Corrective Action Planning, Monitoring and Tracking ...

Corrective Action Planning, Monitoring and Tracking / Sustaining

Accreditation Professional Orientation Certificate Program

Vizient: your accreditation partner

A key element of an organization focused on patient safety and performance excellence is continuous accreditation compliance. The previous webinars for the Accreditation Professional Orientation Program provided you with a foundation of knowledge.

Today, you’ll learn about the fundamentals for developing and monitoring corrective action plans following survey.

Accreditation Professional Orientation Program / Confidential2

Faculty

Twila Loudder, MS, BSN, RN, CPHQAdvisor, Accreditation [email protected]


DisclosureTwila Loudder has no relevant financial or nonfinancial relationships to disclose.

mailto:[email protected]

Objectives


Explain the differences between CMS post-survey report response and voluntary accreditation survey reports.

Recognize the required elements for submitting clarifications (TJC only) and corrective action plans

Identify and discuss the process for reviewing post-survey report and prioritizing findings, potential clarifications (TJC only) and corrective action plans.

Polling questions


1. What is your comfort level in writing ESCs? A. Very comfortable B. Somewhat comfortable C. Not very comfortableD. Have never written

2. What is your comfort level in writing a 2567 response? A. Very comfortable B. Somewhat comfortable C. Not very comfortableD. Have never written

3. How many days do you have to respond to a CMS statement of deficiencies (2567)? A. 10 business days B. 10 calendar days C. 45 days

4. When must all corrective actions be completed? A. Within 60 daysB. Within 45 daysC. 120 days

Post survey process


Post-survey process

CMS: • Exit conference (optional)• Broad review / no specifics• Final report follows (time frame

varies)• Plan of Correction (POC) to be

submitted 10 calendar days from receipt of final report or 5 days for an Immediate Jeopardy (IJ)

TJC:• Exit conference with a

Preliminary Report• Final report within 10 days• Evidence of Standards

Compliance submitted within 60 days


Post-survey process - immediately after survey


EstablishAccountabilityExecutive sponsor – responsible leaderIntegrate evaluation/monitoring of corrective action plan into overall Quality Assessment and Performance Improvement (QAPI) process

DevelopTimelineGantt Calendar

Prioritize Compare deficiencies to survey notes from guide and scribesLevel of impact on patients, staff, operationsResource intensity – easy to correct versus complex actions and resources

MeetMeet with the teamReview concerns addressed during survey. Begin process for identifying POCAnalyze the preliminary report

Center for Medicare and Medicaid Services (CMS) statement of deficiencies and plan of correction


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CMS plan of correction (PoC)An acceptable plan of correction must contain the following:• The plan for correcting the specific deficiency and the processes that

lead to the deficiency cited • The procedure/process for implementing the acceptable plan of

correction for the specific deficiency cited • The title of the person responsible for implementing the acceptable

plan of correction• The monitoring procedure to ensure that the plan of correction is

effective and that specific deficiency cited remains corrected and or in compliance with the regulatory requirements; – How this plan will be monitored to ensure implementation of plan of

correction resulted in sustained improvement– Where or how will monitoring be reported and evaluated (through

organizational QAPI)

Accreditation Professional Orientation Program / Confidential

CMS PoC


Identify the position of the staff person who will

be responsible for implementation and

monitoring

Identify changes that will be made. Policy will be updated, staff will be

educated, and/or process changes

Indicate date completed or to be completed which must be appropriate to

the level of the deficiency(ies).

Collect evidence of completion

Develop plan to audit sustainability after the

complete date

CMS PoC

Note - Although federal regulations allow a maximum of 60 days from date of exit for correction of deficiencies, that is to be considered an outside limit

The original, with the facility’s proposed corrective action, must be returned to the appropriate surveying agency (State Agency or Regional Office) within 10 days of receipt. Please maintain a copy for your records.


