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Promoting the culture of safety, quality and excellence with CAT CAT= Complete, Accurate and Timely communications Survey Readiness Guide Quality matters!
Evidence based Science demands consistent CAT documentation! For Health Care Organizations (Home Health Agencies) October 23, 2013 Promoting the Culture of “Safety, Wellbeing, Quality and Excellence”
Remember: …“If it is not documented, it did not happen” Global Connect Enterprises, Inc. Belai Habte-‐Jesus, MD, MPH
************************************************************************ ………Global Connect, Inc. …Promoting GPS …via… GRS… &… CAT Information Systems…… …….….GPS: Good Governance, ….Progressive Prosperity… &…. Sustainable Security…… Via …………..…. GRS: Green Renaissance Activities… &…. CAT Information Systems!…………………. Connecting Talent, Innovation, Technology and Investments with Goods, Products and Services …………………..//………//Connecting… TiTi,……. 4… GPS…//…………//……………….. **************************************************************************************
Table of Contents
- Good Governance Structure ( Value, Vision, Mission, Goal, objectives)………………………05
Tools for monitoring Good Governance-‐ Qualitative & Quantitative …………………………
a. Research Pyramid -‐(What, Who, When, Where, Why and How)
b. CORT Analysis (Challenges, Opportunities, Risk and Threats)
c. NDSIM: Need, Demand, Supply Interaction Model
d. Option Appraisal (Best Option, Win-‐win Option and Compromise Option
e. Decision Science-‐ Evidence based appraisals
- Good Governance, the basis of safety, quality and excellence………………………………………
Measuring the Provision of Comprehensive set of skilled and non-‐skilled care………………
The role of Accreditation Surveys in the health care setting…………………………………………
SMART Goals, Objectives and Action Plans……………………………………………………………………
Home Care Accreditation Survey Activity List………………………………………………………………
Home Care Accreditation Survey Activity List……………………………………………………………….
Notes and References…………………………………………………………………………………………………
I. Good Governance: The administrative process of managing the resources of public and private enterprises in line with constitutional order, bylaws and shared policies and procedures towards the desired and defined goal and outcome.
Good Governance= Administrative process that is Participatory, Transparent & Accountable to all stakeholders GG= PSAT, Participatory, Stakeholder’s accountability and transparency
Value: Culture of Safety, Security and Excellence! -‐Our value is to promote the culture of safety, security, quality based prosperity and wellbeing for optimal functionality and performance.
Vision: 100% Compliance to professional standard! -‐To foresee a measure of success at 100% Compliance to state, federal and professional standards of quality and productivity.
Mission: Connecting talent and resources for excellence & success. To connect talent, creative ideas, innovation, technology, and resources for effective and efficient and equitable service that promotes the safety, security and quality of health of our client communities.
Goal: Promote the culture of excellence and success in all we do. To promote the culture of Safety, Security, Quality, wellbeing towards positive health outcome for individualized optimal functionality and performance.
SMART Objectives. Calendar based SMART (Specific, Measurable, Appropriate, Realistic and Time Sensitive) objectives towards results oriented measure of Success at 100% Compliance.
SMART Activities. Calendar based activities/productivities that are based on qualitative and quantitative tools of monitoring performance towards 100% compliance to the desired goals and objectives.
II. Tools for Monitoring Good Governance. Research Pyramid, CORT Analysis, NDSIM, Option Appraisals and Decision Science. i. Research Pyramid to understand Root Cause Analysis of challenges and opportunities.
We use Research Pyramid that asks the basic questions-‐(what, who, when, where, why and how) to undertake research so as to understand root cause analysis of challenges and opportunities for potential solutions. ii. CORT Analysis to convert challenges into opportunities.
We use CORT ( Challenges, Opportunities, Risks and Threat) Analysis towards understanding and converting threats into risks, risks in to challenges and challenges into opportunities.
