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In a world of magnets and miracles: Shifting the sands of compliance

At the risk of engaging in non-sequiturial (which autocorrect keeps insisting should be non-equatorial) content, I want to touch on a couple of short items that came across my desk over the last couple of days. I don’t know that they specifically relate to each other, but I can imagine a sufficiently powerful pattern recognition program that could link the two (think really, really big picture).

First up, we have some conversation relative to CMS’ efforts to increase the validity of the process by which CMS oversees (or validates) the work of the various accreditation organizations (AO) as they engage in the deemed status survey process. Until recently, the CMS validation process involved a survey visit close on the heels of the AOs (typically within 60 days or so) to see how closely the completed survey met the expectations of CMS vis-à-vis the Conditions of Participation. Historically, there have always been gaps between what was found by the AOs and what was found by CMS, with a lot of pushback on the part of the AOs relative to the timing of things—healthcare organizations are, if nothing else, fluidity personified. So, in response to the timing pushback, CMS has started co-surveying with TJC in real time; so, instead of dealing with your usual complement of TJC surveyors, you also get to host—at the same time—a group of CMSers. Ostensibly, the purpose of the CMS team is to observe the survey efficacy of the Joint Commission team,  but I think you can see where what has never been a “pleasant” experience could really go sideways. I personally have not heard any tales of folks having experienced this type of event, but I feel certain that someone I know will be able to share some stories of daring do and horror-filled antics. Any takers? It would seem (based on a blog post from TJC) that some organizations have expressed gratitude for not having to go through two separate survey events, and there’s a general sense that the CMS/AO survey findings are of a piece, so I guess that’s a good thing. But somehow…

At any rate, at the moment, if your organization is going to have this extra special survey experience, there will be prior notification, but there appear to be plans afoot to end up at a point in which these extra special surveys will be completely unannounced. It also appears that moving in that direction will require some modification to the language in the Conditions of Participation that authorize the validation surveys. According to the blog, the current process is in place through federal FY 2020 (October 1, 2019 through September 30, 2020), so I guess we’ll have to wait and see how things go.

To take this in a completely different direction (well, maybe not completely…) I came across an article providing some advice on conducting one-on-one meetings with staff. As a consultant, it’s been rather a while since I’ve had to administer one-on-one staff meetings, so this may be old hat to you folks with current operational oversight of line staff, but it did prompt me to think about past practices and I can see where this might be helpful in a lot of different ways. I am a firm believer in trying to make every encounter more useful and I think this might be a strategy worthy of your consideration. So, if you need something to read as we start the wind-down of summer (it’s the last week of August—how did that happen?!?), I think this would be worth your time (and please let me know if you think otherwise—any and all feedback is most appreciated!).

Have a safe and festive Labor Day!

Or the light that never warms

Continuing in our somewhat CMS-centric trajectory, I did want to touch upon one last topic (for the moment) as it portends some angst in the field. A couple of weeks ago (April 14, 2017, to be exact), the friendly folks at CMS issued notice of a proposed regulation change focusing on how Accrediting Organizations (AO) communicate survey results to the general public (you can find the details of the notice here).

At present, the various AOs do not make survey results and subsequent corrective action plans available to the general public, but apparently the intent is for that to change. So, using the Joint Commission data from 2016 as test data, it seems that a lot of folks are going to be highlighted in a manner that is not going to paint the prettiest picture. As we covered last week, hospitals and other healthcare organizations are not CMS’ customers, so their interest is pretty much solely in making sure that their customers are able to obtain information that may be helpful in making healthcare decisions. Returning to the Joint Commission data from last year, pretty much at least 50% of the hospitals surveyed will be “portrayed” as having issues in the environment (I’m standing by my prediction that those numbers are going to increase before they decrease—a prediction about which I will be more than happy to be incorrect). Now, the stated goal of this whole magillah is to improve the quality and safety of services provided to patients (can’t argue with that as a general concept), but I’m not entirely certain how memorializing a missed fire extinguisher check at an outpatient clinic or a missed weekly eyewash station check is going to help patients figure out where they want to obtain healthcare. So, I guess the question becomes one of how the folks we hire to assist with accreditation services (the folks for whom we are the customers) are going to share this information in the name of transparency? (Though I suppose if you were really diligent, it might be a little easier to discern trends in survey findings if you’re of a mind to dig through all the survey results.) It will be interesting to see how this plays out; I can’t imagine that they’d be able to publish survey results particularly quickly (I would think they would have to wait until the corrective action plan/evidence of standards compliance process worked itself through).

As with so many things related to the survey process, I understand what they are trying to do (begging the question: Is transparency always helpful?), but I’m not quite catching how this is going to help the process. I absolutely believe that the CMS and the AOs (could be a band name!) have a duty and an obligation to step in when patients are being placed at risk, as the result of care, environment, abuse, whatever. But does that extend to the “potential” of a process gap that “could” result in something bad happening—even in the presence of evidence that the risk is being appropriately managed? There always have been, and always will be, imperfections in any organization—and interpretations of what those imperfections may or may not represent. Does this process make us better or more fearful?