Survey Readiness: Balancing Joint Commission and CMS requirements Understanding and appreciating the similarities and the differences Kurt A. Patton, MS, RPH President, Patton Healthcare Consulting LLC 1 Survey Readiness: Balancing Joint Commission HISTORY TJC, private, not for profit formed in 1951 by AHA, AMA, ACS, ACP, CMA Concept of accreditation: standards assigned by peers and evaluated by peers 1965 Medicare law includes concept of deemed status for TJC accredited hospitals CMS, HCFA did not have resources or expertise to evaluate hospitals at that time 2 Survey Readiness: Balancing Joint Commission
2009 DEEMED STATUS CHANGE Congress changes the law to now require TJC to apply for deemed status on an ongoing basis and be approved by CMS like other accrediting bodies. Some loss of independence at this time Has already lead to greater consistency between these large agencies. (CMS+TJC) 3 Survey Readiness: Balancing Joint Commission CONSISTENCY VS DIVERGENCE TJC by history was proud of its uniqueness and thrived on being different from CMS. This divergence became confusing and problematic when hospitals did well on TJC survey and poorly on a CMS survey. Independence became problematic when the two agencies did not, or were slow to communicate. 4 Survey Readiness: Balancing Joint Commission
CONSISTENCY AND BETTER COMMUNICATION While standards and elements of performance are different, interpretations and applications in the field are becoming more consistent. Communication has been significantly improved. If you do poorly on anyone's survey, the other body now learns about that quickly. 5 Survey Readiness: Balancing Joint Commission MAJOR FUNCTIONAL DIFFERENCE TJC sets standards and does surveys CMS sets standards and has surveys done CMS is also the payer $$$ and can award carrots and sticks Hospital acquired conditions HAC Value based purchasing VBP Inpatient quality reporting requirements IQR These programs can incentivize desired outcomes and drive performance. 6 Survey Readiness: Balancing Joint Commission
PUBLIC REPORTING CMS Hospital Compare Timeliness and Effectiveness of Care Readmissions and deaths Complications HCAPS Payment rates by certain diagnoses No 2567 s here 7 Survey Readiness: Balancing Joint Commission TJC Quality Check PUBLIC REPORTING Core measure data NPSG compliance post ESC No survey findings except when adverse decision has been reached Layman's terminology will be used instead of actual EP or standard language. May seem worse 8 Survey Readiness: Balancing Joint Commission
CMS COP S Compliance with laws Governing body Patient rights QAPI Medical Staff Nursing Medical Records RX services Radiology Lab Food/dietetic UR Physical Environment Infection Control Discharge Planning Organ procurement Surgical Services Anesthesia Nuclear Med Outpatient Emergency Rehabilitation Respiratory Services 9 Survey Readiness: Balancing Joint Commission APR EC EM HR IC IM LD LS MM TJC CHAPTERS MS NPSG NR PC PI RC TS WT 10 Survey Readiness: Balancing Joint Commission
ALIGNMENT BETWEEN CMS AND TJC Compliance with laws LD Governing body LD Patient rights RI QAPI PI Medical Staff MS Nursing NR Medical Records RC,IM RX services MM Radiology scatter Lab WT Food/dietetic PC UR PC Physical Environment EC, LS Infection Control IC Discharge Planning PC Organ procurement TS Surgical Services PC Anesthesia PC Nuclear Med scatter Outpatient scatter Emergency scatter Rehabilitation Respiratory Services 11 Survey Readiness: Balancing Joint Commission SIGNIFICANT INVISIBLES WITH TJC AND CMS TJC apply your policies and procedures consistently Subjective impression that your policy is insufficient Subjective impression that your policy/practice has risk did you do a risk assessment All the secondary references to NFPA, FGI, CDC, AAMI, AORN and others CMS Uses these same secondary references and will cite did not meet community standards 12 Survey Readiness: Balancing Joint Commission
CMS AND TJC FRUSTRATIONS TJC Issues de jour: laryngoscope blades, eyewash stations, scope cleaning, Cidex test strips, defibrillator clocks, sterilization of medical equipment, EC/LS CMS persistent laser like focus on restraint, rights, EMTALA, grievances and more recently sterilization of medical equipment Surveyor specific areas of focus: sometimes MM, Dietary, Physical environment, IC 13 Survey Readiness: Balancing Joint Commission BIGGEST FRUSTRATION? When one group diverges on a specific issue Accrediting bodies have described temporary privileges in their standards for many years. CMS reviews and approves the standards database from each accrediting body Recent CMS public statement that there is no such thing as temporary privileges Temporary privileges do not get approved by the board Solution, use the TJC Expedited process instead 14 Survey Readiness: Balancing Joint Commission
