Survey Smarts for Hospitals

Overview: 

This presentation provides methods for acute and critical access hospitals to identify best approaches to proactively prepare for CMS or accreditation surveys, manage an ongoing regulatory survey and responding to citations resulting from these surveys. Understanding the best way to cope with adverse regulatory or accreditation adverse actions is to avoid them altogether, attendees will learn how to set themselves up for survey success through a regulatory readiness team approach that extends beyond the quality, safety and regulatory departments. This presentation includes critical areas requiring intense pre-survey focus, the value in preparing point of care providers and leadership, and use of common “day of survey” tools that foster success. Creation of and running a “survey command center or war room” is discussed as is managing the survey team (State/CMS/Accrediting Body), how to prepare policies and procedures and rehearsing point of care to enhance positive survey outcomes.

Objectives:

• Understand how best to manage all phases of regulatory surveys
• Learn how to avoid survey disasters
• Understand how rehearse staff and optimally prepare for survey
• Learn how to implement simple “day of survey” tools and processes to foster successful surveys
• Learn how to respond to incorrect findings during the survey
• Understand best approaches to responding to identified deficient practice in plans of corrective action

Presenters: Denise Irizarry and Kim Wilson, Chartis Clinical Quality Solutions

Denise Irizarry is a Senior Consultant with Chartis Clinical Quality Solutions. She brings more than 35 years of consulting and healthcare experience to the firm. She is an authority in healthcare quality, performance improvement, and patient safety science. Her expertise includes lean facilitation, supervisory skills, clinical transformation, regulatory compliance, and emergency
services operations.

Kim Wilson is a Senior Consultant for Chartis Clinical Quality Solutions (CCQS) with more than 25 years of experience in clinical nursing, leadership, regulatory compliance, and informatics. Kim’s proven approach to simplification and process redesign benefits her clients in a variety of areas. She expertly guides them through survey readiness assessments for the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC).