Best Practice on Corporate Good Governance Compliance Audit- Survey Readiness Guide

Global Connect, Inc.

Connecting (IT)2-integrity based , talent, innovations, technology, and investments

across the world.

Our world is the only heaven known to exist in our universe!

Let us take care of the Globe via positive Global connections!

October 26, 2013

Global Connect, Inc.

Promoting the culture of safety, quality and excellence with CAT

CAT= Complete, Accurate and Timely communications

Compliance Survey Readiness Guide

Quality matters!

Evidence based Science demands consistent CAT documentation!

Compliant Protocol

For

Health Care Organizations

    December 23, 2014

Dedicated to promote the Culture of Compliance

to

“Safety, Integrity, Security, Wellbeing, Quality and Excellence”

Remember: …“If it is not documented, it did not happen” Global Connect Enterprises, Inc.

Belai Habte-Jesus, MD, MPH

23 December 2014


………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

  1. Good Governance Structure (Value, Vision, Mission, Goal, objectives)……………………05
  1. Tools for monitoring Good Governance-­‐ Qualitative & Quantitative ……………………..07
  1. Research Pyramid -­‐(What, Who, When, Where, Why and How)
  1. CORT Analysis (Challenges, Opportunities, Risk and Threats)
  1. NDSIM: Need, Demand, Supply Interaction Model
  1. Option Appraisal (Best Option, Win-­‐win Option and Compromise Option
  1. Decision Science-­‐ Evidence based appraisals
  1. Good Governance, the basis of safety, integrity, quality and excellence………….09
  1. Measuring the Provision of Comprehensive set of skilled and non-­‐skilled …….09
  1. The role of Accreditation Surveys in the health care setting………………………………….11
  1. SMART Goals, Objectives and Action Plans……………………………………………………………16
  1. Health Care Accreditation Survey Activity List………………………………………………………17
  1. Health Care Accreditation Survey Activity List…………………………………………………….18
  2. Notes and References…………………………………………………………………………………………..19

This guidance is designed to give direction and readiness tools for those organizations preparing for licensing, credentialing and accreditation compliance surveys.

The guidance integrates tools for ensuring the overall corporate, human resources, professional/clinical and financial integrity of the organization by incorporating the construct of Good Governance, transparency and accountability.

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 with transparency and accountability.

Good Governance= Administrative process that is Participatory, Transparent & Accountable to all stakeholders

GG= PSAT, Participatory, Stakeholder’s accountability and transparency

Value: Promoting the Culture of Safety, integrity, Security and Excellence! -­‐Our value is to promote the culture of safety, security, integrity, quality based prosperity and wellbeing for optimal functionality and   performance.

Vision: Towards 100% Compliance to professional standard! -­‐To foresee a measure of success at towards a 100% Compliance to state, federal, international and professional standards of quality and productivity. A >90% Measure of Success is a desired compliance standard.

Mission: A Compliance driven 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.

  1. Tools for Monitoring Good Governance.

We use qualitative and quantitative Evaluation tools for monitoring the integrity, good governance and compliance of corporate structures and functionality towards consistent and sustainable compliance at >90% Measure of Success.

Qualitative tools include individual and group interviews, supported by surveys to understand the perspective of all stakeholders.

Quantitative tools include review of documentation and productivity reports with statistical data/Minimum Data Sets that show indicators of performance over time.

Research Pyramid, CORT Analysis, NDSIM, Option Appraisals and Decision Science.

  1. Research Pyramid questions are used 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.

  1. CORT Analysis to convert challenges into opportunities.

We use CORT (Challenges, Opportunities, Risks and Threat) Analysis towards understanding and eliminating threats, reducing risks, and converting challenges into opportunities.

Our Strategy: Eliminating threats, Reducing Risks and Converting challenges into opportunities.

Remember: Some one’s challenges are another person’s opportunities!

  • 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.

  1. Option Appraisal. This tool uses the scientific basis of Option Appraisal by taking into consideration, key components of risk assessments, 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: Best Option, B. Win-­‐win option and C. Compromise Options.
  1. 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 promoting Affordability, Accessibility, Accountability for Effective, Efficient and Effective Goods, Products and Services within Constitutional Order or rule of law (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
  • Good Governance the basis of Safety, Quality and Security

We promote GPS=Good Governance, Progressive Prosperity & Sustainable Security

3.1. Good Governance = SAT=Compliance to Stakeholder’s Participation, Accountability and Transparency towards constitutional order, bylaws, standards and desired goals.

