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Soar with Four – What Does the Survey Journey Tell Us?


What Does the Survey Journey Tell Us?

Learning From Actual RFIs Scored and How to Address Them

Hospital CMS Mock SurveySurveys continue to grow in intensity, but that’s not necessarily a minus. Jill Ryan, C&A Chief Executive Officer and presenter of March’s webinar, shared her thoughts, “Increased scrutiny allows us to sharpen our practice. The findings allow us to become reflective of what the issues are and to work towards positive resolution.” Looking at seven random surveys from colleagues around the country who shared their experiences anonymously, Ms. Ryan shared some of the top TJC focal points. Not surprisingly, there was a consistent focus on the top 20 scoring issues, mainly in life safety, environment of care and infection control. Post-survey clarifications have also become more challenging. While TJC allows a process for refuting findings, it is increasingly more difficult to make the case against the finding. “Up to 30 RFIs are being cited, on the rise, but not surprising. This is not indicative of poorer care being provided or failure in processes, but rather a deeper dive into processes and organizational adherence,” she said.

Because of the disparity rate between TJC and CMS, there is increased focused attention on areas that haven’t been trending for some time as well as those that have been present in recent years. One example is to look at performance improvement. How is data being aggregated and analyzed? How is data associated with quality improvements? Are contracted services given the same scrutiny as other areas? Another major area to look at is alarm safety. This is the newest of the National Patient Safety Goals, and must be an organizational priority. Ms. Ryan shared that another current trend is looking at how organizations are delivering patient education and engagement of the patient in their care.

Regardless of what your findings are, whether these are in the top 20 or beyond that, organizations will have to be mindful of the post-survey timeline. Ms. Ryan summarized the timeline:

  • Clarifications = Refute
    • Due within 10 business days of posted report
  • ESC = Corrective action
    • Due within 45 calendar days (direct impact) or 60 calendar days (indirect impact) of posted report
  • Condition Level Finding (CDL) Re-survey
    • Must occur within 45 calendar days of the last day of the survey
  • Accreditation with Follow-up Survey
    • Up to 6 months

It is critical to understand TJC’s top scoring and risk-associated requirements. Use tracer activity, record and review and leadership rounding to identify areas needing attention. Ms. Ryan reminds organizations that “by understanding your strengths and knowing in advance where your vulnerabilities are, you can chart a course to patient safety excellence and a successful survey.”

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Kerrie Bellisario

Author Kerrie Bellisario

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