MOVE FORWARD RENEW YOUR SURVEY READINESS STRATEGIES€¦ · 7/4/13& FLOYD,&DONNA&1& MOVE FORWARD:...

7/4/13&

FLOYD,&DONNA&1&

MOVE FORWARD: RENEW YOUR SURVEY READINESS

STRATEGIES

©2013&The&Crag&Business&Group,&Inc.&&

&Presented&for:&Home&Care&AssociaKon&of&Florida&2013&Annual&Conference&M&FORWARD&


SURVEY READINESS

7/4/13&

FLOYD,&DONNA&2&

Tradi&onal*


•  “The&accreditaKon&expires&in&six&months&–&get&me&the&audits/policies/forms&for&the&accreditaKon&evidence&report.”&

•  “We&have&to&have&all&the&charts&right&from&today&forward”&&

•  Everyone&will&be&at&mandatory&meeKngs&•  Chart&audits&will&be&done&weekly&•  “You&were&told&in&orientaKon&what&was&expected”&&&&&&&&&&&&&&&&&&&&2&years&ago&

RENEWED


•  Begin*1*year*to*6*months*before*the*renewal*informa&on*has*to*go*out*OR*before*the*6*month*to*survey*mark*

•  Be*sure*of*orienta&on**

•  Develop*opera&onal*awareness*

•  Really*include*your*team*

7/4/13&

FLOYD,&DONNA&3&

SURVEY READINESS – THE SURVEY


Why*Surveys*MaCer*

•  Public&InformaKon&

•  IdenKfy&leadership’s&scope&of&work&•  PenalKes&


7/4/13&

FLOYD,&DONNA&4&

Survey*and*Enforcement*Requirements*for*Home*Health*Agencies&Earlier&this&year,&a&CMS&representaKve&stated&in&a&meeKng&with&HCAF&members&M&that&CMS&surveys&will&place&an&emphasis&on&conKnued&–&rather&than&cyclical&–&compliance.&Surveyors&will&determine&whether&policies&are&established&to&correct&deficient&pracKces&and&if&the&correcKon&is&lasKng.&AddiKonally,&surveyors&must&determine&if&home&health&agencies’&deficiencies&are&addressed&promptly,&and&whether&or&not&the&HHA&in&quesKon&takes&the&iniKaKve&and&responsibility&for&monitoring&performance&to&sustain&compliance.&

Why*Surveys*MaCer*


*Triggers*for*Significant*Deficiencies*

•  Ineffectual&complaint&response&&

•  Response&to&onMcall&issues&that&is&either&not&visible&or&not&effecKve&

•  RepeKKve&errors&in&any&area&•  A&wide&variance&between&what&is&in&the&policy&and&in&the&records&


7/4/13&

FLOYD,&DONNA&5&

The&Cost&of&Surveys&.&.&.&&


.*.*.*is*going*UP*Home*Health*Survey*Sanc&ons&The&speaker&also&reported&on&the&status&of&implementaKon&of&alternaKve&sancKons.&CMS&plan&to&impose&sancKons&beginning&July&1,&2013,&with&the&excepKon&of&civil&money&penalKes&and&payment&suspension.&Monetary&penalKes&will&be&imposed&beginning&July&1,&2014.&SancKons,&which&can&remain&in&place&for&up&to&six&months,&include:&488.835&–&Temporary&management&488.840&–&Suspension&of&payment&for&all&new&admissions&488.845&–&Civil&money&penalKes&488.850&–&Directed&plan&of&correcKon&488.855&–&Directed&inMservice&training&499.860&–&ConKnuaKon&of&payments&to&an&HHA&with&deficiencies&488.865&–&TerminaKon&of&provider&agreement&as&the&final&acKon&should&a&provider&fail&to&come&into&compliance.&

OPERATIONAL AWARENESS – KEYS


7/4/13&

FLOYD,&DONNA&6&

Opera&onal*Awareness*

SomeKmes&known&as&the&30,000&foot&view&

•  Able&to&track&mulKple&moving&targets&

•  Real&Kme&knowledge&of&status&and&efficacy&of&organizaKonal&key&funcKons&

•  Dynamic&vision&of&organizaKonal&operaKons&in#line#with#regulaKons,&rules&and&standards&


Dynamic*interrela&onships*of*Malcolm*Baldrige*Na&onal*Quality*Award*criteria*•  ©2013&The&Crag&Business&Group,&Inc.&&

7/4/13&

FLOYD,&DONNA&7&

CMS&top&ten&survey&deficiencies&

•  G158&–&Wrigen&Plan&of&Care&established&&&periodically&reviewed&•  G337&–&Assessment&includes&review&of&all&medicaKons&•  G159&–&Plan&of&Care&covers&diagnosis,&required&services,&visits,&etc.&•  G236&–&Record&with&past/current&findings&maintained&for&all&paKents&•  G121&–&Compliance&with&accepted&professional&standards/principles&•  G170&–&Skilled&Nursing&Services&furnished&in&accordance&with&Plan&of&

Care&•  G143&–&CoordinaKon&of&PaKent&Services&•  G229&–&Supervisory&visits,&if&skilled&care&,&no&less&than&once&every&2&

weeks&•  G176&–&RN&prepares&notes,&coordinates,&informs&MD,&other&staff&of&

changes&•  G165&–&Drugs&and&treatment&administered&only&as&ordered&by&

physician&


The*Governing*Body/Administrator*and*Deficiencies*

•  All&deficiencies&can&be&connected&back&to&the&Governing&Body&or&Administrator&

OIG&report&on&May&15th&to&CMS&stated&that&0M50%&of&agencies&surveyed&receive&a&condiKon&level&deficiency&

AND&because&of&the&variaKons&M&OIG&recommended&increased&CMS&validaKon&surveys&


7/4/13&

FLOYD,&DONNA&8&

Operational Awareness–

Knowledge of Self

•  ©2013&The&Crag&Business&Group,&Inc.&&

Knowledge*of*Self*

•  Who&knows&you&best?&&

•  What&are&your&key&team&members&willing&to&say&about&your&leadership&&

– &Biggest&Strengths&– &OpportuniKes&to&Improve&

– *Something&everyone&should&see&

– *Staff&vision&of&your&leadership&•  What&holds&you&back?&&


7/4/13&

FLOYD,&DONNA&9&

Knowledge*of*Self*

•  What*you*don’t*know*or*won’t*recognize*impacts*EVERYTHING*

– HR*– Clinical*Effec&veness*– Opera&onal*Efficiency*– Customer*Service*

The*Agency’s*Existence*©2013&The&Crag&Business&Group,&Inc.&&

Knowledge*of*Self*

•  Making&a&oneMKme&self&assessment&is&not&sufficient&

•  Set&metrics&for&yourself&

•  Get&feedback&


7/4/13&

FLOYD,&DONNA&10&

Knowledge&of&Self&

•  Consider&personality&style&assessments&

•  Commit&to&coaching&

•  ConKnually&monitor&&

Confidence&is&contagious&


Operational Awareness –

Dynamic Awareness of Resource


7/4/13&

FLOYD,&DONNA&11&

Knowledge*is*Based*on*Factual*Real[Time*Data*

•  Where&do&you&get&data&from&and&how&olen&

•  Dashboards&

•  What&do&you&do&with&this&insight?&&– Test&validity&– Give&feedback&–  IdenKfy&Trends&


Knowledge*of*Staff*

•  More&than&the&staKsKcs&

•  What&is&the&staff&awareness&/&perspecKve&on&the&agency&and&it’s&mission?&&

•  What&skill&sets&exist&&–  in&your&managers?&– &in&your&field&staff?&


7/4/13&

FLOYD,&DONNA&12&

Knowledge&of&Staff&

•  Define*skills*that*will*benefit*each*project*

•  Really*involve*those*staff,*and*give*them*&me*to*be*effec&ve*

•  Keep*in*touch*with*staff*during*any*new*implementa&on*–*whether*new*to*agency*or*individuals*


Team*Based*Philosophy*

In&studies&in&both&the&US&and&UK&it&has&been&shown:&&•  Only&the&people&that&work&in&the&area&know&all&the&details&for&the&processes&to&be&changed&&

•  Empowering&people&to&change&their&own&job,&generates&much&beger&coMoperaKon&than&forcing&change&upon&them&&

•  By&being&part&of&the&team,&even&on&a&partMKme&basis,&staff&really&understand&and&trust&the&change&project&and&the&leadership’s&commitment&

•  Trust&enhances&communicaKons&with&the&wider&organizaKon&


7/4/13&

FLOYD,&DONNA&13&


•  IdenKfy&the&issue&the&team&is&called&to&work&on&then&consider&.&.&.&&

– Who&has&experience/experKse&in&key&points&

– Who&trains&on&what&

– Who&monitors&what&

Team Based Survey Prep


Team Based Survey Prep   All team members are trained

together on the project

  The team should have comfort with the tools. This may mean re-design.

