How focusing on high-priority patient safety issues helps health systems ace regulatory and accreditation surveys

Staffing shortages and pandemic-related process changes have resulted in rising patient safety issues, which has drawn the attention of CMS, state agencies, and The Joint Commission. Not only do health systems have to pass regular accreditation surveys but they must now deal with a rising number of state surveys triggered by patient complaints.

In a June Becker's Hospital Review webinar sponsored by Chartis Clinical Quality Solutions (formerly The Greeley Company), compliance experts discussed the current focus on state survey agencies, practical approaches to addressing common pain points, and how to apply these approaches to improve patient safety. Panelists from Chartis included:

  • Cherilyn Ashlock, DNP, RN, advisory consultant
  • Lisa Eddy, RN, vice president, clinical compliance, and high reliability practice
  • Bud Pate, vice president, content

Three key takeaways were:

  1. The pandemic exposed the healthcare system as broken at the weak points. Staff shortages and broken processes have increased safety-related patient issues, leading CMS to seek more authority over accreditors. According to Ms. Ashlock, 30 percent of nurses have left the profession, leaving a major gap at the bedside. As a result of this gap, safety-related metrics have suffered. "We're seeing increases in overall hospital infection rates, more patient safety events and an uptick in complaints and grievances," she said. "These deficits have caused CMS to seek more authority over accreditors; they want deeper and broader oversight of hospitals that are receiving their dollars."

  2. To ensure compliance, health systems must understand the priorities and evaluation tools of state survey agencies and The Joint Commission. Mr. Pate explained that regulatory encounters are either triggered by a significant complaint or are scheduled regularly. "State survey agencies are the ones who can see the results of complaint-driven encounters," Mr. Pate said. Adverse clinical events and infection prevention issues are the most frequent citations. "To prepare for these, it is incredibly important that hospitals have a good safety program."

    Regularly scheduled surveys are typified by visits from The Joint Commission, which recently created a safety matrix that illustrates severity levels of findings. "Only about 25 percent have higher significance, and that's where the focus needs to be," Mr. Pate said. "The most important thing you can do is permanently fix those higher-importance findings that you've been cited for."

  1. Six strategies can help health systems create sustainable, long-term change. "It's about playing the long game," Ms. Eddy said. "Here are some approaches we think are necessary for health systems to achieve not just survey survival, but organizational excellence."
    • Increase oversight. Health systems must manage quality, safety and compliance just as they manage finances — with more accountability and fewer meetings. "Manage quality and safety as tightly as the budget," Ms. Eddy said.
    • Simplify nursing documentation. "Most documentation systems contain overbuilt, excessively complex documentation processes that submerge communication," Ms. Eddy said. "It's our experience that more than 60 percent of nursing documentation is unnecessary and can be eliminated."
    • Encourage adverse event reporting. Create a leadership-led significant negative event communication system to rapidly identify and report harm events. "Staff must feel empowered and excited to report events," Ms. Eddy emphasized. "They have to believe it's an opportunity to fix problems. When safety event recording goes up, harm events go down."  
    • Manage crowded emergency department waiting rooms. Adjust staff and streamline documentation to quickly move ED patients to the correct level of care.
    • Focus on process maturity. By evaluating executive sponsorship, program effectiveness and staffing and organization, health systems can strategically assess and improve the maturity of hospital processes such as infection prevention.
    • Improve suicide prevention. "Suicide prevention continues to be a problem because it's the perfect storm of misplaced priorities matched with excessive expectations that are not frequently operationalized because they don't make complete clinical sense," Ms. Eddy said. Instead, suicide screening should be done with primary behavioral health complaints while other patients are simply observed as needed. 

A goal of health systems is to avoid creating chaos in the name of compliance. To achieve this goal, health systems must play the long game by focusing on the highest-priority patient safety issues and taking the time to permanently solve them. This proactive approach will help health systems better prepare for and respond to compliance surveys in the future.

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