past.
Since surveyors always returned to units where the patient tracer originated, the staff at those units wound up spending a significant amount of time with the surveyor, Larson says. "That did take time away from patient care, so this aspect was difficult and time-consuming for staff," she says. "However, staff did like having the opportunity to truly show off the care they provide."
The surveyors didn’t expect staff to remember the particular patient they were tracing. Instead, they asked about the processes involved in caring for this type of patient, Larson says.
"Questions are directed at various standards and elements of performance, while always looking for environment of care, infection control, and patient safety issues," she says.
Surveyors mostly spoke with individual staff members one-on-one, except when they returned to the originating unit for a second time, Larson explains. "At that point, they had more of a multidisciplinary conversation when possible, and engaged the pharmacist, dietitian, social worker, nurse, and physician."
Staff had mixed reactions to the amount of feedback they received from the surveyors, says Feather. "Some told us that they didn’t get the consultation they thought they would get from surveyors, while others said that specific surveyors did sit down with them and talk about their involvement with patient care."
According to Larson, surveyors frequently made recommendations and gave examples of how to meet the elements of performance.
"I have found they have been in an educative mode for some years now, and that was very evident during the pilot," she says.
But one thing everyone agreed on was that surveyors talked to more unit staff than ever. "I think everybody was surprised at just how much interaction there was, and how many people interacted with the surveyors in each area that they visited," Feather stresses.
"Before, surveyors weren’t out and about, and staff already knew who was being hand-picked to talk to them," she says. "It’s not that way anymore. The surveyors do the hand-picking."
[For more about the pilot surveys, contact:
• Helena Feather, Vice President, Compliance and Health Information, Trident Health System, 9330 Medical Plaza Drive, Charleston, SC 29406. Phone: (843) 797-4299. Fax: (843) 797-4648. E-mail: Helena.Feather@HCAHealthcare.com.
• Debra Anthony Larson, Director, Quality Management, Mercy Hospital Grayling, 1100 Michigan Ave., Grayling, MI 49738. Phone: (989) 348-0401. Fax: (989) 348-0479. E-mail: firstname.lastname@example.org.]