  The team should be cross-trained and may be assigned to work across disciplines.

  The members complete individual reports AND work on a comprehensive report developing a sense of organizational areas for improvement

7/4/13&

FLOYD,&DONNA&14&

Knowledge*of*Training*

•  More&than&the&offerings&

•  What&is&said&in&orientaKon&

•  Training&simply&to&meet&a&numerical&target&is&a&waste&of&resources&

•  Measure&efficacy&


Knowledge*of*Produc&vity*

•  ProducKvity&is&NOT&a&bad&word&

•  Allows&strategic&planning&and&implementaKon&of&the&correcKve&acKons&idenKfied&

•  Impacts&HR,&Customer&Service,&Clinical&EffecKveness&and&OperaKonal&Efficiency&


7/4/13&

FLOYD,&DONNA&15&

Operational Awareness – Willingness to be

Proactive


READINESS&IS&KEY&FEDERAL&REGISTER&&11M&M2012&CY&2013&

F.&Unannounced&Surveys&(§&488.725)&SecKon&1891(c)(1)&of&the&Act&requires&that&standard&surveys&be&unannounced.&&

Moreover,&CMS&policy&(State&OperaKons&Manual&(SOM)&secKon&2700A)&requires&that&all&HHA&surveys&be&unannounced;&this&policy&is&set&out&at&proposed&§&488.725,&which&also#provides#that#surveys#be#conducted#with#procedures#and#scheduling#that#renders#the#onsite#surveys#as#unpredictable#in#their#5ming#as#possible.#In#addi5on,#sec5on#1891(c)(1)#of#the#Act#requires#CMS#to#review#state#scheduling#and#survey#procedures#to#ensure#that#the#agency#has#taken#all#reasonable#steps#to#avoid#giving#advance#no5ce#to#HHAs#of#impending#surveys#through#these#procedures.##

Typesesng&changes&added&for&emphasis&


7/4/13&

FLOYD,&DONNA&16&

When*to*implement*.*.*.**

•  Be&ready&for&a&survey&everyday&– Assume&1M2&years&of&work&for&success&&

– IF&you&don’t&have&1M2&years&start&NOW&


OPERATIONAL AWARENESS & YOUR ORGANIZATION’S OVERALL

PERFORMANCE


7/4/13&

FLOYD,&DONNA&17&

Operational Awareness

It’s is not just for surveys ©2013&The&Crag&Business&Group,&Inc.&&

ApplicaKon&to&ResignaKon&

Staff&Magers&


7/4/13&

FLOYD,&DONNA&18&

Impacts&surveys,&Kmely&&&accurate&billing&

Medical&Records&


You&have&to&be&involved&

Customer&Service&


7/4/13&

FLOYD,&DONNA&19&

• Progressive&thinking&is&opKonal,&but&changes&are&coming&

1&

• Move&forward&–&become&an&example&of&success&• Mastery&is&not&achieved&overnight&

2&

• The&cost&of&integraKng&changes&is&less&than&the&alternaKves&

3&

QUESTIONS?*

7/4/13&

FLOYD,&DONNA&20&

Resources&

•  HCAF&–&Membership&magers&www.homecarefla.org&&&&

•  The&Crag&Business&Group&www.CragConsulKng.org&&

&&&&888M428M2724,&ext&707&

&&&Donna&Floyd,&RN,&BSN&&&

MOVE FORWARD RENEW YOUR SURVEY READINESS STRATEGIES€¦ · 7/4/13& FLOYD,&DONNA&1& MOVE FORWARD:...

Documents

Transcript of MOVE FORWARD RENEW YOUR SURVEY READINESS STRATEGIES€¦ · 7/4/13& FLOYD,&DONNA&1& MOVE FORWARD:...