The key to resolving regulatory citations from federal, state or accreditation auditors? Resist the urge to over-correct.
The Greeley Co.'s Bud Pate, vice president and senior consultant, and Steve Bryant, president and CEO, shared best strategies for hospitals when responding to regulatory and compliance challenges during a presentation April 12 at Becker's Hospital Review 9th Annual Conference in Chicago.
After hospital executives receive results from a regulatory audit, Mr. Bryant advised them against immediately designing corrective action plans that are overly ambitious.
"One of the most significant challenges hospitals face when they develop action plans after surveys is over-committing to a solution that is too robust," Mr. Bryant said. "When organizations form an overly robust correct action plan, then when the federal or state government or accrediting agency comes back to check in, [the provider] still hasn't met their improvement agreement — or even worse, trying to meet that [service improvement agreement] has caused clinicians to overlook other patient care issues."
Over-committing to corrective action plans that go above and beyond regulatory requirements is a common knee-jerk reaction, Mr. Bryant said. Instead, Mrs. Bryant and Pate recommended hospital leaders start by analyzing the survey results and separating the most critical findings from the least urgent.
"You can triage the findings according to three categories," Mr. Pate said. "The first category is invalid findings. … One thing we realized from looking at Joint Commission reports is that at least 50 percent of findings were not valid due to the surveyor's misunderstanding of either the hospital processes or the regulatory requirements."
The second category includes one-off findings, or findings that don't represent a systemic or significant problem. The remaining survey findings are high-priority issues where hospital leaders should focus corrective efforts.
"You can’t change a system in 30 to 60 days, at least not in a way that is sustainable," Mr. Pate said. "You have to spend extra resources in the first 30 to 60 days [following the audit] to get on track and appease the auditors, and then you take the time to design a simple, repeatable system that clinicians want to comply with."
Some hospitals and health systems call on consultants from The Greeley Co. to help identify the root cause driving noncompliance in certain clinical practices and for help developing simple, coherent corrective policies clinicians agree with and understand.
"[The Greeley Co.'s] consultants look for solutions to complex issues that are simple, clinically efficient processes clinicians want to comply with," Mr. Bryant said. "It’s very easy to make a process complex, but a complex process will never be sustained or even implemented. Making a simple process is very difficult. If you want clinicians to comply with a process, it has to be simple, understandable and make sense."