SURVEYOR Volume 2024 | No. 2 Quality Review Edition
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
03 CORNER VIEW
04 FROM THE PROGRAM DIRECTOR
05 FREQUENT DEFICIENCIES IN SLEEP
LEADERSHIP TEAM
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY
achc.org | (855) 937-2242 | 1
Volume 2024 | No. 2
SURVEYOR
Welcome to the 2024 Surveyor Quality Review. Each year, program-focused editions of this CORNER VIEW publication analyze compliance with ACHC standards over 12 months of surveys. This year’s data span initial and renewal surveys conducted between June 1, 2023, and May 31, 2024. ACHC-accredited organizations use the data to benchmark their performance by comparing these frequently-cited standards against their own survey report. There is value for non-accredited organizations, too. Because ACHC standards are closely aligned with CMS requirements, the information is relevant regardless of how your organization achieves its Medicare certification. For programs outside the Medicare regulations, the value remains. ACHC standards represent an important risk management/quality improvement framework. Reviewing the kinds of issues that arise in your peer organizations is an opportunity to act preemptively to manage your own risks. This is a critical business function in all healthcare settings. We know that some standards consistently present more compliance challenges than others. Frankly, if we offered only a list of frequent deficiencies, this publication wouldn’t vary much from year to year. Instead, Surveyor Quality Review gives insight into trends by quoting findings and offering practical tips to avoid citations. Some standards appear almost annually because of a large number of required elements. Perhaps a policy needs clarification, or staff members were not fully trained on a revision that impacts their work. Perhaps new or contract employees were not adequately oriented to a requirement for documentation, or employees made a change in their workspace that compromises fire safety. For a complex standard, any of these examples represents a potential deficiency and a risk to the organization, its staff, or its patients.
By sharing the observations of ACHC Surveyors, we offer an expert’s perspective on the most current issues impacting organizations. Trends by Program Internally, we use these data to guide the development of educational resources. Organizations seeking to renew their ACHC accreditation in 2024 were also surveyed in 2021. This year, our leaders are including comparative comments as they introduce their program findings. When we experience a large uptick in the number of initial surveys, as we have for several programs in this period, those difficult standards are likely to be prominent as new organizations confront them for the first time. However, we hope to see at least incremental improvement in standards that appeared as frequent deficiencies for this cohort of organizations three years ago. If we don’t see triennial improvements for some of the most frequently cited standards, it means we need to give more educational focus to these in the resources (webinars, workshops, tools) we offer. It is never ACHC’s intention to leave clients wondering about what is expected. To the contrary, our goal is to provide a range of resources that engage and enrich the experience of continuous quality improvement in the healthcare markets we serve. In this year’s first issue of Surveyor , I wrote about team collaboration and handoffs. Remember that ACHC serves as an extension of your team, ready to confer and coach. With Surveyor Quality Review , we are passing an evidence-based guidance tool to you. I hope you grasp it firmly and run with it!
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
José Domingos President & CEO
achc.org | (855) 937-2242 | 3
2
Volume 2024 | No. 2
SURVEYOR
SLEEP FROM THE PROGRAM DIRECTOR
Whether your organization conducts sleep testing in the lab, at home, or both, ACHC is proud to be an active participant in your success. As the industry grows and technology changes, we’re keeping a close eye on the regulatory response. Our standards remain flexible enough to accommodate both LCD requirements and your individual business model, without sacrificing integrity and quality of care. Sleep Results Only two standards were cited at a frequency above 20%, indicating that ACHC-accredited providers have once again raised the bar for excellence. However, a few individual standards have become increasingly noncompliant over time, particularly when it comes to gaps in documentation and recordkeeping. SLC5-1A was most frequently cited at 34%, mostly due to missing elements in the client/patient record. Providers should pay close attention to the requirement for sleep study questionnaires. The easiest, most effective way to combat this deficiency is to institute a checklist, conduct periodic audits, and include measurement of complete records in your Performance Improvement Program. Three of the six highlighted standards have experienced a dramatic increase in findings over the past three years: SLC2-4B was cited at 8% in 2021 and is now at 20%. SLC4-6D has grown from 6% to 15% in frequency. SLC 6-1D was once 9% and is now 17%. While we hope that analysis will always show that fewer than 20% of organizations seeking accreditation for sleep services, this trend is troubling. The cohort surveyed in the period covered by this report includes many organizations that were also surveyed three years ago. That means compliance has declined for these sleep labs. I hope this report will spur all ACHC customers to look again at the requirements and rededicate themselves to meeting the standards.
