Note: At Courtemanche & Associates, our office staff will occasionally accompany consultants on a mock survey to learn more about the process and to see firsthand the experiences our clients have. Kerrie Bellisario, Chief Strategist, accompanied Senior Consultants Sharon Dills, Marty Piepoli and Nancy McLean on their second day of a mock survey to a hospital with several off campus sites. The following is Kerrie’s perspective of what a day in the life of these mock surveyors looked like.
Armed with coffees in hand, laptops and legal pads, C&A’s three-member consulting team entered the board room for an executive debriefing to kick off day 2 of the mock survey. Each member of the team shared highlights of their findings from the first day of the visit, pointing out strengths and areas of vulnerability they had identified. The executives in the room took notes and asked questions. After the debriefing, each member of the consulting team split up to visit off-site campuses, conduct clinical tracing, and conduct a life safety building tour respectively.
On the clinical side, first there was a visit to the Cath Lab where a patient was undergoing a procedure. Our consultant viewed the procedure being conducted through an observation window and shared with a hospital team participating in the mock survey in-the-moment observations of what was working well and what was out of compliance. Whether conducting a time out or properly labeling medication vials, the processes surrounding the procedure were analyzed. The consultant’s approach was not only to identify trouble spots, but to educate about what needs to be done to rectify the issue, emphasizing why it needs to be done. Next up was a trip to the Critical Care Unit where the patient from the Cath Lab had come from. A review of the chart and a discussion with nursing staff and a nutritionist was conducted.
Next on the agenda was a medication management session. In the session a group of hospital staff asked questions about how to prepare for The Joint Commission’s medication management session and heard from the consultant about medication related issues identified throughout the course of the mock survey. The session was very educational with an emphasis on how to strengthen systems and processes supporting medication management.
After a brief lunch, a trip to an off-campus physical therapy center was conducted. The big take away at this center is that all patients, whether Medicare or other-insured, need equal treatment in terms of patient treatment procedures. A visit to an off-site sleep lab was next on the docket. With sleep equipment likely to be a focus by the accreditation and regulatory surveyors, the consultant emphasized the need to follow manufacturer guidelines on infection control practices. From the sleep lab was a visit to an Infusion Center where chemotherapy among other intravenous treatments were administered in a calm and warm environment. A review of patient charts was conducted along with a tour of the facility.
As the day was drawing to a near, one of the consultants came back from the building tour with blueprints in hand. He studied the blueprints explaining what he was seeing in the way of fire suppression systems and barrier structures.
All of this activity was only a birds’ eye view of what occurs during one day of a mock survey. This C&A consultant team still had two more days to survey the hospital, provide briefings and prepare reports for the hospital staff who will take the findings and develop action plans to strengthen areas in need of improvement.
The hard working hospital staff was eager to learn from the mock survey team and were especially appreciative of the way the mock survey team provided actions to meet their compliance goals.
This is just one example of what a day in a mock survey might look like. Click here to explore what a detailed mock survey agenda might look like.