OR Manager - January 2018 - 7

Regulations
Surveys
Continued from page 1
" Today it is very clear that CMS is
driving the agenda, " says John R. Rosing,
MHA, FACHE, an expert on Joint
Commission accreditation and regulatory
compliance and executive vice president
and principal, Patton Healthcare
Consulting, Naperville, Illinois.
John R.
Rosing,
MHA, FACHE
There are also now
three other accrediting
organizations that have
deemed status in addition
to the Joint Commission,
but the Joint
Commission is the largest,
with about 80% of
market share.
The other three organizations
are:
* Det Norske Veritas (DNV), a Norwegian
company that specializes in ISO
(International Organization for Standardization)
9000 certification. They
survey to the CoPs but then overlay
certification in ISO as a feature.
* Healthcare Facilities Accreditation
Program (HFAP), which historically
has been tied to osteopathic hospitals,
but has for some time been an
option for all hospitals and is now a
part of the Accreditation Association
for Ambulatory Health Care (AAAHC).
* Center for Improvement in Healthcare
Quality (CIHQ), which only accredits
acute care hospitals.
To make sure these accrediting
agencies are in compliance with the
CoPs, CMS conducts validation surveys
in 5% of hospitals surveyed by each accrediting
organization each year.
" These unannounced validation surveys
by CMS have driven the Joint Commission
and the other accrediting organizations
to 'turn up the fire' on their
surveyors to be less consultative and
more stringent as they survey against
the standards and ultimately the CoPs, "
says Rosing.
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Deficiency in infection prevention
is the most common finding.
New survey process
" The goals of the Joint Commission's
new survey process have shifted from
'exam and score' to continuous improvement,
even though it often still
feels like a 'white-glove' inspection after
the survey is finished, " says Rosing.
The focus is on actual performance
(not stated capacity) and execution (not
potential).
Yet surveyors still tend to gravitate
toward the easily detected and irrefutable
finding or the " low-hanging fruit, "
he notes. " The surveyor spots a flower
vase under a sink and learns that under-sink
storage is prohibited by hospital
policy. Everyone present also sees
the vase and affirms the content of the
policy, and an easy finding results. "
Recognizing that these more trivial
findings appeared in reports equal in
weight to more serious findings that
might actually negatively affect patient
outcomes is one of the principle reasons
the Joint Commission is now using
a new scoring methodology called the
" SAFER™ Matrix, " says Rosing. The
SAFER™ (Survey Analysis for Evaluating
Risk) Matrix provides a grid that visually
risk-stratifies each finding (https://
www.jointcommission.org/topics/safer_
matrix_resources.aspx ).
" It is a way to prioritize their findings
according to risk and prevalence, " he
says. " If there are 20 findings, the surveyors
want to provide hospital administrators
with a better sense of gravity
about which findings are most serious
and widespread so there is a clear differentiation
between a serious medication
management or infection prevention
concern juxtaposed with the flower
vase under the sink. " Surveyors have a
scoring algorithm to help pinpoint where
on the grid a finding should rest.
Preventive analysis is a term the
Joint Commission introduced this year
in reference to the SAFER™ Matrix,
notes Rosing. It is similar to a rootcause
analysis in which the OR manager
says: " This high-risk, prevalent
issue was found noncompliant. Why
was it noncompliant? Were we 'asleep
at the wheel?' Did we have the wrong
policy in place? Did we miss an update
somewhere? "
OR managers basically have to put
into their action plan an admission of
why they think the process failed, which
can sometimes be very difficult to arrive
at, Rosing says. Thus far, the SAFER™
Matrix is doing pretty much what they
thought it would do, he says. There
were concerns that surveyors would be
tempted to err on the side of scoring at
a higher level. However, the computer
scoring algorithm that guides them has
produced numbers that probably reflect
what is actually out there.
Learn from others' mistakes
In preparation for a survey, OR managers
should look at the Joint Commission's
frequently scored standards,
along with the Standards Interpretations,
or FAQs (frequently asked questions)
found at https://www.jointcommission.org/standards_information/
jcfaq.aspx.
" You
want to make sure you learn
from problems others have encountered
and take care of them before the survey
because if the surveyors see it and
score it at most hospitals they visit,
there is no chance they are going to
look the other way at your hospital, "
says Rosing (sidebar, p 8).
One of the reasons these standards
are frequently cited is that they represent
processes that are difficult to masContinued
on page 8
OR Manager | January 2018
7
http://https:// http://www.jointcommission.org/topics/safer_ https://www.jointcom http://www.mission.org/standards_information/ http://www.ormanager.com
OR Manager - January 2018

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