HOW IS THIS SUPPOSED TO WORK? If accredited by TJC CMS does not do routine surveys. To a large extent CMS does not have a consistent schedule for routine surveys at unaccredited hospitals. CMS still does complaint based surveys at accredited hospitals using state surveyors on behalf of CMS CMS does do 5% validation surveys within 60 days of a TJC survey 15 Survey Readiness: Balancing Joint Commission VALIDATION SURVEY VALIDATION Each year, CMS and TJC (and other accreditors) compare results from surveys conducted at the same hospitals to analyze if similar findings are being seen. This is reported to Congress as a component of a large financial report from CMS. Consistently, for many years that has been a disparity report that does not meet expectations. TJC has enough volume to be analyzed, others do not, and a significant percentage of disparities still exist. DNV has data but validation volume is small for comparison purposes 16 Survey Readiness: Balancing Joint Commission
VALIDATION SURVEY CONCLUSION Work still needs to be done by the accrediting bodies to identify a larger number of COP level findings to be consistent with CMS. This used to be easier when we could equate Type 1 s as similar to COP Now these must actually be scored at a COP level with a repeat survey by the accrediting body. Crystal Ball? Likely to see more COP level findings in the future from TJC. 17 Survey Readiness: Balancing Joint Commission TJC STANDARDS STRUCTURE Chapter: PC, EC, MM, etc. Standards: High level concepts that are not directly evaluated. Elements of performance are evaluated which in turn leads to a standard level score. EP s are nice, bite size requirements. Fairly clear and concise in most cases, especially when compared to the old Intent statements. When the EP isn t clear there are published FAQ s 18 Survey Readiness: Balancing Joint Commission
CMS STANDARDS STRUCTURE COP S equivalent to TJC chapter Standards or tags, similar to TJC standards Interpretive Guidelines narrative document that describes what you must do and how you must do it. Not as easy to find the to do s But a much better format for understanding complexity, nuance, detail like a journal article. E.g definitions of restraint, new radiology requirements. 19 Survey Readiness: Balancing Joint Commission STANDARD FINDING VS COP LEVEL Manner and degree how widespread, how significant? Both agencies try to use this approach. TJC has embedded some rules for consistency E.g. air pressure relationship, gap in HLD or sterilization. Bottom line, it becomes subjective 20 Survey Readiness: Balancing Joint Commission
WHERE DO I LOOK TO FIND? Clear definitions of what is and is not restraint? CMS State Operations Manual (SOM) How to document the update of a history and physical? CMS SOM What is required for discharge planning? CMS SOM What rights to visitors have? CMS SOM What is required for utilization review? CMS SOM How to handle grievances? CMS SOM What are the requirements for medical records? CMS SOM 21 Survey Readiness: Balancing Joint Commission WHERE DO I LOOK TO FIND? What should be in my medical staff bylaws? TJC standards What PI measures should I collect? TJC What is expected of leadership? TJC What EOC/LS issues should I be concerned about? TJC What are the expectations for competency validation? TJC 22 Survey Readiness: Balancing Joint Commission
TJC STANDARDS DEVELOPMENT PTAC conceptual approval to start Field review with opportunity for all of us to comment and shape the outcome Review and approval by PTAC, SSP committee of their Board. Publication on the web, in Perspectives usually with lead time to implement. Rush when CMS makes a change they have to meet. 23 Survey Readiness: Balancing Joint Commission CMS STANDARDS DEVELOPMENT Issue analysis with staff Involvement by invitation of content experts as needed Survey and Certification Memo published to the web Look each month Its effective when published SC memo content included in red the next time the entire SOM is updated. 24 Survey Readiness: Balancing Joint Commission
PUBLICATION SCHEDULE AND FORMAT TJC Every January and often an update in July Printed book format Summarized things to come from Perspectives and web postings E Edition searchable and reportable format CMS No set schedule Downloadable PDF Searchable not reportable Summarizes new content from SC memos 25 Survey Readiness: Balancing Joint Commission TJC POST SURVEY PROCESS Preliminary report left on site and in most cases <24 hour turn around on a final report You can clarify findings that you believe to be incorrect. To some extent you can whine and complain if you feel you were treated unfairly. You complete and electronic description of the corrective actions taken to bring you back into compliance. If COP out, they will come back to 45 days to validate corrective actions are in effect. 26 Survey Readiness: Balancing Joint Commission
