Use tool to prepare staff for new survey process

Shown here is a case presentation developed by Catherine M. Fay, RN, director of performance improvement at Paradise Valley Hospital in National City, CA, to help managers prepare staff for the Shared Visions — New Pathways survey process, including the new tracer methodology:

1. During the opening conference, the surveyor may select a patient with a diagnosis of cerebral vascular accident (CVA).

2. After determining the location of the patient, the surveyor will go to the unit.

3. Upon arriving on the unit, the surveyor will approach a staff member and start to question him or her about the patient:

  • "How long has this patient been in the hospital?"
  • "When he/she was admitted, how was the plan of care for this patient determined?"

Depending on the answer, the surveyor may ask:

  • "What is the plan of care?"
  • "Who contributed to the plan of care?"
  • "How are components of the plan prioritized?"

Or the surveyor may ask:

  • "How is the patient assessed?"
  • "What is the hospital policy for assessment?"
  • "Where is the assessment documented?"
  • "Can we see the documented assessment and a copy of the policy on assessment?"

After looking at the assessment, the surveyor may say:

  • "I see the patient is having difficulty swallowing. Do you do swallow studies here?"
  • "Who does swallowing studies?"
  • "How are swallowing studies ordered?"
  • "Did this patient have a swallowing study?" If the answer is yes, the surveyor may ask to be taken to the department of the personnel who do the swallow studies.

4. When there are linkages in care that the surveyor wants to follow, and those linkages direct him or her to another department, the questions will be about a patient "with" a procedure, diagnosis etc. The questions won’t necessarily ask about a specific patient who was provided care or services by the staff member. The surveyors are looking for knowledge of and consistent application of processes. It is expected that staff know the processes.

5. Upon arriving in the department, the surveyor may ask to speak to the staff person who does the swallowing study. Questions he or she may ask include:

  • "How do you get referrals for swallowing studies?"
  • "What is the process for the study?"
  • "How were you trained to do the study?" (The surveyor then may ask to see that person’s file to confirm competency.)
  • "How do you communicate the results of the study to other members of the care team?"
  • "Is there any follow-up to the original study?" (The surveyor is looking to see if there is a re-assessment after recommendations are implemented or there is improvement in the patient’s condition.)
  • "How is the dietician involved in the management of a patient with swallowing difficulty?"

6. The answers to this question could direct the surveyor to the dietary department to ask about referrals, assessment, and criteria for nutrition management.

7. When finished in the dietary department, the surveyor could return to the location of the patient for a thorough review of the medical record to verify that everything was documented to reflect the process answers that were given.

8. After review of the patient’s medical record, the surveyor could ask from where the patient was admitted. If the answer is the emergency department (ED), the surveyor probably will go to the ED and review the processes as they apply to this patient (or any patient with a CVA).