POST SURVEY EVIDENCE OF STANDARDS
COMPLIANCE AND CLARIFICATION
– UNIVERSITY HEALTH CONSORTIUM
– Kurt A. Patton, Patton Healthcare Consulting,
former Executive Director Hospital Accreditation
Program, Joint Commission
– October 2013
1
POST SURVEY ACTIVITIES
• In past years: Celebrate departure of the
survey team, take a few days off to recover.
• Today: Scan the preliminary report left onsite
to look for clarification opportunities.
– Talk with escorts and scribes
– Talk with area managers and staff
– Compare survey findings with your own internal
monitoring data
2
GETTING STARTED
• Access, print and review 3 TJC documents
from extranet
– Evidence of standards compliance navigation
instructions
• Overview of navigation instructions contains important
content requirements for all key dates and
“sustainability” of corrective action.
– Clarification instructions
– ESC instructions
3
FINDING CLARIFICATION
OPPORTUNITIES
• The issue documented by the surveyor in the
observation does not seem related to the EP.
• The issue documented by the surveyor does have a
policy.
• Staff answered this question incorrectly
• We do have a risk assessment, staff just did not
know this
• While the observations are correct, I know our data
is better than 90% compliant.
4
REMEMBER YOU’RE A’s and C’s
• A elements of performance, yes there is a
policy or we do have that process or the
performance was perfect and compliant.
• C elements of performance, yes the surveyor
was correct, but after we conduct a large scale
audit we can demonstrate greater than 90%
compliant.
– No option to avoid an audit, no matter how
bizarre the finding or how much you disagree
5
CLARIFICATION WINDOW
• You only have 10 business days to submit
• You have to e-sign the clarification agreement
attesting that this information demonstrates
compliance at the time of the survey.
• After 10 days the window closes
• If you are trying to clarify findings that relate to a
COP issue, simultaneously consider preparation for
onsite follow up survey.
– 10 business days plus time for SIG review can run
dangerously close to repeat visit timeframe.
6
UNDERSTANDING A CLARIFICATION
• OCO doesn’t avoid the RFI
• Fixing it quickly doesn’t allow for clarification
• A frightened department head who fears
repercussions is dangerous. Verify that all
evidence was actually prior to survey.
• If you use consultants to interview
department heads, verify the evidence before
submitting to TJC.
7
IF WE DISAGREE WHILE THE
SURVEYORS ARE STILL HERE….
• Should we argue, should we flag, should we
surrender and do OCO?
– If you argue, things might get worse
– If you flag SIG will review that finding and may
review others and things may get worse
– If you do OCO, you just plead guilty and
clarification is no longer an option
8
HOW SHOULD WE HANDLE
DISAGREEMENTS?
• Allow your report to flow through the TJC
continuous flow process and be posted to
your extranet.
• Clarify those few issues where there was
disagreement or evidence of compliance.
– The clarification opens up that EP to SIG review
9
WHEN, IF EVER SHOULD WE USE
OCO?
• If the surveyor mentions that the issue they
plan to score is so critical that it will result in a
COP level finding.
– “The OR airflow was negative instead of positive”.
• Get engineering in STAT to fix it, get your vendor in STAT
to retest and validate compliance.
– You may be able to avoid a COP resurvey
10
COMPONENT REQUIREMENTS OF
THE CLARIFICATION
• Who – approved existing policy
• What – does the policy state, what did the
surveyor take issue with that really is
compliant
• When – was the policy approved, updated and
staff trained
• How – do policies get disseminated
• Why – did the surveyor not see this
11
REMEMBER IF IT’S A C, YOU MUST
AUDIT
• You can’t just argue, even if you think the
surveyor was completely wrong.
• Your audit must demonstrate 90% or better
compliance with your policy and the EP.
• Data entering the clarification audit is tedious
and time consuming. Leave at least 2 or more
days from your 10 business days to do this!
12
KEEP ALL THE EVIDENCE
ORGANIZED
• The clarification you submit is potentially subject to an
onsite examination by TJC.
– Does not happen often, but it can
• Keep all the policies you referenced
• Keep track of the patient lists you sample from
• Make sure your randomization is fair no cherry picking
• Keep track of your paper tally sheets
• TJC would need to reach the same conclusion you did during
a re-audit review
13
WHAT DO I AUDIT?
•
•
•
•
Medical records
HR records
EC documentation
Records of inspections done
14
AUDIT TIMEFRAME
• Medical records audits must be 30 days prior
to the survey begin date, thus no post survey
effect, no changes
– Recommend a list of patients admitted and
discharged in that 30 day period. ( screens out any
post survey effect)
• EC audits must be 12 months, e.g. generator
testing, fire extinguisher testing, etc
15
AUDITS AND SAMPLE SIZE
•
•
•
•
•
POPULATION
Less than 30, audit all records
31-100, audit 30
101- 500, audit 50
>500, audit 70
16
RANDOMIZING THE AUDIT
• Easy way: If the population is 700 total
patients divide 700 by required sample size of
70 and identify every tenth record to review.
• More complex way: use @Rand from excel or
let IT do it.
– Either way, keep the total list, highlight those
reviewed, keep it honest
17
FOCUSING THE AUDIT
• If the observations are just from the ICU, limit the
audit to just the ICU
• If the observations are from 2 or more inpatient
locations, use the entire inpatient population
• If the observations are from inpatient and outpatient
locations, use both populations but split the sample.
Easy way % of revenue or % of total names.
• Describe how you identified the population, split the
sample and randomized in your HOW section.