  • Progressive Prosperity and Wellbeing= We promote the culture of Comprehensive well being and prosperity that includes (Physical, Psychological, Emotional, Social, Cultural, Economical and Spiritual well being) with optimal functionality relative to the individual’s age, gender, ability or (dis) ability and educational performance.
  • Sustainable Security= Promoting sustainable and consistent 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.
  1. Measuring the Provision of Comprehensive set of skilled and non-­‐skilled care
  • Individualized and comprehensive Service. Mobile health services such as Home Health provides a comprehensive set of skilled and non skilled care to home bound clients 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.
  • Cost effective and user-­‐friendly

Providing care in the comfort/security of client’s home. As such mobile home health care is considered to be the best form of cost effective and individualized /client user-­‐friendly care and services provided to individuals/clients in their own home environment, surrounded by their own families and community support systems.

  • 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 fact and reality of the cost effectiveness and positive benefit of mobile home health care systems around the world. Bringing care to people at the comfort of their own home is considered the most effective way of encouraging and facilitating healing and recovery.

The wave of future care. Mobile Health is considered the most viable option of care to home bound clients due to injury, disease and disability. Remember: The practice of medicine and health care is to facilitate the natural process of healing to the body, mind and spirit in atmosphere of comfort and freedom from risky environments such as abuse, infection, injury, neglect at emotional, psychological, physical level, etc. The home is considered to be the safest place for care, and the advance of technology makes it possible to care for patients in their own home. This is the wave of the future

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.

  1. The role of Accreditation Surveys in the health care setting.
  • 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 Surveys and interviews as well as productivity reports are critical tools of evaluation and measure of success of compliance.
  • 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.

  • Surveys and Audits as Year round compliance activities measuring tool.

As such surveys and internal and external audits, be it for licensing, certifications, accreditation and credentialing are not a one time event but a consistent weekly, monthly, quarterly and 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.

  • Use of Qualitative and Quantitative tools.

As such surveys are important tools of qualitative (satisfaction surveys, interviews) and quantitative (minimum data sets such as ratios, percentages and trends), etc. to support compliance measures toward a consistent and sustainable measure of success of compliance.

  • Survey Desired Outcome: Compliance and full accreditation
  • Survey Objective: Compliance evaluation:
    • 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.
      • Continuity of Care (CoC) for care in multiple disciplines and institutions
      • Coordination of Care (CoC) for complex cases-­‐multi-­‐disciplinary care within and without the same institutions
      • Infection control program-­‐ integument care, orifices, wound, surgical sites
      • Medication Management: name of drugs, dose, frequency, side effects and complications
  • 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.
  • Compliance Measure: Qualitative and Quantitative Tools towards % compliance as a measure of success.
  1. Evaluation: Design, Process and Outcome
  1. Monitoring Tools: Qualitative Measures: Satisfaction Surveys, Group and individual interviews
  1. Measure of Success. Quantitative Measures: Productivity reports in terms of numbers, %, ratios
  1. Evidence based Outcome. Presentation of data in reports, tables, charts,
  1. Solutions and Action Plans

 

Sample trending table

Series 1

Series 2

Series 3

Category 1                Category 2                Category 3                Category 4

  1. . SMART Goals, Objectives and Action Plans

We recommend SMART goals, objectives and action plan to ensure consistent and sustainable compliance.

  1. Specific in time, place and person
  2. Measurable in qualitative and quantitative terms
  3. Appropriate to the specific situation at hand
  4. Realistic in terms of what can be done and achieved.
  5. Time Sensitive with signature and date at the initiation, process, action and outcome
  1. The SMART Goal: Prepare a Survey Readiness Package
  1. Pre-­‐Survey Readiness
  2. During Survey Readiness
  3. Post Survey Readiness
  4. Plan of Correction Readiness
  5. Measure of Success Readiness
  6. Periodic Performance Review Readiness
  7. Priority Focus Area Readiness
  1. Home Care Accreditation Program Document List and Survey Activity List
  1. Pre-­‐Survey Planning Sessions
  1. During Survey Sessions
  2. Post Survey Sessions
  3. Plan of Corrections and Compliance Review
  4. 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.

