By Bud Pate
A few themes will continue into 2020 and beyond:
- Accreditation surveys will generate a growing number of findings (The average number of RFIs on a Joint Commission survey rose to 33.7 in the first half of 2019.);
- Follow-up surveys to validate compliance will continue to be the norm (57% of full Joint Commission surveys resulted in a follow-up survey; and
- State surveyors will continue to cite hospitals on behalf of CMS for serious preventable adverse events (Over half of the CMS Conditions “not met” relate to adverse events.).
There will also be a lower tolerance for repeat citations, emphasizing the need to truly fix flawed systems, rather than merely getting a 10-day Plan of Correction or a 60-day Evidence of Standards Compliance accepted by the agency.
Hospital leaders must therefore take a new approach to responding to and preparing for survey. We recommend the following methodology: Sort, Focus, and Simplify.
Survey Hot Spots
First, a quick look at the facts.
For Joint Commission surveys in the first half of 2019:
- 257 (39%) of the “RFIs” representing a “High Likelihood to Harm” were related to suicide and ligature resistance.
- 226 (34%) of “High Likelihood” RFIs related to infection prevention.
- 127 (19%) were “by virtue of” findings, meaning that the governance process, the process for accountability, policy implementation or the process to identify safety risks must have been faulty by virtue of other significant findings.
- The remaining 8% of the “High Likelihood” findings were scattered between medication management, inspection and maintenance of high-risk environment of care systems, eye wash stations and failure to implement interim life safety measures.
Infection Control is the second most frequent “not met” Condition of Participation during state/CMS surveys, just behind survey findings related to preventable adverse events.
New for 2020
Both CMS and the Joint Commission have made a few recent changes to their requirements.
Most changes to Joint Commission requirements have been communicated through “Frequently Asked Questions” on the Joint Commission’s web site and columns in its monthly Perspectives publication. Relatively few have come about as a result of language changes to the Elements of Performance.
On July 1, 2020, however, two brand new Joint Commission standards relating to maternal hemorrhage and preeclampsia will take effect. The anticoagulation safety goal has also been enhanced to address oral anticoagulants in the ambulatory setting.
CMS published new language for various Conditions of Participation that becomes effective on November 29, 2019. These changes include:
- The Discharge Planning and Infection Control Conditions of Participation were completely rewritten, but without big changes in expectations.
- CMS is offering physicians the option of substituting a pre-surgical assessment in lieu of a pre-surgical History and Physical for some patients undergoing some outpatient procedures. Be forewarned, however as there are many hoops to jump through to benefit from this change.
- The Emergency Management Condition of Participation was changed to allow greater flexibility for plan review, training and drills/rehearsals.
- Unified quality and infection control plans across a hospital chain are now allowed.
- Psychologists may now attend patients in free-standing psychiatric hospitals.
- Restraint may now be ordered by “licensed practitioners” instead of only “Licensed Independent Practitioners.”
- The Nursing and Laboratory Conditions of Participation were clarified.
- There were other minor changes the CoPs for hospitals and other provider/supplier types.
Survey agencies are getting serious about compliance
Hospitals will be increasingly challenged to truly fix processes that are likely to cause harm in 2020 and beyond. But, how can a hospital possibly do this if it’s coping with 40, 50 or more agency findings on top of other safety concerns? The answer: Sort, Focus and Simplify.
Sort findings into three categories:
- “One Off” (findings that represent minor flaws in a good system)
- “Inaccurate” (findings with no relationship to the requirement or patient safety); and
- Significant “Systems” flaws that put patients or the hospital at risk.
Focus hospital resources on the “Systems” issues. Do not be distracted by “One Off” and “Inaccurate” findings.
Simplify: Making things simple is very difficult.It takes time, wisdom, and deep expertise to simplify an inherently complex and problem prone process. However, process simplification is the only way we know of to sustain compliance and increase process reliability.
Focus on suicide and infection prevention, adverse events management and truly fixing flawed systems in 2020 and beyond.
First, hospital leadership must avoid the distraction of “one off” and inaccurate survey findings. Although the number of such non-critical findings is growing by the day, they must be recognized for what they are, and resources allocated accordingly.
Bud Pate is Vice President for Content at The Greeley Company.