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CMS Survey: 2567 statement of deficiencies, plan of correction

Survey Type:• Complaint

Survey• Validation

Survey• Focused

Survey

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms2567.pdfAccreditation Professional Orientation Program / Confidential

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CMS 2567 instructions


CMS deficiencies are public• The CMS Form 2567 and the plan of care are documents released to

the public so providers must omit any Protected Health Information (PHI) or Privacy Act Information.

• Survey & Certification Memo June 16, 2017: 17-34-ALL New Guidance for the Formatting of the Plans of Correction

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-34.pdf

• CMS Hospital, Critical Access Hospital and Transplant Program deficiency reports are available via CMS website (as of March 2020)https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals


https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-34.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals

The Joint Commission (TJC) Requirements for Improvement, Clarifications, Evidence of Standards Compliance


TJC survey report• Lead surveyor will provide a preliminary onsite report upon exit• Final report posted to TJC Connect extranet within 10 days of

exit• Report includes:

– Executive Summary– What’s Next – Follow-up Activity– Program specific (i.e. Hospital) SAFER™ Matrix– CMS Summary– Requirements for Improvement (RFI)– Appendix CMS Conditions of Participation (CoP) text Standards/Elements of Performance (EP) language Report Section Descriptions Clarification Instruction


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SAFER™ MatrixSurvey Analysis for Evaluating Risk™ (SAFER™) Matrix


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SAFER™ MatrixSAFER™ Matrix - Placement of RFI on SAFER™ Matrix and Follow-Up Activity


Non-compliance observed and corrected (OCO) on site


Deficient observations can be and should be if possible, corrected at the time of the survey

Surveyors will verify correction and compliance during survey

The deficient observation will remain on the final survey report

A correction is still required to be documented in the evidence of standards compliance (ESC) report

When to ask for OCO documentation in the final report?

TJC immediately post survey


Compare preliminary survey findings with your notes, your own internal monitoring data

Determine if an opportunity to clarify exists

Access and review TJC extranet resources

• ESC navigation instructions• Overview of navigation instructions contains important content

requirements for all key dates and “sustainability” of corrective action• Clarification instructions• ESC instructions

TJC clarifications


Why and when should you submit a clarification for an observation of non-compliance?

• To demonstrate compliance with standards scored as “not-compliant” when the organization believes they were compliant at the time of the survey

• 10 business days to submit one or more clarifications (ESC due dates remain the same)

Authenticate (e-sign) the clarification

Do not submit supplemental documentation with clarification

Do not wait for acceptance of clarifications to prepare for a TJC follow up survey

NOTE: 10 business days plus time for Standards Interpretation Group (SIG) review can run dangerously close to repeat visit timeframe

Clarifications – acceptable and unacceptable


Acceptable reasons for clarifications (still may not be accepted)

Organization believes it had adequate evidence available to the surveyor(s) and was in compliance

at the time of the survey

Organization has detailed evidence that was not immediately available

at the time of the survey.

Unacceptable reasons for clarifications

Required Documents are not eligible for clarification (checklist on

extranet)Clerical Errors

Audits are no longer an option for clarifications

Clarification: component requirements

• Who – approved existing policy, process?• What – does the policy state or what was the process during the

survey, what did the surveyor take issue with that really is compliant?• When – was the policy approved, updated and staff trained?• How – do policies get disseminated?• Why – did the surveyor not see this or was this information provided?

Do not provide any supporting documents in place at time of survey until requested to do so.