18
POTENTIAL AUDITS
• 2 Unapproved abbreviations (very easy to
pass)
• Failure to have 2 up to date competencies
• Failure to inspect 2 fire extinguishers
• Failure to check a medication room
refrigerator on two dates
• Failure of 2 fire doors to latch
19
AUDIT WORKLOAD
• The Joint Commission just left, the audit
requires a lot of work, the narrative requires a
lot of work and I only have 10 business days.
– Check to see if there is an MOS which would
require a similar audit every month for 4 months
• Failure to time record entries may not be worth the
work effort.
– Consider avoidance of PFP “points”, and future
minimal risk of public disclosure
20
INABILITY TO AUDIT DUE TO LACK
OF PRESURVEY DATA
• 2 fire doors fail to latch in our 500 bed
hospital
• 2 expired drugs or medical supplies are noted
• 2 dusty air vents
• 2 areas violating the 18 inch rule
– We think we do pretty well on these issues, but
there is nothing we can audit like a medical record
21
DESIGNING FOR AUDIT
PROTECTION
• Rumors have floated around for a while that
TJC and CMS disagree on the viability of C
elements.
• 2013 EB did not announce any elimination of
C elements
• Could we better design a paper trail that gives
us something to audit? YES!
22
DESIGNING FOR AUDITS
• Someone inspects fire doors routinely
• Someone inspects for expired medications
and supplies routinely
• EC/IC conduct unit inspections routinely
– Drill down through the data, or develop data that
is more granular than today.
23
DESIGNING FOR AUDITS
• Did you inspect the fire doors for proper
latching this month?
– Yes boss, I did (worthless)
– Yes boss. Here is the documentation. Each fire
door is identified on the inventory, each
inspection pass or fail is noted, and when one
failed I corrected it immediately. The percentage
that passed first time through was 98.5%
24
DESIGNING FOR AUDITS
• Did you inspect the medical supply closet for
expired medical supplies?
– Yes boss, I did ( worthless)
• Yes, we have an automated inventory and par
level worksheet with 227 line items. I found 4
line items expired and removed them from
inventory.
25
DESIGNING FOR AUDITS
• Without any real extra work it may be possible
to design documentation that provides you
numerator/denominator data that could be
used in audits.
• Almost all will easily provide evidence of
greater than 90% compliance
• If CMS orders TJC to stop C elements this will
all go away.
26
CLARIFICATION EVIDENCE
• Can I attach policies and memo’s to the
clarification?
– NO! Describe what the policy says that proves
your point.
• Can I indent, use bullets, use bold code,
underlining, color fonts to make my point?
– NO! The extranet will wipe out the effort. Use text
and whole sentences in a narrative format to
explain.
27
CLARIFICATION EVIDENCE
• Can I send them my Excel spreadsheet's which
demonstrate greater than 90% compliance?
– NO! You must create a spreadsheet within the
extranet by defining how many rows, how many
columns and re-enter all the data.
• This takes a lot of time so don’t wait until the 10th
business day to start.
28
WHAT HAS TO BE ON THE AUDIT
SPREADSHEET?
• Record number or employee ID, or door number
• Number of observations where compliance can be
evaluated
• Number of compliant observations
• Ending percentage compliance
• E.g. 70 records, 1000 correct uses of abbreviations,
1004 total abbreviations, 4 of which are prohibited
for a 99.6% compliance rate
29
WHY WAS THAT ABBREVIATIONS
AUDIT DATA SO GOOD?
• Its not pass/fail at the record level.
• Each record may have 10-20 correct uses and
likely 0-1 incorrect
• Morphine, 4 mg PO daily for pain.
– Morphine instead of MS is 1 correct use
– 4 mg instead of 4.0 mg is the second
– Daily instead of qd is the third
• No body fails this audit!
30
EVIDENCE OF STANDARDS
COMPLIANCE
• Today there are two timeframes or deadlines,
45 days and 60 days
• Remember that if you are scored at a
condition level the resurvey may occur before
you even submit your ESC for fix things quickly
• Process is similar to clarification
31
ESC HEADERS
• Who: “one individual with ultimate
responsibility”. Similar language to the CMS
2567.
• More TJC fussiness seen 2013
• Not a team, not a partnership, not
joint/shared responsibility.
32
ESC HEADERS
• What: did you do to fix the problem?
– Created a policy
– Trained staff on the new policy
• Never use future tense for this header. Always
use past tense.
– “we trained all staff, we wrote the policy, we
distributed the policy, we had it approved”
– Not we will complete training next month.
33
ESC HEADERS
• When: Document the deadline(s) in which
corrective actions took place.
– We approved the new policy Oct 1
– We distributed the new policy Oct 2
– We conducted unit training on the new policy Oct
3 and 4.
• Again, more fussiness seen in detailed the
steps than in past years.
34
ESC HEADERS
• How: How will compliance be sustained? Not
just how do you distribute policies to staff?
• Conceptually this runs right into Evaluation
Method for C elements
– Your going to do audits, just like described for
clarification including appropriate sample size,
randomization and locations of the audits.
35
MEASURE OF SUCCESS
• 90% is the minimum expectation, don’t pick
any other number
• Design a measurement strategy you know is
going to work
• Start test measurement before you are
required to ensure success
• Official measurement does not start until ESC
is accepted by TJC.
36
MEASURE OF SUCCESS
• If the outcome isn’t reaching 90% or even
close or if the work effort is so severe the
audit may not get done, try to create a new
strategy.
37