SURVEY PREPARATION TECHNIQUES

 

One of the more misunderstood and neglected survey preparation tools is the Quality Assurance/Quality Improvement Process. 

Many of the facilities that I have visited see this process as only a formality carried out to satisfy State and Federal regulation requirements.  I believe that this a factor as to why so many of our colleagues fail.  They don’t take this critical process seriously, and then are shocked and angry as to why the survey inspection was abysmal.  And in some cases, career ending.

     Quality Assurance must be a combination of standard, year to year reviews, such as Resident Room Water Temperature checks, Resident Food Temperature checks, or Medication Room drug date status, as a few examples.  These types of reviews must be on-going.  However, in regard to other areas, they must be flexible and focused. 

The question is how do we identify them?  

     Over the past few years, I’ve come up with a system that I thought was unique and brilliant. 

Brilliant, until I was studying the Federal F-Tags manual and noticed that this idea and suggestion is already listed there.  Oh, well, so much for my originality.  In essence, it’s a system that consists of four elements:  

1. The already mentioned “standard” item checks aspect.

2. A review of the past three years of survey inspections results.

3. A review of the most recent Casper Report.

4. A review of the most recent Quality Measures report from your individual Star Program.

     What I do with element 2,3, and 4 is to make a chart with three columns, one for past survey results, one for Casper Report Data, and a third for Quality Measures Data.

For the survey column, I list each deficiency listed by topic vertically, oldest to most recent.

Then for the Casper Report, listing the same way, selecting any topic area scoring 75 percentile or higher. 

Finally, I do the same process for any items on the Quality Measures Report for items flagging in that system.  

     After the chart is created, I review the results.  Any issues flagged in more than one of my columns now become targets. 

For example, if the facility received a deficiency on pressure sores in last year’s survey, and pressure sores also flagged in either of the Casper or Quality Measures Reports, I know that I have a possible problem. 

So what do you think will be one of my top priorities in the up-coming QA Committee meeting?  You guessed it- Pressure Sores.  On the other hand, if Catheter care is listed on at least one of the reports, but not cited multiply, I’ll review it, but not as a priority.