Clarifications must demonstrate:Evidence was present

• Policy, plan or practice was in place or in compliance

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Clarification• Not broken at the time of survey - there is nothing we need to fix• Not the same as “we fixed it quickly, we fixed it before the survey

was over”• Repeat findings (sequential triennial surveys) are considered when

reviewing the final accreditation decision, so clarifying observations may have a positive impact on future surveys

ESC• We agree; it was broken and we have fixed it

TJC Clarification versus ESC


Evidence of Standards Compliance (ESC) requirements


• Assigning accountability

• Correcting the non-compliance

• Ensuring sustained compliance

ESC Compliance

Form is divided in to 3 sections:

ESC requirements


Assign accountability

Add title of this person, “one individual with ultimate responsibility” similar language to the CMS 2567

Not a team, not a partnership, not a joint or shared responsibility

Will require additional leadership involvement if indicated based on the SAFER matrix

If required, you will describe how the leadership will help support compliance in the future

ESC requirementsCorrecting the non-compliance • A preventive analysis with leadership involvement will be required if

indicated based on the SAFER matrix• What actions were taken for each finding and when?

– What did you do to fix the problem? Created a policy, developed, revised or refined a process Trained staff on the new policy, process along with return

demonstration• Description must illustrate the finding was fully corrected• Corrective actions must be completed prior to date of submission, and

may be multiple dates, but the final date of all completed corrective actions must be entered. Cannot be a future date.

• Note-Do not copy and paste entire policies, bylaws, or other documents in this field.


ESC requirementsEnsuring sustained compliance

• What procedures or activities have been identified to monitor compliance to the element of performance?

• What is the frequency of monitoring activities?

• What data will be collected from the activities?

• To whom, and how often, will this data be reported?


Preventive analysis• Why is it important?

• What is a preventive analysis?

• When does it have to be completed?

• How does it get completed?• Use tools to get to the root cause

– 5 Why’s– Fishbone diagram

• Others to consider– Root cause analysis (RCA)– Failure mode effects analysis (FMEA)– Pareto charts– Process mapping


Medicare deficiency survey

• Condition level deficiencies must be corrected in 45 days

• If you have a Medicare Deficiency survey for condition level issues of non-compliance the resurvey will likely occur before you submit your ESC.

• Any condition level should be resolved as soon as possible with supporting evidence in preparation for the follow up (f/u) survey

• IMPORTANT to fix things thoughtfully and quickly

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Quality monitoring plan


Begin with a 4-month audit period for TJC; CMS should be 4-6 months, IJ consider a longer period – 6 months

Design a measurement strategy you know is going to work

Start test measurement before you are required to ensure success

Official measurement does not start until ESC is accepted by TJC

Watch the results closely throughout the process:

If the outcome isn’t reaching goal or even close, examine whether the corrective action plan is sufficient or begin having daily audits instead of weekly or monthly till you reach goal

If not, consider new strategy and escalate to leadership

Resources on Joint Commission Connect


ESC guidelines and instructions

Program specific examples of successful ESC responses

Perspective and Joint Commission Online articles about change

An ESC and SAFER Matrix infographic

A preventative analysis resource guide

Updated ESC frequently asked questions (FAQs)

Continuous accreditation compliance summary


Summary: corrective action process

Corrections: should be thoughtful with the ability to sustain the improvement

Common cause / root cause analysis including the investigation of the “Why” behind the issue so that action taken can help to prevent reoccurrence


Leadership Accountability

Operational Standards

Resource Management

OutcomesPatient/Staff Satisfaction

Analysis / Action /

Evaluation / Improvement

Questions?


Next steps

1. Complete evaluation

2. Stay connected –• Network Members - register for Fundamental and Advanced

webinar series and encourage operational partners to listen in to pertinent webinars

• Attend Vizient conferences to stay up to date with trends and requirements

• Connect with the colleagues during the course• Connect with your Vizient faculty


Be proactive

Keep your sights on the patient

Improve patient safety

No surprises

Thoughtful process change

38 Accreditation Professional Orientation Program / Confidential

This information is proprietary and highly confidential. Any unauthorized dissemination, distribution or copying is strictly prohibited. Any violation of this prohibition may be subject to penalties and recourse under the law. Copyright 2016 Vizient, Inc. All rights reserved.

Contact: Diana Scott, Associate VP, Accreditation Advisory Services, [email protected] Webb, Accreditation Director, [email protected]




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