Remember: Some one’s challenges are another person’s opportunities!
iii. NDSIM. Matching Supply and Demand. The Needs, Demands, Supply Interaction Model is a unique tool for needs assessment, for converting need into demand by price modulations so as to promote a cost effective supply of resources that match the changing needs of the market. Remember: We pay the price that matches the value of goods, products and services we need at the specific time of market activities.
iv. Option Appraisal. This tool uses the scientific basis of Option Appraisal by taking into consideration, key components of resource allocation and divergent stakeholders perspective (the market, demand, price, supply and purchase decision, etc.) that considers the major components of time, space, person, product/goods/services and matching resources towards feasible options of:
A. Best Option,
B. Win-‐win option and
C. Compromise Options.
v. Decision Science. Use of Scientific tools towards promoting Good governance, Progressive Prosperity and Sustainable security that promotes( 3A+3Es within CO and FO) , that is Affordability, Accessibility, Accountability for Effective, Efficient and Effective Goods, Products and Service within Constitutional Order (bylaws, policies and procedure, etc.) and Freedom of Choice (Governing Board, Professional Advisory Committee and Senior Management Team) productivity reports towards measure of success at >99% Compliance to expected and desired outcome.
III. Good Governance the basis of Safety, Quality and Security! We promote GPS=Good Governance, Progressive Prosperity & Sustainable Security
3.1. Good Governance= PSAT=Stakeholder’s Participation, Accountability and Transparency towards constitutional order, bylaws, standards and desired goals.
3.2 Progressive Prosperity and Wellbeing= We promote Comprehensive well being and prosperity that includes (Physical, Psychological, Emotional, Social, Economical and Spiritual well being) with optimal functionality relative to the individual’s age, gender, (dis)ability and educational performance.
3.3 Sustainable Security= Promoting safety, security and positive health within a safe environment of care to meet the changing needs of the individual within the family and community setting. Promoting regular proactive surveillance based on documented qualitative and quantitative CAT (Complete, Accurate and Timely) information system.
IV. Measuring the Provision of Comprehensive set of skilled and non-‐skilled care
4.1 Individualized and comprehensive Service. Home Health provides a comprehensive set of skilled and non skilled care provided by skilled and non skilled professionals, that include mobile medical, nursing, therapies (PT/ST/OT), medical social services and home health care services that provide support to activities of daily living, that responds to the changing needs of individuals in the comfort of their homes, under the direction and guidance of their attending physicians.
4.2 Cost effective and user-‐friendly service. Providing care in the comfort/security of client’s home. As such home health care is considered to be the best form of cost effective and individual/client user-‐friendly care and services provided to individuals/clients in their own home environment, surrounded by their own families and community support systems.
4.3 Digitalized ehealth supported Mobile Home Health The advent of technological advancement, mobile health and eHealth system, (portable medical record system) and relevant privacy and HIPAA (Health Insurance Portability & Accountability Act) regulations, and the advent of health insurance exchange market supported with results of evidence based science and medicine.
4.4 Affordable Care Act and Home Health Cost effective Care. CeC-‐The ongoing lessons from the Health Care Reforms around the world, and the more recent US based ACA, (Affordable Care Act), otherwise popularly referred to “OBAMA Care” testify to the cost effectiveness and positive benefit of mobile home health care.
It is considered the most viable option of care to home bound clients due to injury, disease and disability. User-‐friendly and quality care. It is preferred due to its appropriateness and responsiveness to the changing needs of home bound clients, with clear cut guidance and support by their respective attending physicians with MD Plan of Care towards providing care and services to individuals in the comfort of their home is truly an “Idea whose time has come”! Use of technology and patient choice.
As such the advent of digitalized medical record system, face-‐to-‐face encounter requirements by the attending physician, the patient education and participation requirement in their care, supported by (HIPAA) privacy and portability of insurance and the exchange market is making home health care the ideal choice for quality and cost effective care.
The general public and health professionals need to take notice of this unique opportunity and make it work to our respective client communities. “Mobile Home health” care is an idea whose time has come! It brings modern health care and technology to the patient’s home and communities. 4.5 Promoting the culture of safety, security and wellbeing. Our goal is to promote the culture of safety, security and wellness-‐based prosperity, towards results oriented positive health outcome, confirmed by measure of success towards client satisfaction and compliance to professional standards and desired goals.
V. The role of Accreditation Surveys in the health care setting.
5.1 Survey as a tool for quality measure. Accreditation is one of the critical tools that promotes consistent and constant assurance of quality and safety provided to home health care clients and is promoted by constant and consistent positive outcome of licensing and certification surveys as well as accreditations and credentialing surveys with professional quality organizations and public and private insurance systems credentialing respectively. Surveys and interviews as well as productivity reports are critical tools of evaluation and measure of success of compliance.