CMS POST SURVEY PROCESS No preliminary report take good notes during exit briefing. At some later time a paper report form 2567 will be mailed with the findings and level of impact. Corrective actions must be reported on that 2567 Need to have full Adobe or an old typewriter 27 Survey Readiness: Balancing Joint Commission TJC OUTCOMES AFTER SURVEY Remain accredited with an electronic ESC and MOS Remain accredited with an onsite ESC Accredited with follow up survey (AFS) Contingent accreditation Preliminary denial of accreditation (PDA) Requires Accreditation committee decision If upheld next step is Review Hearing Panel Denial of accreditation Read the decision rules section in the ACC chapter and Perspectives March 2015 28 Survey Readiness: Balancing Joint Commission
CMS DECISION OUTCOMES Respond to a paper 2567 documenting corrective actions COP level findings may result in a follow up survey to validate implementation if approved by RO. May be risk of termination track See SC 13 27 4/19/13 for details and flow charts if you enter this pathway. 29 Survey Readiness: Balancing Joint Commission IMMEDIATE AND WORST POSSIBLE SURVEY OUTCOME TJC immediate threat to life PDA after discussion with TJC president or designee Try to dissuade on significance STAT Once the call is over, its too late Try to abate on the spot If cannot abate on the spot, prepare for an abatement survey If successful you will next be placed in contingent accreditation with a follow up survey to verify the issue has stayed fixed. 30 Survey Readiness: Balancing Joint Commission
IMMEDIATE AND WORST POSSIBLE SURVEY OUTCOME CMS Immediate jeopardy, IJ Fix it stat, show it to the surveyors! May enter termination track May have IJ follow up survey or full survey See SC 13 27 31 Survey Readiness: Balancing Joint Commission TJC END OF THE ROAD TJC PDA upheld by AC with unconvincing corrective action per RHP, a well deserved PDA leading to DA. Your world does not end. Does not automatically result in loss of Medicare Only CMS can remove Medicare certification Review 3 rd party payer contracts to verify language says accredited or Medicare certified Talk with TJC about coming back to accreditation and having a full survey providing reason for loss of accreditation was not falsification. 32 Survey Readiness: Balancing Joint Commission
CMS END OF THE ROAD This really is loss of Medicare certification Most hospitals this would not be survivable and it would be devastating to many communities. A process exists to prevent this called a systems improvement agreement to prevent the termination. Legal process negotiated by your attorneys and CMS attorneys. This is expensive and you better get it fixed before CMS returns. 33 Survey Readiness: Balancing Joint Commission IF YOU ARE TJC ACCREDITED While you focus on TJC and prepare for TJC it is inappropriate to not keep up with, and study equally hard new information from CMS. Survey and certification memo check monthly Download new SOM: Put it in e reader or computer for complete read. Use surveyor worksheets Download accessible findings spreadsheets and read survey reports to understand vulnerabilities. 34 Survey Readiness: Balancing Joint Commission
WHERE DO I FIND CMS TOP SCORED FROM COMPLAINT SURVEYS? Association of Healthcare Journalists: http://www.hospitalinspections.org Actual 2567 reports including yours published as a large searchable Excel file, zipped: https://www.cms.gov/medicare/provider Enrollment and Certification/CertificationandComplianc/Hospitals.html Open and repair Last column extends to the right with the actual language of the 2567 finding. 35 Survey Readiness: Balancing Joint Commission WHAT DO I DO WITH THE DATA? Read every survey report from your state to determine what your states surveyors are scoring most often. Try searching and sorting by COP nationwide or refer to an IT expert for sorting 36 Survey Readiness: Balancing Joint Commission
TJC AND CMS Is one better than the other? Is one set of standards the best source of truth? What would I miss if I focused on one agency only? 37 Survey Readiness: Balancing Joint Commission CONCLUSION Act like an accreditation junkie: Study all that you can If you have staff, assign at least one to keep up with CMS changes Keep up with changes from both agencies Apply CMS narratives to implementation of your TJC standards 38 Survey Readiness: Balancing Joint Commission
39 Survey Readiness: Balancing Joint Commission Questions?