  1. Pre-­‐Survey Readiness
  1. Survey Readiness Documentation
  1. Greeting Identify staff at the main entrance of the organization:
  1. Verify Surveyor’s Look for identification badge, a picture ID.
  1. Who to notify on the Identify leaders: Administrators, Alternate Adm and DON: names and telephone numbers:
  2. Pyramid Communication List of names, phone numbers, text and email address
  1. Surveyor contact person during the survey:
  1. Identify alternate individuals:
  1. Identify a location for surveyors as you contact the leadership team
  1. Identify a location for surveyors that will serve as a base: Usually a conference room with a desk, phone, electrical and internet access
  1. Validation of Person responsible for the validation of the survey and

surveyors:_                                                                                                           

  1. Readiness Guide and Accreditation Program-­‐specific documentation Lists
  1. Individual tracer survey: identify who will escort the surveyors
  1. Identify person who will assist in the review of electronic records of care
  1. Priority Focus Clinical Servicer Groups and Priority Focus Areas
  1. Customer Value Assessment: What is important to you?
  1. 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
  1. Evidence of Compliance to Federal, State Regulations such as : OSHA &    Civil Rights regulation compliance to culture of safety & wellbeing

Does the organization has Access to :

  1. Positive Environment of Care


  • Exit
  • Electrical outlets
  • Ease of use
  • Fire
  • Fall Prevention
  • Safety & Wellness

 

 

 

  1. Professionalism & Diversity:
  • Age/Sex/race
  • Disability/Gender/culture
  • Nationality/Faith and Religion
  • Comprehensive Compliance
  • Equal opportunity
  • At will employment
  1. National Patient Safety Goals
  • Demographic identification
  • Universal Precautions
  • o Hand Washing Program
  • o Emergency Management
  • o Vulnerability Analysis

 


  1. Risk Assessment
  1. Pain management
  2. Medication management
  3. Environment of Care
  4. Fall Risk Prevention
  5. Emergency Management
  6. Level of Care: I, II, III
  1. B. During Survey Sessions
  1. Corporate Compliance: Leadership, HR, Clinical and Fiscal Management Documentation
  1. Governance: Article of Incorporation, Bylaws and Organizational Structure, licenses: state, federal, CLIA, Accreditation and Credentialing Certifications, Contractual Agreements,
  2. Review of Policies and Procedures: Human Resources, and Operational Manual, Patient and Staff Orientation
  3. Productivity Reports: Governing Body, Professional Advisory Committee, Senior Management Team: minutes and productivity reports
  4. Authorizations. Job Descriptions and Appointment Letters and Performance Evaluation
  5. MIS/Management Information System: HIPAA Compliance: CAT Documentation, Storage, Retrieval and distribution; Compliance to health record system, OASIS/485, Visit notes,
  6. Performance Review. Organizational, Clinical, Fiscal and HR Performance Evaluation Reports
  7. Performance Improvement Documentation: Governance, HR, Clinical, Fiscal Documentation
  • Environment of Care
  1. Safety and Wellbeing: National Patient Safety Goals and Emergency Management Compliance
  2. Home safety-­‐ Safety checklist, Oxygen signs, fire extinguishers, smoke alarm
  3. Medication error. Do not use abbreviations and approved abbreviations
  4. 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
  5. Emergency Management: Vulnerability Analysis and Risk Assessment and Drills
  6. 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
  8. National Patient Safety Goals: Patient ID, Medication ID: dosage, frequency, duration, side effects and contraindication, medication safety and
  1. Plan of Care: MD/RN/PT/OT/ST/MSW/HHA
    1. Admission Protocol: Referral, Demographic data, Insurance verification, billable hours & MD Plan of Care with Written and Signed
    2. Assessment and Re Assessment Policies. MD Plan of Care, RN/Therapy Care Plan, HHA Care Plan, Level of Care: I, II,
    3. Coordination of Care and Continuity of Care: Evidence of compliance with Coordination/Continuity of Care documentation.
    4. Case Conferences: Process and policy for Case Conferences, documentation evidence of compliance
    5. Risk Assessment: Patient ID, Pain, Medication, Fall Prevention, Infection Control, Emergency Management, Perception of Care Assessment: PSS & PCR
    6. Universal Precautions: Hand washing Program: policy, goals, surveillance data
    7. Emergency Management Plan: Annual Drills and evaluation of drills
    8. Perception of Care: Complaint Process and policy: Complaint Log, Investigation forms
    9. PCR and PSS-­‐ Root Cause Analysis, investigation, recommendations and Follow up Action Plans
    10. Fiscal Compliance: Budget, Financial Statement, Profit, Loss, AR and Surety Bond, DMEPOS
    11. Medical Supply List: list and Equipment Cleaning Policy-­‐ DMEPOS
    12. Time management. Working hours and after hour on call log-­‐ Mon-­‐Friday and Weekend plans of work with daily and weekly productivity
  1. Compliance Checklists
    • Personnel/Human Resource: HR Compliance Checklist (10)
    • Clinical Operations: CO Compliance Checklist (10)
    • 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