Surveyor comments repeatedly noted failure to implement consistent recordkeeping practices. At first glance, these look like small errors, but a deeper examination reveals a lack of organizational oversight. The inability to maintain accurate, complete documentation impacts adherence to healthcare regulations and, by extension, patient safety. Many providers correct documentation deficiencies during the survey and follow up by submitting a process to prevent recurrence. However, sustained and ongoing compliance is the real challenge. How are you ensuring compliance throughout your accreditation cycle? Resist the temptation to “quick fix” a systemic issue. Consider that this responsibility lies not just with one person, or one team; prioritize standardized recordkeeping processes at all levels of your organization. A New Chapter As you may know, my tenure as the Program Director of the Sleep Program is drawing to a close. The landscape of sleep testing has grown and changed over the years, but one thing has remained constant – my belief in the power of accreditation. To put it simply, accreditation makes your organization better. If your organization is better, other organizations will follow suit. And before you know it, the entire industry has improved. ACHC continues to evolve and ensure that the cycle continues. It has been my honor to assist organizations from single owner start-ups to corporate entities with hundreds of locations over the past 18 years. While I fully intend to enjoy my retirement, you may still see me from time to time. As always, please don’t hesitate to reach out to your account advisor with any questions.
SLEEP ACCREDITATION
Services
Sleep Lab/Sleep Center Services
Home Sleep Testing
FREQUENT DEFICIENCIES FROM SLEEP SURVEYS
60%
50%
40%
30%
20%
10%
0%
SLC2-4B
SLC3-4A
SLC4-6D
SLC5-1A
SLC6-1A
SLC6-1D
Tim Safley, MBA, RRT, RCP Program Director
Fiscal Management
Program/Service Operations
Human Resource Management
Provision of Care and Record Management
Quality Outcomes/ Performance Improvement
achc.org | (855) 937-2242 | 5
4
Volume 2024 | No. 2
SURVEYOR
SLEEP
SECTION 3: FISCAL MANAGEMENT SLC3-4A
SECTION 2: PROGRAM/SERVICE OPERATIONS SLC2-4B Overview of the requirement:
Overview of the requirement:
The client/patient is advised of their financial responsibility for care/service at, or prior to, the receipt of care/services. Compliance is evaluated through interviews and review of client/patient records. Most deficiencies were cited due to lack of documentation of compliance. Surveyors noted that organizations surveyed for reaccreditation had repeat deficiencies in this area, reflecting challenges with sustained compliance.
Sleep lab clients/patients are provided with information that covers how to communicate a grievance/complaint to the organization, relevant state agencies, and ACHC. Compliance with this standard is evaluated through review of new client/ patient admission packets and client/patient records. Deficiencies were cited for repeated failure to provide essential contact information, lack of adherence to regulatory requirements, and absence of clear processes for informing patients about handling complaints.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
14%
Examples of surveyor findings:
n Client/patient records did not have evidence that the client/patient was informed of charges and the expected reimbursement from third-party payors. n Upon interview, a patient confirmed that no information had been provided about any possible charges after payment is received from insurance. n Records did not document that the client/patient was informed of the charges for a separate professional fee. n Provide clear explanations of charges and expected reimbursements at the initiation of services, and document acknowledgement of these communications. n Develop and implement a process to ensure patients are consistently informed about financial details.
Frequency of citation:
20%
Examples of surveyor findings:
n Written information provided to the client/patient did not include the state regulatory body’s hotline numbers, hours of operation, and the purpose of complaint resolution systems. n Client/patient records did not contain proof the patient received contact information for ACHC if they wish to voice a concern or complaint regarding the care received at the sleep center. n There was no evidence the client had been informed how to contact the SLC, state agencies, and ACHC concerning a complaint or grievance. n Provide each client/patient with an admission packet detailing the complaint resolution process, including ACHC’s phone number and contact information. (Note: the requirement to include ACHC’s contact information is not applicable to organizations that are not yet accredited.) n Maintain documentation of receipt of information within client/patient records; reeducate personnel as necessary. n Develop and implement a process to ensure all clients receive information regarding investigation, and resolution of patient/client complaints about care/ services provided. Conducts audit to ensure ongoing compliance.
Tips for compliance:
Tip s for complianc e:
Do you have an admissions checklist? A checklist may help ensure that staff is including all required elements.
achc.org | (855) 937-2242 | 7
6
Volume 2024 | No. 2
SURVEYOR
SLEEP
SECTION 4: HUMAN RESOURCE MANAGEMENT SLC4-6D
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT SLC5-1A
Overview of the requirement:
The sleep lab’s medical director or certified sleep physician conducts monthly education for personnel. This standard is evaluated through review of training logs. Deficiencies cited lack of written evidence that the required professional was involved in the monthly education. Individual personnel files were often missing evidence of attendance.
Overview of the requirement:
The standard ensures that an individual record is maintained for each client/ patient and that the record contains specific required elements. Surveyors assess compliance through review of policies and procedures and client/patient records. Most deficiencies resulted from insufficient documentation, especially the lack of pre/post sleep study questionnaires.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
34%
Frequency of citation:
15%
Examples of surveyor findings:
n Client records did not contain: Pre/post study questionnaires.
