Safeguarding Your Operation Through Successful Accreditation Surveys

1. Safeguarding Your Operation Through Successful Accreditation Surveys Prepared for GAMES Spring 2014 Attendees By Mary Nicholas, MHA President / CEO HQAA, Inc.

2. Planning & Preparation

3. Planning & Preparation • Failure is not a desired outcome with accreditation • No one proceeds with accreditation with the goal of failure • What then are some of the pitfalls you run in to preventing your planning and preparing?

4. Planning & Preparation • Day to day responsibilities often take priority over maintaining accreditation compliance

5. Planning & Preparation Why important? Our data indicates that in the past 8 months for renewal surveys: An average of 58% of all surveys had repeated deficiencies Lowest percentage in a month = 40% Highest percentage in a month = 77%

6. Planning & Preparation Where to begin?

7. Execution • Let’s look at the areas with the highest frequencies of cited deficiencies: • Human Resources area claims three of the top 5 cited deficiency areas: • Lack of demonstrated compliance to maintaining a Competency Program = # 1 • Maintaining Personnel Files = # 2 • Maintaining Annual Educational Programs = #3

8. Execution Employee Competency • Create a process – assign responsibility • Start at the time of hire: observe person completing tasks they were hired to perform • Annually ensure the same checklist is evaluated; update it as tasks & skill levels change • Create opportunities for staff to observe each other; provide feedback and discussion • Ensure opportunities for learning are included in annual education calendar

9. Execution Personnel Files • Use the standard(s) as your guide for what is required • Ensure someone is responsible for upkeep • Maintain all files in consistent manner • Place a checklist in each file and note when components required are filed, updated, added • Ensure secure storage

10. Execution Annual Education Program • Again, use the standard as your guide (mandatory vs. non) • Designate someone to schedule, manage and implement • If using a 3rd Party Education Program, assign specific courses to each employee; track progress • Ask employees what types of courses interest them • Bring experts in for all staff meetings • Use sign in sheets for validation

11. Execution The next two highest cited deficiencies are: Infection Control = 34% of surveys Quality Management = 34% of surveys

12. Execution Infection Control • Thoroughly review expectations of the standard • Maintaining a Clean, Safe & Organized Work Environment is where we’ve found the deficiencies • Know what your policy states you comply with • Educate all on safety issues with the chemicals they encounter • Separation of clean & dirty items • Involve several employees in maintaining items • Complete a checklist daily/weekly/monthly – turn in

13. Execution Quality Monitoring • The general concept of having, implementing, maintaining a QI program is inconsistent • Generally placing one person in charge to manage helps to keep it running • Break down requirements based upon standard • Define how each performance measurement is managed • Integrate actions across staff positions; include EVERYONE • Create a structure to keep on task

16. For QI Quarterly Reports: • Bring all P*D*S*A projects to meetings or offer written reports to central person • Speak to the progress being made • How was the planning done? • What happened when implemented? Improve? No improvement? • When analyzing, was it apparent what went wrong? What went right? • In implementing, has the process improved to your satisfaction?

17. For QI Quarterly Reports: • Use a specific format to the meetings / for the meeting minutes • Bring issues relating to processes • Talk through what goes on before and what goes on after each process: Input – Throughput – Output • Report progress and recommendations if less than expected • Document * Document * Document • Who was at meeting • ID the date / time • Outline discussion items and action items • File the “minutes” in same place always

18. Discussion What areas are you experiencing the most difficulty? What ideas can you share to help others? Resource Handout – FREE access to aids to help organize

19. Thank you very much! Mary Nicholas, MHA President / CEO Healthcare Quality Association on Accreditation 866.690.9851