OR Manager - January 2018 - 9

Regulations
hang a string or sheet and commit suicide.
" You
can't necessarily change your
environment that quickly, " says Rosing,
" and hospitals in April, May, June, and
July were cited severely on this point. "
The only warning was the notice published
in Perspectives, and then it was
effective immediately, he says.
Changes to standards
Several important changes were made
in the 2017 standards.
Elimination of A and C elements
of performance (EP). " The A elements
were structured standards: You needed
a policy on X, and you either had it or
you didn't. It was a yes or no, black or
white kind of answer, " says Rosing.
" The C elements were rate-based requirements:
You had a policy on X, and
then were you following that policy? "
For example, says Rosing, using pain
assessment and reassessment: " You
had a policy, so you met the A standard.
Next,
if you were following the
policy, what was your rate of doing assessments
and reassessments? "
Previously there had to be three
strikes before a finding was issued. In
other words, they would have to find
three missing reassessments. That
was changed to two, and this year, on
CMS's command, they went down to
one. " If they see it, they cite it, " says
Rosing.
Removal of direct and indirect impact
requirements. All elements of
performance were classified as direct
impact or indirect impact requirements
to reflect the potential impact on quality
of care and patient safety as the result
of noncompliance. " Today, everything is
equal weight, " he says.
Removal of measure of success.
Most people see this removal as a
good thing, says Rosing. " Post survey, if
you were cited on something, about half
of the standards had what was called
a 'measure of success,' which forced
you to do an audit for 4 months, and
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you had to reach 90% conformance, "
he says. " They still want you to have a
monitoring plan, but you don't need to
submit the results of the data collection
to them as in the past. "
Elimination of postsurvey clarifications.
" You used to be able to argue
a finding after surveyors left the building,
either because you thought they
were 'dead wrong,' or you found a document
you weren't able to find when the
surveyors were there, " says Rosing. In
2017, they have sharply curtailed the
opportunity to submit postsurvey clarifications,
he says. " The time to contest
a finding is with your survey team leader
during the survey. This may entail a
three-way phone conversation with the
Joint Commission's Central Office to
arrive at a correct interpretation of a
standard and your compliance with that
standard. "
a sustainable manner.
* Condition-level deficiency: This is
where critical, high-risk findings are
cited that trip a Medicare CoPs (eg,
significant deficiencies in sterile
processing or high-level disinfection
procedures or improper ventilation
pressure gradients in critical areas
like the OR and sterile processing
department), or there are too many
findings in any one performance
area or chapter. " We are seeing a
higher percentage of surveys end
up with a condition-level deficiency, "
notes Rosing. " The consequences
are that the surveyors come back
in 45 days to see if the issues
have been fixed, and you need to
be 100% compliant with the issues
that gave rise to that condition level
when they come back in order to
pass the follow-up survey. "
To prepare for a
survey, check the
frequently scored
standards.
All of these changes have resulted
in longer reports and a 50% increase in
findings. In 2016, the average number
of findings in 1,442 surveys was 20.5.
In the first 6 months of 2017, there
have been 30.3 findings in 1,820 surveys.
Survey
outcomes
Several outcomes can result from a survey,
including:
* Accredited.
* Accredited with follow-up survey: Too
many total findings and too many repeat
findings from prior surveys were
found. This requires the surveyors to
come back in 60 days to determine
if you have corrected the findings in
* Preliminary denial of accreditation:
There are way too many findings and
way too many repeat findings, along
with maybe a couple of conditionlevel
findings. This category was
rare 3 or 4 years ago, but it is far
more common today, says Rosing.
" You have to do a 10-day plan of
correction, and the surveyors return
in 60 days, and every issue must
be 100% compliant at that time, " he
explains.
* Immediate threat to life: This is the
most serious outcome and includes
any situation the surveyor observes
that appears to represent an immediate
risk. " Absolutely avoid these
outcomes if you can, " says Rosing.
" Look at the issues that cause
them, and make sure you understand
what the high-focus areas
are. "
The survey process became " way
harder in 2017 now that 100% of the
standards must each be 100% compliant;
90% is no longer sufficient, " he
says.
Continued on page 10
OR Manager | January 2018
9
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