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Understanding the Core Survey Process

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Presentation on theme: "Understanding the Core Survey Process"— Presentation transcript:

1 Understanding the Core Survey Process
Glenda M. Payne, MS, RN, CNN Director of Clinical Services Nephrology Clinical Solutions

2 Objectives Describe reasons for changes & primary differences
Define key elements in a “Culture of Safety” Identify actions to decrease common citations Develop routines to stay “survey ready”

3 Changes to the Survey Process

4 Why Change? #1: Decrease the time required #2: Ensure detection of deficient practices that affect patient outcomes #3: Promote a culture of safety

5 What Are The Differences?
Core Organized by task Covers all CfC Pre survey data review Requires: Review of Administrative records if triggered Basic Organized by task Covers all CfC Pre survey data review Requires: Review of selected: Administrative records Contracts Agreements

6 What Is A Trigger? Indicates potential deficient practice
Citation or further investigation is warranted Examples: “Dummy” drip chamber Covered access Disrespectful communication Equipment not calibrated as required Absence of a functional IDT that monitors, recognizes and addresses barriers to attainment of identified outcome goals

7 What Are The Differences?
Basic Requires: Review of selected: Personnel records QAPI Clinical records Observations of care delivery and water/dialysate safety Interviews of patients, direct care staff and support staff (MD, MSW, RD, Nurse Manager) Core Priority: “Flash” observations of care Treatment area Water/Dialysate Home therapies Reuse Is there a “Culture of Safety?”

8 a culture of safety Key Elements

9 Culture of Safety: Open Communication
Transparency High comfort level with questions and answers All levels of staff included “in the know” No surprises Changes discussed before being made Reasons for decisions are clear

10 Culture of Safety: Patient Engagement
Questions from CMS Patient Interview Guide: How do the staff at this facility encourage you to give input? If you had a complaint, how would you file it here or elsewhere? How do staff encourage you to participate in care planning and consider your needs, wishes and goals? How do staff help you address barriers to meeting goals (targets)? Do staff discuss changes in your prescription before making them?

11 Culture of Safety: Engagement
Ideas for Patients Engage during rounds Detect adverse events Empower patients to speak up for safe care Include patient input Ideas for Staff Include all levels in improvement teams Reward reporting Audit teams Reward ideas to improve safety

12 Culture of Safety: Clear Expectations for Staff
Role descriptions are clear Policies and procedures are up-to-date “There is a right way, staff know that right way, and staff do their assigned work the right way.” --Glenda Harbert, ESRD Network of Texas

13 Culture of Safety: Reporting Without Fear
Reporting rewarded Errors and “good catches” Patient and staff complaints Non-punitive responses to adverse events/errors If you use shame and punishment of all errors: System vulnerabilities won’t be identified Errors will be concealed Accountability is balanced by a “just culture” Barnsteiner (2011) Teaching the culture of safety. OJIN: The Online Journal of Issues in Nursing. 16(3) Manuscript 5.

14 “Just Culture” An atmosphere of trust
People are encouraged/rewarded for reporting There is a line between acceptable/non-acceptable behavior Meadows, S. (2005)

15 Types of Errors Inadvertent or simple human error At risk behavior
Reckless behavior

16 Simple Human Error Example: a nurse or PCT forgets to turn the blood pump to the prescribed blood flow rate at the beginning of treatment Management response: Console the PCT/nurse; consider ways to simplify task, improve training Greenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in process

17 At Risk Behavior Example: a nurse or PCT, in the interest of time, leaves her first patient at a 200 BFR until she completes the initiation of all her patients. She then returns to set all the blood pumps to the prescribed blood flow rate, resulting in decreased adequacy of treatment for each patient where the ordered BFR was delayed. Management response: Coach the nurse/PCT; improve leadership messaging regarding the risks of decreased patient outcomes. Greenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in process

18 Reckless Behavior Example: a nurse or PCT comes in angry, leaves all her patients at a 200 BFR for the whole shift and does not monitor her patients’ status during the treatment, resulting in decreased adequacy for all four patients and a drop in blood pressure for one patient Management response: Zero tolerance; remedial action; review vulnerabilities in supervision Greenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in process

19 Decision Tree Were the actions intended?
Does there appear to be ill health or substance abuse? Did the individual break protocol or procedure? Have access to protocol and needed supplies? Choose to act off protocol to reduce risk? Would a comparably educated and experienced person be likely to behave the same way in similar circumstances? If not, were there deficiencies in training or supervision? Meadows, S. (2005)

20 Back to the core…

21 What Are The Differences?
Basic Guidance suggests use of data to focus survey Clinical record review Complete for part of sample QAPI review Separate review Core Requires use of data to focus survey Clinical record review Focused reviews QAPI Review Integrated throughout

22 Core Survey “Themes” Data Use Infection Control QAPI Focus the survey
Use checklists Make more observations QAPI Functional, effective program Required internal audits replace survey tasks