  1. Documentation Required for Deemed Status Surveys
  2. 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
  1. Discharged patients for the past 12 months with Diagnosis, Start of Care and Disciplines
  1. Last state survey report if applicable
  1. PAC Meeting Minutes & Board Meeting Minutes
  1. Annual Program Evaluation
  1. Budget: Capital Expenditures for three years
  1. Quarterly Record Review Documentation for past 12 months
  1. HHA Training Program, and 12 months education calendar
  1. OBQA/OBQI/HHA Provider Reports
    1. OBQM: Adverse Outcome Report
    2. OBQI: Avoidable Event Report/Outcome Report/Case Mix Report
    3. OASIS Submission statistics by Agency
    4. 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

  • Logistical Identify a location where a surveyor can wait for organizational staff greeting and for a base for surveyors through out the survey period.
  1. Implement your Surveyor Readiness Guide
  2. Notify Key Organizational Members
  3. Validate the surveyor is legitimate
  4. Access your Accreditation web site and read the introductory letter
  5. Check surveyor name and biographical information
  6. Scheduled survey dates
  7. Priority Focus Process PFA and Clinical Service Groups (CSG)
  8. Download your survey agenda
  9. Gather and present documentation according to the Document List Application
  10. A patient undergoing acute care re-­‐hospitalization
  11. A patient receiving personal care and support services
  12. A patient receiving alternative or complementary care
  13. A patient receiving oxygen therapy
  14. A patient in a terminal condition
  • Guides to Mock Audits/Surveys-­‐Tracer Individual and System Activity and Clinical Service Groups
  • Selection Criteria: Cases with Complexity of care and potential risk for complications
  1. Individuals served related to system tracers such as
    1. Infection control, patients with risk for infection, wound management,
    2. Medication Management (Patients with high risk medication or piece of equipment
    3. High risk patients: On ventilator care
    4. A patient less than 18 years
    5. A patient receiving Maternal and Child Care
    6. A patient receiving IV infusion Care
    7. A patient receiving Blood to Blood Component administration/transfusion
  1. Individuals who move between program services such as follow up at Ambulatory care, home care, hospital, long term care, assisted living radiology and laboratory
    1. Coordination of care
    2. Continuity of Care
    3. Transfer and Discharge Patients
  1. Post Survey Sessions
    1. Exit Interview
    2. Survey Decision: Full Accreditation, Accreditation with Improvement, Conditional Accreditation
    3. Plan of Correction: Responding to Who, What, Where ,When , and how the compliance is
    4. Measure of Success for four months to six months
    5. Measure of Success Review Survey to evaluate Success of Plan of Correction
    6. Periodic Performance Review at Quarterly Interview focusing on PFA (Priority Focus Area)
    7. Review of Weekly Productivity Reports, Monthly Senior Management Reports, Quarterly PAC and Annual Governing Body Minutes and Reports
  1. Annual Evaluation of Goals and Results based on Five Pillar of Success
    1. Profitability: Census data, billable hours, referral/Admission ratio, profit, loss, charity
    2. Quality Improvement: Compliance to CMS conditions of participation
    3. Perception of Care: Patient Satisfaction and Patient Compliant Resolution
    4. Growth and Referrals: Desired goals of growth 15-20 % Increase annually
    5. HR: Staff Recruitment, Orientation, Retention and Satisfaction
  1. Annual Calendar for Business Management
  2. Governing Body: Annually at around 15th January
  3. Professional Advisory Committee Meetings: 15 January, 15 April, 15 July, 15 October
  4. Monthly Senior Management Meetings
  5. Weekly Productivity reports for HR, Clinical, Billing and Management
  • Notes and References
  1. http://cms.gov
  2. http://www.cms.gov/Medicare/Provider-­‐Enrollment-­‐and-­‐ Certification/GuidanceforLawsAndRegulations/index.html?redirect=/guidanceforlawsandregul ations/
  3. http://www.cms.gov/site-­‐search/search-­‐results.html?q=home%20health%20regulations
  4. http://JointCommission.org
  5. http://www.hhs.gov
  6. http://www.cdc.gov
  7. who.org
  8. http://www.who.int/en/
  9. http://www.whitehouse.gov
  10. http://healthcare.gov

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 for Excellence!

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