Top 4 things Hospitals can do to avoid a survey disaster
The following 4 items will help you avoid landing in the unlucky 50% of hospitals who are in serious trouble after an accreditation survey.
Your hospital has a 50-50 chance of being in serious trouble when the survey team walks out of your door at the end of your next full Joint Commission, CMS or other accreditation agency survey. That means half of accredited hospitals will need to prepare for a Medicare Deficiency Follow-up Survey (MED DEF) about 45 days following the summation conference. Some will also need to prepare for 60-day and 4-month follow-up Joint Commission survey to resolve Preliminary Denial of Accreditation.
These four areas are ones that most often put organizations at-risk for non-compliance. You can start taking steps to resolve these issues before the visit from your accreditation agency by identifying which of the below areas your hospital also needs to correct. If you want additional information on not only how to avoid a survey disaster, but what to do in the event that you are faced with a follow-up survey, fill out the form to watch our Greeley Insights free webinar recording.
1. ENVIRONMENT OF CARE AND LIFE SAFETY
Environment of Care (EC) and Life Safety(LS) issues account for the majority of survey findings.
Reports to the oversight committee(s) should be focused on true systems issues like the process for assuring appropriate air conditioning, timeliness for preventive maintenance for both utilities and clinical equipment, etc.
Current EC issues that lead to a condition-level finding include:
- Ligature resistant construction in behavioral health settings;
- Temperature and Humidity in the operating rooms; and
- Air flow in sensitive or “critical” areas.
The list of EC and LS heavy hitters changes over time, so it’s important to stay connected to Greeley and similar resources to help you separate common systems problems from frequent one-offs and inaccurate findings.
True systems issues related to the environment of care should be on the executive team’s agenda.
Greeley offers frequent workshops on high risk environment of care issues. Our most recent workshop on Ligature restraint is available on-demand here.
2. SUICIDE PREVENTION
At least for now, flaws in the identification and protection of patients who are at high risk for suicide account for many condition-level survey findings. The largest problem we find is that organizations over commit and under perform.
Greeley has a separate workshop on this ever-changing issue that includes simple tools for all settings. We find most hospitals create unrealistic expectations for screening and assessments that cause patients to be on precautions (such as 1:1 observation) that are neither indicated nor consistently implementable.
Each hospital should thoroughly understand suicide prevention requirements and take the time to create a simple, appropriate, safe, and implementable solution. Watch our seminar on suicide assessment and prevention on-demand here.
3. HIGH-LEVEL DISINFECTION
There is a reason high-level disinfection has remained problem prone in recent years (and often leads to MED DEF follow-up surveys or worse). Check out these Greeley resources and our Simplify and Comply workshop on Infection Prevention: Disinfection and Sterilization:
- Infection Prevention Workshop: Disinfection and Sterilization
- Blog: Common Survey Challenges Infection Control
- Blog: The Joint Commission’s “Enhanced Survey Process” Puts a Microscope on the Sterilization/Disinfection Cycle
Always remember to:
- Pay attention to participants in the entire disinfection / sterilization cycle, not just the disinfection / sterilization segment;
- Invest in a comprehensive disinfection / sterilization gap analysis; and
- Develop a long-term improvement plan that takes the pervasive nature of disinfection / sterilization into account.
4. Everything Else: Focus and Simplify
Many hospital leaders and survey coordinators think “if I can just identify all of our vulnerabilities and fix every one of them then I’ll pass the survey with ease.” They therefore focus on issue identification, which is never-ending and usually leads to overload and paralysis. Fixes to “everything” are usually ineffective. Much of what hospitals try to fix was not broken in the first place.
Instead, we recommend focusing only on true systems issues. There are more systems issues than we have the time and resources to address, so they must be prioritized.
The approach to fixing a true systems issue is to make the process easier to understand and implement. The easy thing to do should be the right thing to do.
Remember, compliance is nothing more than the consistent implementation of safe and efficient practices. If you don’t understand the real (not imagined) operational connection between compliance and safety, you will not succeed in sustaining your solution. Creating sustainable improvements to flawed systems takes experience, expertise and skill.
Fill out the form to watch the on-demand version of our most recent webinar, 'Navigating a Joint Commission Survey Disaster'.