By Faith Knight
Today’s hospitals must comply with numerous federal and state regulations as well as standards from a variety of additional accrediting entities. A regulatory audit requires a large amount of documentation, which may take hospital employees hours and
hours to compile. Most hospitals have moved toward the use of electronic document management systems to help track all their required survey data, but for some, like Saint Thomas Health of Ascension Hospitals in Nashville, preparedness until recently
was a manual process.
“We were auditing everything on paper and using spreadsheets to manually count and monitor compliance,” said Julie M. Farmer, accreditation manager for Saint Thomas Health, Ascension Hospitals. “(It was a) very slow
process and (we) probably missed opportunities for improvement.”
Of course, the data gathered are useful only if the organization commits to using them to achieve a higher standard of care. Carrie Williams, chief press officer for the Texas
Health and Human Services Commission, offered this perspective on one regulatory tool in particular – the CMS- 2567 Statement of Deficiencies and Plans of Correction.
“The CMS 2567 indicates to hospital leadership what improvements may need
to be made within their organization. When a facility receives a Statement of Deficiencies for a particular regulatory infraction, the goal should be systemic improvement, based on an assessment of what caused the infraction and what within the organization
needs to change so that the infraction does not occur again, rather than a response that focuses only on that particular behavior or error.”
EFFICIENCY THROUGH TECHNOLOGY
Improving the quality of care is where software providers like Verge Health can help. Saint Thomas Health wanted a comprehensive process for survey preparedness, and Verge had the expertise it needed.
“Verge is great for assisting us with
staff training and improving our data collection and report writing skills, ” said Farmer.
Kenneth D. Slifer, director of product marketing for Verge Health, said the right tools can make all the difference. “Organizations should have a program that includes broad, comprehensive data collection like tracers, as well as focused
performance improvement tools to address their organization-specific trends.”
The Joint Commission’s on-site survey process includes tracer methodology to follow a patient’s care experience through an organization’s entire health care delivery process, allowing surveyors to identify performance issues within that
process. A similar system could be set up to ‘mock’ the tracer methodology before the hospital undergoes an audit.
“Mock surveys are an excellent way to prepare,” said Jill Ryan, CEO of Courtemanche & Associates, a health care consulting
firm that partners with Verge. “They validate areas of compliance and identify opportunities for improvement or potential deficiencies.”
To help hospitals meet the challenge of survey preparedness, Verge Health combines its integrated
software platform, Converge, with its Strategic Advisory Services to break down silos. The Converge platform gives hospital staff the ability to pull all policies, incidents, credentialing and compliance into one location.
A CHALLENGE-SPECIFIC APPROACH
As shown in the box below, The Joint Commission releases an annual list of the most challenging areas for hospitals post-audit. Verge Health’s suite of compliance tools can address such challenges. Consider the first issue on the list: maintaining
a safe, functional environment. If a hospital’s goal is to solicit safety incidents from physicians, employees and staff, it might provide a safety survey to each targeted group. But creating a survey that could integrate reported incidents (such
as a medication incident with a fall incident) might be difficult. Verge Health pulls both types of incidents into its Event Reporting module. The module both shows the relationship between incidents and captures feedback. “Verge has an active
user community that shares best practices. For each of these areas, we have audits, rounds or tracers that support the monitoring and management of respective areas to ensure compliance,” said Slifer. Verge Health’s other accreditation and regulatory
modules make managing specific compliance challenges easier by giving customers access to multiple agency standards with the goal of driving improvement and avoiding errors, adverse events and policy violations.
Once Saint Thomas Health
received the assistance it needed from Verge Health’s suite of compliance tools, Farmer says things greatly improved.
“As part of Ascension Health we have multiple performance improvement mandates to ensure we provide safe patient care
and meet federal and other regulatory expectations. Verge is a very important component in helping us meet those goals,” said Farmer
VERGE HEALTH OFFERS HOSPITALS:
- Custom assessment tools that collect/aggregate data and provide real-time regulatory updates.
- The ability to link evidence to support compliance and perform predictive modeling.
- The ability to support ongoing staff education by easily searching standards.
- The ability to create action plans, assign tasks, set deadlines and send reminders.