5.2 Surveys as regular and Consistent Compliance tools. Regular accreditation, licensing and certifications surveys supported by periodic performance review/priority focused activities and processes are critical to ensure the compliance of home health agencies to the CMS Conditions of Participation and the professional Accreditation and Credentialing standards in line with the agencies policies and procedures.
5.3 Surveys as Year round compliance activities measuring tool. As such surveys be it licensing, certifications, accreditation and credentialing are not a one time event but a consistent annual event supported by a series of weekly productivity reports, monthly senior management reviews, quarterly Professional Advisory Committee reports and Annual Governing Board reviews of compliance.
5.4 Use of Qualitative and Quantitative tools. As such surveys are important tools of qualitative (satisfaction surveys, interviews) and quantitative (ratios, percentages and trends) compliance measures toward a consistent measure of success of compliance.
5.5 Survey Desired Outcome: Compliance and full accreditation
5.5.1 Survey Objective: Compliance evaluation: o Tracer Activities (individual and system based), looking at high risk areas and complex service systems, as well as Staff and Leadership Interview, observation, analysis and report for root cause analysis towards solution recommendation and action plans for corrections towards consistent compliance of standards.
o Continuity of Care (CoC) for care in multiple disciplines and institutions o Coordination of Care(CoC) for complex cases-‐multi-‐disciplinary care within and without the same institutions
o Infection control program-‐ integument care, orifices, wound, surgical sites o Medication Management: name of drugs, dose, frequency, side effects and complications
o The surveyor evaluates the organization’s compliance to the standards/CMS Conditions of Participation for HHAs as they relate to the care and services provided to individuals/patients/residents, etc.
5.5.2 Compliance Measure: Qualitative and Quantitative Tools towards % compliance as a measure of success.
- Evaluation: Design, Process and Outcome
Monitoring Tools: Qualitative Measures: Satisfaction Surveys, Group and individual interviews
Measure of Success. Quantitative Measures: Productivity reports in terms of numbers, %, ratios
Evidence based Outcome. Presentation of data in reports, tables, charts, trends. Sample trending table
6 5 4 Series 1 3 Series 2 Series 3 2 1 0 Category 1 Category 2 Category 3 Category 4
- Recommendations. Solutions and Action Plans VI. . SMART Goals, Objectives and Action Plans 1. Specific 2. Measurable 3. Appropriate 4. Realistic 5.Time Sensitive
The SMART Goal: Prepare a Survey Readiness Package
During Survey Readiness
Post Survey Readiness
Plan of Correction Readiness
Measure of Success Readiness
Periodic Performance Review Readiness
Priority Focus Area Readiness
VI. Home Care Accreditation Program Document List and Survey Activity List
A. Pre-‐Survey Planning Sessions
B. During Survey Sessions
C. Post Survey Sessions
D. Plan of Corrections and Compliance Review
E. Calendar based Periodic Performance Review of Consistent Compliance (at weekly, monthly, quarterly and annual interval) Preparation and practice is key to the success of health care organizations in their effort for successful accreditation.
The preparation process begins with a checklist for each area of activity and standard of care supported with appropriate measure of success As such, qualitative and quantitative tools are used for ensuring in the utilization of Quality Assurance Protocol towards a measure of success at>90% or 100% compliance. Use of monitoring tools involves SMART productivity tools that match the standard and its effective implementation. It is always a good idea to have a checklist for each activity and provide evidence of written activities that is dated, signed by all participants.
A. Pre-‐Survey Readiness i. Survey Readiness Documentation
- Greeting surveyors. Identify staff at the main entrance of the organization:
Verify Surveyor’s identity. Look for identification badge, a picture ID.
Who o notify on the arrival. Identify leaders: Administrators, Alternate Adm and DON: names and telephone numbers:
Pyramid Communication List of names, phone numbers, text and email address
Surveyor contact person during the survey:
Identify alternate individuals:
Identify a location for surveyors as you contact the leadership team
Identify a location for surveyors that will serve as a base: Usually a conference room with a desk, phone, electrical and internet access
Validation of Survey. Person responsible for the validation of the survey and surveyors:_
Readiness Guide and Accreditation Program-‐specific documentation Lists
Individual tracer survey: identify who will escort the surveyors
Identify person who will assist in the review of electronic records of care
Priority Focus Process. Clinical Servicer Groups and Priority Focus Areas
Customer Value Assessment: What is important to you?
