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– UNIVERSITY HEALTH CONSORTIUM– Kurt A. Patton, Patton Healthcare Consulting,

former Executive Director Hospital Accreditation Program, Joint Commission

– October 2013

POST SURVEY EVIDENCE OF STANDARDS COMPLIANCE AND CLARIFICATION

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• 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

POST SURVEY ACTIVITIES

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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

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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.

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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

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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.

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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.

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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

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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

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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

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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

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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!

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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

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WHAT DO I AUDIT?

• Medical records• HR records• EC documentation• Records of inspections done

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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

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AUDITS AND SAMPLE SIZE

• POPULATION• Less than 30, audit all records• 31-100, audit 30• 101- 500, audit 50• >500, audit 70

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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

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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.

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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

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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

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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

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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!

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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.

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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%

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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.

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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.

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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.

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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.

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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

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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!

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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

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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.

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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.

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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.

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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.

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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.

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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.