23 Core Survey “Threads” “Culture of Safety” Safety of Dialysis Delivery
Operation, maintenance & monitoring of dialysis technical systems: Water/dialysate Reprocessing Dialysis delivery equipment/systems Patient Voice Listening to patient’s point of view An environment where patient input is welcomed

24 Patient Engagement Review
Patient health outcomes-physical and mental functioning review: To verify that the facility QAPI Team is focused on patients’ psychosocial status by regular monitoring through the administration and use of a standardized survey that assesses the patients' physical and mental functioning. Ask: How do you track and trend eligible patients' scores in an age-appropriate standardized physical and mental functioning survey, e.g., KDQOL-36? What is your facility’s threshold for patients completing and refusing the survey annually? Note: Although it is expected that a few patients may refuse to participate in the assessment of their physical and mental functioning, high refusal rates, e.g., >20% would indicate a problem which should be recognized and addressed by the QAPI Team. Review the QAPI documentation related to patient physical and mental functioning outcomes monitoring. Does the facility’s QAPI Team track and trend the % of eligible patients who complete and refuse the physical and mental functioning survey? Does the facility’s QAPI Team track and trend the scores on a facility level? ☐Yes ☐No (V628)-Explain If the trends of facility level scores showed a decline or the refusal rate increased, is there evidence that the facility’s QAPI Team recognized a problem existed, investigated the possible causes, and took meaningful actions to address the issue(s) and attain improvements? ☐Yes ☐N/A ☐No (V628)- Explain CMS QAPI tool, page 9 of 10

25 What Are The Differences?
Basic Completion not defined May be cited for “work in progress” Core Complete when all triggers investigated Lower level citation if problem has been Recognized and Adequately addressed by QAPI

26 How Are Surveys Done? O Observe A Ask R Review

27 Observe Pay attention to practice Direct care delivery
Medication preparation and administration Water treatment Start up Testing Dialysate preparation

28 Ask Interview people doing the work Nurses Patient care technicians
Dietitians Social workers Physicians Biomedical staff

29 Ask Interview patients and families In person/by phone
Potential questions: How do staff encourage you to give input to your care here? Have you ever or do you feel you could speak up about something you felt was unsafe? Do you see staff cleaning hands and changing gloves?

30 Review Dialysis Facility Reports Clinical records
Laboratory reports: aggregate and specific Operational logs QAPI materials Personnel records Physician credential files

31 How To Prevent Negative Findings
Infection Control (7 of top10 nationally-2013) Expectations have changed CDC focus: medication administration; initiation /termination of treatment; “scrub the hub” Patient/station treated separately Self audits expected/required Educate Audit practice Repeat Celebrate success!

32 How To Prevent Negative Findings
Physical Environment (# 3 nationally--2013) Access visible: patient engagement critical Environmental rounds: Make them REAL Take action promptly Equipment: Functional system to stay current with PM Audit record keeping system Report in QAPI

33 Staying survey “ready”

34 Ensuring a Successful State Agency Survey
March 2007 Readiness Tip #1 Know what's happening in the Back Room Glenda M. Payne, RN, MS, CNN Centers for Medicare & Medicaid Services

35 Ensuring a Successful State Agency Survey
March 2007 Readiness Tip #2 Observe Care Glenda M. Payne, RN, MS, CNN Centers for Medicare & Medicaid Services

36 Ensuring a Successful State Agency Survey
March 2007 Readiness Tip #3 PCP not about paper Glenda M. Payne, RN, MS, CNN Centers for Medicare & Medicaid Services

37 Ensuring a Successful State Agency Survey
March 2007 Readiness Tip #4 Put QAPI to Work For You Glenda M. Payne, RN, MS, CNN Centers for Medicare & Medicaid Services

38 Questions?

39 Thanks for the Work you do!

40 Selected References Barnsteiner (2011) Teaching the culture of safety. OJIN: The Online Journal of Issues in Nursing. 16(3) Manuscript 5. doi: /ojin.Vol16No03Man05 Greenspan, B. (2015) Core Curriculum for Nephrology Nursing, 6th Edition, in process Gregory, B. & Kaprielian,V. (2005). Anatomy of an error. Retrieved March 1, 2014 from Institute of Medicine (1999) To Err is Human. available at

41 Selected References Levinson, D. (2012). Hospital incident reporting systems do not capture most patient harm. Report from the Office of Inspector General. Retrieved March 1, 2014 from https://oig.hhs.gov/oei/reports/oei pdf Meadows, S., Baker, K., & Butler, J. (2005). The incident decision tree: guidelines for action following patient safety incidents. In Henricksen, K., Battles, J., Marks, E. et al. (Eds). Advances in patient safety; from research to implementation: Vol 4 Programs, tools, and products. Rockville (MD): Agency for Healthcare Research and Quality Last retrieved from

42 Selected References Reason, J. (1997). Managing the risks of organizational accidents. Aldershot: Ashgate Taylor, J. (2010). Safety culture: Assessing and changing the behavior of organizations. Surrey, England: Gower Publishing Limited


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