Promote the culture of Safety, Quality and Excellence to clients, staff and surveyors at all time! Show evidence of compliance: Documentation, charts, trends, qualitative & quantitative tools 16. Evidence of OSHA & Civil Rights regulation compliance-‐ culture of safety & wellbeing Access to :
o Exit o Electrical outlets o Ease of use
o Fire o Fall Prevention
o Safety & Wellness
o Professionalism Diversity: Age/Sex/race
o Disability/Gender/cultur e o Nationality/culture o Environment of Care
o Equal opportunity
o At will employment o Universal Precautions o Hand Washing Program
o Emergency Management
o Vulnerability Anal
o Risk Assessment
B. During Survey Sessions
ii. Leadership, HR, Clinical and Fiscal Management Documentation
- Governance: Article of Incorporation, Bylaws and Organizational Structure, licenses: state, federal, CLIA, Accreditation and Credentialing Certifications, Contractual Agreements, etc.
Review of Policies and Procedures: Human Resources, and Operational Manual, Patient and Staff Orientation Manuals.
Productivity Reports: Governing Body, Professional Advisory Committee, Senior Management Team: minutes and productivity reports
Authorizations. Job Descriptions and Appointment Letters and Performance Evaluation
MIS/Management Information System: HIPAA Compliance: CAT Documentation, Storage, Retrieval and distribution; Compliance to health record system, OASIS/485, Visit notes, etc.
Performance Review. Organizational, Clinical, Fiscal and HR Performance Evaluation Reports
Performance Improvement Documentation: Governance, HR, Clinical, Fiscal Documentation III.
Environment of Care
- Safety and Wellbeing: National Patient Safety Goals and Emergency Management Compliance
Home safety-‐ Safety checklist, Oxygen signs, fire extinguishers, smoke alarm
Medication error. Do not use abbreviations and approved abbreviations
Medication management policy: High risk medications and Look alike and Sound Alike (LASA) drugs list, name, dose, frequency, duration and contra-‐indications and side effects
Emergency Management: Vulnerability Analysis and Risk Assessment and Drills
Level of Care: Levels I, II, III Assessment at admission, care, transfer and discharge
7.Universal Precaution. Infection Prevention and control, hand washing, body fluids
- National Patient Safety Goals: Patient ID, Medication ID: dosage, frequency, duration, side effects and contraindication, medication safety and reconciliation. iv. Plan of Care: MD/RN/PT/OT/ST/MSW/HHA
Admission Protocol: Referral, Demographic data, Insurance verification, billable hours & MD Plan of Care with Written and Signed orders. 2. Assessment and Re Assessment Policies. MD Plan of Care, RN/Therapy Care Plan, HHA Care Plan, Level of Care: I, II, III.
Coordination of Care and Continuity of Care: Evidence of compliance with Coordination/Continuity of Care documentation.
Case Conferences: Process and policy for Case Conferences, documentation evidence of compliance
Risk Assessment: Patient ID, Pain, Medication, Fall Prevention, Infection Control, Emergency Management, Perception of Care Assessment: PSS & PCR
Universal Precautions: Hand washing Program: policy, goals, surveillance data
Emergency Management Plan: Annual Drills and evaluation of drills
Perception of Care: Complaint Process and policy: Complaint Log, Investigation forms
PCR and PSS-‐ Root Cause Analysis, investigation, recommendations and Follow up Action Plans
Fiscal Compliance: Budget, Financial Statement, Profit, Loss, AR and Surety Bond, DMEPOS
Medical Supply List: list and Equipment Cleaning Policy-‐ DMEPOS
Time management. Working hours and after hour on call log-‐ Mon-‐Friday and Weekend plans of work with daily and weekly productivity reports.
V. Compliance Checklists
1) Personnel/Human Resource: HR Compliance Checklist (10)
2) Clinical Operations: CO Compliance Checklist (10)
3) Billing and Finance Compliance Checklist (05) Selected personnel files for employees and contractors for review Performance Monitoring and Improvement Documentation: Show trends, charts, etc.
