Hospitals have faced a considerable number of challenges during the pandemic, from managing shrinking margins to adapting to “surge standards of care.” Responding to regulatory and accrediting agency activities has not been one of these concerns, but as surveying activities resume, quality and safety scrutiny will be higher than ever in the days and months ahead. While hospitals cannot afford the cost of fending off severe regulatory findings, they also cannot afford to waste precious resources addressing minor, often inconsequential, issues. It is now more important than ever for hospital leaders to play offense and, not only ready themselves for survey activity, but also identify and solve the issues that truly impact safety.
As surveying resumes, hospital leaders need to understand the root causes of persistent vulnerabilities and take deliberate steps to mitigate risks once and for all, providing their organizations and patients with a true sense of safety. A practical approach to survey readiness — focused on efficient processes and high-impact, sustainable improvements — can help build a culture of compliance and ensure your organization is on the path to high-reliability care.
Preparing Your Organization for Heightened Scrutiny
As the COVID-19 pandemic initially took hold of the nation, survey agencies shifted from enforcement to a supportive approach. Accreditation surveyors were taken out of the field; state survey agencies were busy approving new testing sites; complaint investigations and follow-up surveys were conducted virtually or deferred; and waivers were plentiful. Survey agencies have now begun to slowly re-engage with hospitals and other healthcare organizations. While agencies will continue to support expansion of care delivery, their primary responsibility will be to ensure healthcare organizations are ready for potential future waves of novel infections and strictly complying with safety and clinical quality standards.
Organizations must prepare themselves for what’s to come — heightened agency scrutiny, expanded areas of focus and reduced tolerance for non-compliance with regulations and standards. As policies, minutes and data are more thoroughly reviewed through the new off-site, virtual pre-survey document review, there will be more significant findings related to burdensome policy expectations and lack of effective follow-through. Avoiding adverse actions will require identification and remediation of high-focus vulnerabilities and Joint Commission “hot spots:”
