Be Prepared as CMS and Joint Commission Surveys Come Back “on line”

Recorded Live: September 30, 2020

CMS instructed its State and Accreditation Agencies to resume normal survey activities (enhanced by the edition of focused COVID-related infection prevention reviews) as of August 17, 2020.

Yet survey preparation has not been at the top of hospital priority lists as institutions across the country continue to be whipsawed between surges in coronavirus patients and reduced volumes and revenues. The news is already filled with horror stories of distinguished institutions threatened with the loss of accreditation or Medicare certification due to adverse findings ranging from suicide prevention to environment of care to infection prevention.

Don’t be one of these institutions. The time to prepare is now.

Our webinar focused on:

  • exactly what to expect before, during, and after post-pandemic surveys,
  • the documents that will need to be ready for survey (and possibly uploaded to the Joint Commission “cloud”) prior to survey,
  • a revised model for survey support and readiness to match changing survey expectations,
  • how to understand and implement sustained improvements by simplifying policies and documentation, and
  • how to prepare for The Joint Commission’s emerging emphasis on leadership accountability and follow through.

Increased focus on sustainability

Survey agencies like The Joint Commission ceased field activities when the pandemic hit in March 2020. Although limited on-site surveys have resumed, The Joint Commission estimates that only a fraction of US hospitals are currently able to host a traditional onsite survey team, prompting the agency to perform various review activities remotely, without the need for an on-site surveyor. CMS and The Joint Commission are exploring the possibility of “virtually enhanced surveys,” whereby:

  • requested survey documents (patient and medical staff rosters, policies, environment of care documentation, minutes, findings by external survey agencies, contracts, etc.) will be uploaded to a secure cloud-based server for review by the team before the on-site portion of the survey begins;
  • some or all conferences and “systems tracers” will be conducted via video link (Zoom, etc.); and
  • surveyors will log onto your electronic medical record for remote chart reviews.

The Joint Commission is even experimenting with tours of the physical environment and observation of clinical activities using portable video cameras in smart phones and tablets.

Although CMS has yet to approve these methods, we expect these and other novel approaches will be adopted to allow survey agencies to catch up and keep up.

Impact on Survey Outcomes

We expect the remote review of documents and records will enable surveyors to enhance their focus on high-risk issues.

  • Sustained Compliance: The remote review of recent state, CMS and TJC survey documents will focus surveyors on leadership’s ability to permanently resolve past deficiencies.
  • Root Causes: A detailed review of minutes will arm the team with data relevant to the effectiveness of root cause identification and resolution.
  • Unrealistic Policy Expectations: Surveyors will have more time to critically review policies and other documents, potentially exposing survey vulnerabilities inherent to overly-complex and unrealistic policies.
  • Medical Records: The offsite review of medical records enables better focus and more familiarity with the electronic record, enhancing the likelihood of opening a gap between policy and performance.

When and How to Prepare

The time to prepare is now, before you are threatened with loss of accreditation or termination of Medicare certification.

Learn how to prepare by listening to the replay of The Greeley Company’s free webinar that was held on Wednesday, September 30, 2020. Learn how to cope with changes in the survey process from our decades of experience with state, CMS and Joint Commission reviews.

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