Examples of surveyor findings:
n The organization does not offer monthly in-service and/or educational sessions conducted by the medical director or a certified sleep physician. n Personnel files contain evidence that monthly education was attended, however there is no evidence that the medical director conducted the sessions. n Work with the medical director to develop and implement ongoing educational sessions conducted by the medical director for inclusion in the monthly meetings. Topics should include, at a minimum: New equipment. Facility policies and procedures. Clinical protocols. n Conduct periodic audits to ensure inclusion into the employee record.
Referral order and notes from referring physician. Appropriate order for the test performed. Type of device used for home sleep study (HST). Epworth Sleepiness Scale documentation. Emergency contact. Client information sheet completed prior to the sleep test.
Tips for compliance:
n Written policies and procedures did not indicate that HST client/patient records must include documentation of client/patient ability to understand and use the equipment/supplies provided. n Ensure that written policies and procedures fully define the required contents of the client/patient record. n Reeducate personnel on the process for obtaining all required items for client/ patient records. Consider monitoring for these items in your PI activity for client/ patient record review. Develop and implement a protocol to clearly document the inclusion of sleep questionnaires in HST device packaging. If the questionnaires are not included in the returned device’s packaging, document in the medical record the unsuccessful attempts to receive the patient’s questionnaires.
Tips for compliance:
Consider implementing a sign-in sheet for every session and creating an internal auditing process to ensure attendance is consistently captured.
achc.org | (855) 937-2242 | 9
8
Volume 2024 | No. 2
SURVEYOR
SLEEP
SLC6-1D Overview of the requirement:
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT SLC6-1A
The organization writes a comprehensive annual performance improvement report. Data for the report is obtained from a variety of sources and methods. Surveyors review the annual PI report to assess compliance. Most deficiencies were cited due to incomplete or missing annual summaries.
Overview of the requirement:
The organization develops and maintains an ongoing organization-wide Performance Improvement Program that measures, analyzes, and tracks quality indicators. Analysis of data enables the SLC to assess processes of care, services and operations. PI activities are summarized and shared at least biannually. Compliance is evaluated based on response to interviews and review of policies, procedures, and performance improvement reports. The standard was repeatedly cited due to lack of annual clinical competencies, as well as other missing aspects of measurement.
Comment on deficiencies:
Frequency of citation:
17%
Examples of surveyor findings:
n The organization does have a PI program in place. However, no written annual PI summaries have been completed. n The organization’s written annual summary did not include: Description of the PI activities. ٝ Activity findings. Corrective actions that relate to the care/service provided. n Develop a comprehensive, written annual PI report that describes the selected and required activities, findings, and plans of correction as indicated. n The final annual report is a single document, but improvement activities must be conducted at various times during the year. Use your dedicated monthly/ quarterly PI audits and findings to identify trends and opportunities for further improvement. n Develop an internal plan of correction that includes a process to ensure the written PI summary is completed annually for all indicators. n If using a contracted agency to provide sleep studies or sleep technicians, ensure that services provided by the agency are monitored as part of the PI program and summarized in the annual PI report. Have all parties work together to develop and document the annual written PI report that outlines all PI activities.
Comment on deficiencies:
Frequency of citation:
23%
Examples of surveyor findings:
n The organizations written biannual summary does not include: Annual clinical competency of the personnel administering sleep testing. Satisfaction surveys. Adverse events. Client/patient complaints. Client/patient records. Monitoring of time frames from the time of study to the time the information is sent back to the referring physician. Ongoing monitoring of scoring reliability and consistency (including manual and computer assisted) between the sleep technicians (clinical personnel) and the medical director. At least one important aspect of care/service provided. n Upon interview it was indicated that the governing body does not receive reports regarding the PI Program. n The PI plan did not include descriptions of methods used to collect and review data. n Ensure that the written biannual summary addresses all PI activities required by standard and that the report is provided to the governing body/owner. n Define methods used to collect and review data, including: Current documentation (e.g., review of client/patient records, incident reports, satisfaction surveys). Client/patient care/services. Direct observation in care/service setting. Interviews with clients/patients and/or personnel. n Develop an internal auditing process to ensure ongoing compliance. Avoid unnecessary stress right before the survey and reach out to ACHC throughout your accreditation cycle. Ask your Account Advisor about our PI tools and resources. Remember that performance improvement is more than just a requirement; it’s beneficial to your organization’s growth.
Tips for compliance:
Tips for compliance:
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
achc.org | (855) 937-2242 | 11
10
ACHC Redefining the Culture of Accreditation
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
Cary, NC | achc.org ©2024 Accreditation Commission for Health Care, Inc.
SURVEYOR 2024, NO. 2
Page 1 Page 2-3 Page 4-5 Page 6-7 Page 8-9 Page 10-11 Page 12-13 Page 14Made with FlippingBook. PDF to flipbook with ease