Organization Review and Annual Evaluation
VI. Documentation Required for Deemed Status Surveys
- Unduplicated admission list for the past 12 months (Name, Address, tel no, Date of Admission Diagnosis, Disciplines: RN/PT/OT/ST/MSW/HHA-‐ Name and telephone numbers
Discharged patients for the past 12 months with Diagnosis, Start of Care and Disciplines
Last state survey report if applicable
PAC Meeting Minutes & Board Meeting Minutes
Annual Program Evaluation
Budget: Capital Expenditures for three years
Quarterly Record Review Documentation for past 12 months
HHA Training Program, and 12 months education calendar
OBQA/OBQI/HHA Provider Reports a. OBQM: Adverse Outcome Report b. OBQI: Avoidable Event Report/Outcome Report/Case Mix Report c. OASIS Submission statistics by Agency d. Error Summary Report by HHA
VII. Home Care Accreditation Survey Activity List Surveyor Arrival: Usually it is a good idea to expect surveyors to arrive any where at 7:30-‐7:45 for 8:00 am start of day as documented by the Agency under survey
7.1 Logistical Needs. Identify a location where a surveyor can wait for organizational staff greeting and for a base for surveyors through out the survey period.
- Implement your Surveyor Readiness Guide
Notify Key Organizational Members
Validate the surveyor is legitimate
Access your Accreditation web site and read the introductory letter
Check surveyor name and biographical information
Scheduled survey dates
Priority Focus Process information. PFA and Clinical Service Groups (CSG)
Download your survey agenda
Gather and present documentation according to the Document List Application
A patient undergoing acute care re-‐hospitalization
A patient receiving personal care and support services
A patient receiving alternative or complementary care
A patient receiving oxygen therapy
A patient in a terminal condition
7.2 Guides to Mock-‐Tracer Individual and System Activity and Clinical Service Groups Selection Criteria: Cases with Complexity of care and potential risk for complications A. Individuals served related to system tracers such as 1. Infection control, patients with risk for infection, wound management,
- Medication Management (Patients with high risk medicatio
n or piece of equipment
- High risk patients: On ventilator care
A patient less than 18 years
A patient receiving Maternal and Child Care
A patient receiving IV infusion Care
A patient receiving Blood to Blood Component administration/transfusion
B. Individuals who move between program services such as follow up at Ambulatory care, home care, hospital, long term care, assisted living radiology and laboratory services.
- Coordination of care
Continuity of Care
Transfer and Discharge Patients
C. Post Survey Sessions
- Exit Interview
Survey Decision: Full Accreditation, Accreditation with Improvement, Conditional Accreditation
Plan of Correction: Responding to Who, What, Where ,When , and how the compliance is sustained.
Measure of Success for four months to six months
Measure of Success Review Survey to evaluate Success of Plan of Correction
Periodic Performance Review at Quarterly Interview focusing on PFA (Priority Focus Area)
Review of Weekly Productivity Reports, Monthly Senior Management Reports, Quarterly PAC and Annual Governing Body Minutes and Reports
D. Annual Evaluation of Goals and Results based on Five Pillar of Success
Perception of Care: Patient Satisfaction and Patient Compliant Resolution
Growth and Referrals
HR: Staff Recruitment, Orientation, Retention and Satisfaction
E. Annual Calendar for Business Management
a. Governing Body: Annually at around 15th January
b. Professional Advisory Committee Meetings: 15 January, 15 April, 15 July, 15 October
c. Monthly Senior Management Meetings d. Weekly Productivity reports for HR, Clinical, Billing and Management
VII. Notes and References
http://www.cms.gov/Medicare/Provider-‐Enrollment-‐and-‐ Certification/GuidanceforLawsAndRegulations/index.html?redirect=/guidanceforlawsandregul ations/
Global Connect, Inc.
Connecting talent, innovations, technology, and investment across the globe! Global Connect, Inc. a US Incorporated Global Enterprises What a beautiful world! If only we can survey it periodically for its survival! Global Connect Inc.
is committed to our individual and collective potential! What a beautiful world! If only we can survey it periodically for its survival! & Global Connect, Inc. is committed to our individual and collective potential!