Hospital Regulatory Survey Command Center Training Sarah Yelton, RN, CPHQ, HACP, LSSGB SLH Quality Resources Updated 2/20/18
Purpose of a Command Center To assemble a small, coordinated, supportive team working behind the scenes to help make the survey go smoother.
The Command Center Typical Tasks: Prepare and gather data, reports, documents, & policies. Take the desired items to the surveyors after cleared by the team to do so. Communicate with the senior leaders and others via phone, email, etc. Meet the needs of the surveyors. (e.g., meals, water/coffee, folders with their names on them, etc.) Arrange for scribes, runners, and surveyor escorts. Keep track of issues, observations, and where the surveyors are going next. Determine if the surveyor is stating opinions or regulations.
Where is the Command Center? The Command Center should be a conference room with a table to accommodate several people. Needed in the room: Conference phone (know the phone number/extension) Electrical outlets for laptops Printer (or access to one nearby)
Command Center Team Team Lead Director of Quality & Patient Safety Others: Regulatory Compliance Quality Analyst Risk Management Attorney Senior Leaders and physicians will visit the command center off and on as they are available
Chain of Command for Survey Team Leader Dir. Of Quality Quality Analyst/Regulatory Escorts Electronic health record expert Scribes Policies & Procedure Expert
Flip Chart Pages It is helpful to put up big self-adhesive flip chart pages on the wall. For example: 1. Citations noted in AM briefings 2. Surveyor Issues (e.g., hand hygiene) to relay to the clinical nurse managers throughout the hospital. The scribes will share this information with the command center. 3. Requested items (e.g., reports, policies, documents, 1:1 conversations, etc.) 4. Questions (e.g., Ask (name) about xyz. ) 5. Small group meeting information (time, location, attendees, info, etc.) Be sure the markers used won t mar the wall!
Provisions Needed Private conference room (usually in the executive office) The Survey document Black Box or Binders Laptops (several) Communication info./phone numbers of key personnel Phone/conference phone Power supply cords (several) Access to the regulations Office supplies (pens, paper, highlighters, flip chart pages, folders, markers, stapler, binder clips, etc.) Access to printer (you will be printing a lot!) Small chocolate candies (helps calm folks and keeps energy up)
Attitude & Atmosphere The command center will be very busy. Stress and anxiety run high during regulatory compliance surveys. People react differently. Keep a cool head. Be kind. Be helpful. Try to staff only calm natured people in the command center. Try to relax and go with the flow survey days will be long ones. Some things are within your control and some are beyond your control. Eat meals, keep hydrated, and take short breaks.
Chocolate Helps Quality dark chocolate is rich in Fiber, Iron, Magnesium, Copper, Manganese and a few other minerals. Enjoy a stress-busting chocolate fix!
Tips Wear comfortable shoes. For women, be sure your jacket has pockets. Have an ipad available if possible. Have your cell phone with you. Keep the command center phone number with you. Bring the rolling survey suitcase that is full of info and provisions. Laminate the survey contact list makes it easy to find in a stack of papers.
Action Photo s! Put up the flip chart sheets These are suggested. You can customize. Kudos: Keep track of the nice things the surveyor says about the hospital and your staff! So encouraging! Possible Issues: The topics that may turn into citations. Or hot topics. Cell phone numbers: Helpful to have! These are in addition to your regular phone list.
Flip Charts Continued Staff: Ask the scribe to keep track of full names of people the surveyor talks with. These are usually the very ones that are asked for during the HR credentialing and competency session. Requested Documents: Keep a list of the policies/documents/proof that surveyors ask for. Also note who is obtaining the info. Patients: Keep track of patient names during tracers. (Grab a sticker.) This will help narrow down units during corrective action writing.
Flip Chart Markers Be positive that your markers won t bleed through the paper and onto the wall!
Action Photo s! The Command Center helpers! There are several laptops where people can search for policies, documents, regulations, etc. Also a telephone is on the table to contact units or individuals. Note the surveyors bios and photos on the table.
Phone a Friend Hello 6 East, they are coming your way next. They are focusing on crash cart logs be sure you only have one month on the clipboard. The surveyor asked about PI projects on 5 North. Be sure to show individualized care plans & education. The surveyor has been talking with new grads and float nurses.
Action Photo s! Snacks help! Snacks & water there are for anyone who needs a quick burst of energy. Scribes and tour guides need to keep hydrated and fortified. Office Supplies: There are many small items in the blue pencil box in the photo.
Action Photo s! Keep Calm and Carry On! There are clipboards ready for the scribes on the table. Scribes like the four color ink pens too. That way they can emphasize important things.
My Survey Bag Laptop bag on wheels. Most of the contents are pre-packed. Organized and easy to grab and go! Update contents annually Hard plastic pencil case with assorted small office supplies, post-it notes, and a presentation clicker with pointer. Assorted colors of flip chart markers Laminated list of hospital units/department contacts and phone numbers (on bright pink paper) Laminated list of key personnel cell phone numbers Laminated color copy of the TJC Safer Matrix Laptop, mouse, power cord Cell phone, ipad, ear buds, charging cord Comfort items: Advil, Kleenex, lip balm, hand lotion Steno-pad of paper May need a hospital approved power tap for extra plugs
Expected Surveys Pre-pack a small cart to roll into the Command Center: Flip chart pages Document binders Rolling survey bag with laptop etc. Scribe clipboards, paper, & pens Bowl of Snacks/bottles of water Master laminated copy and several additional copies of agenda, scribe/tour assignments
Unexpected Surveys Recover from the shock! Get the surveyors settled in their home room Notify the senior leaders and others that surveyors are inhouse Print a hospital census and OP/Procedure schedule Grab the rolling cart with your laptop inside & flip chart sheets Get your document binder Set up the command center Secure meeting rooms as needed
Daily Survey Updates A survey leader sends a recap email each evening to the senior leaders, directors, and managers. Communication, Communication, Communication!
Who, What, When, & Where? The 2 sided cheat sheet! Make several copies Keep a master version in a clear sheet protector
Keep Track Yearly It is amazing how quickly we forget! When preparing reports, hospital leaders often ask: When was that survey? You will always know!
Thank you!