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CMS Validation Surveys: On the Rise?

Matt Phillion, April 20, 2009

Reports from the field indicate that validation surveys by state surveyors on behalf of the CMS are happening with greater frequency in 2009.

Validation surveys are unannounced surveys used to validate an organization's accreditation process. These surveys are conducted on a representative sample basis, or in response to substantial allegations of noncompliance. Unlike in the case of a for-cause survey, hospitals are selected at random for validation surveys. It could be that CMS is requesting more validation surveys to be ready to review the Joint Commission's soon-to-be-submitted applications for continued deeming authority.

Central Maine Medical Center in Lewiston, ME, faced a slightly different challenge than the average hospital—the facility is a 250-bed hospital but is interconnected with 30 outpatient practices as part of the hospital's license.

"CMS goes to all sites," says Patricia Roy, RN, director of professional quality services at Central Maine. "We had to have multiple surveyors out to every physical location we have."

The five-day survey, which took place five weeks after the close of the Joint Commission survey, involved up to 11 surveyors each day.

"The [CMS] visit was a surprise—when they came to the door I thought, 'You've got to be kidding!'" says Roy.

On the upside, however, the entire facility was still very much in survey mode.

"We still had binders we hadn't put away from the Joint Commission visit," says Roy. "As soon as they came in, we went right into response mode. They let us do an opening presentation, and we had it updated and ready."

Again, the surveyors did not arrive together as they would in a Joint Commission survey.

"They sort of staggered in on the first day rather than arriving en masse," says Roy. "The lead surveyor showed up first, then a few more, then we had the rest arrive a few hours later."

This allowed for even more prep time to get escorts ready for surveyors and prepare staff. The pharmacist surveyor arrived on day four, while the engineer surveyor arrived on day two.

"The amount of resources and people needed as opposed to a Joint Commission survey just to play host is quite a bit more," says Roy. "Managers and directors always want to be back in their departments to help them get ready, but we really had to have eight or nine people playing host."

With so many outpatient facilities, transportation was a unique problem as well.

"Just to have enough people to drive them around was tough," says Roy. "We had two fire marshals for all of the days as well who also had to go to every physical site. It was an awful lot of traveling."

To help keep things streamlined and organized, Central Maine developed in preparation for its most recent survey a command center concept.

"This worked very well for us, so we did the same for the CMS survey," says Roy.

Staff were dedicated to the command center, passing out information to survey hosts, and were the repository for information coming in from staff regarding what surveyors were looking for and which files they wanted.

"It helped us coordinate who was with who, where they were going, printing out the right schedules," says Roy. "We had a managers briefing every night after the surveyors left with notes about what they were seeing, what their concerns were, so that the managers and staff could be prepared and calm."

Roy found the focuses varied between surveys.

"Compared to the Joint Commission survey, the CMS team focused tremendously on performance improvement and quality," says Roy. "Hours and hours and hours spent discussing minutes, when did [a certain decision go] to the board, details around one chapter of the regulations."

For the Joint Commission survey, these things were discussed but not highlighted in such a key way.

"I spent three days with two surveyors talking about quality," she says. "What are you working to improve upon, what are your safety items?"

The survey team pulled out the regulations and went through it line by line.

"The Joint Commission are much more trying to get the gestalt of the standard," says Roy. "In the CMS survey, it's much more black and white—they pull out a chapter of the CMS regulations and check off yes or no."

In the end the survey was very positive, with no recommendations from the survey team.


Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals.

 

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