Accreditation

Greeley Reflections

Accreditation Connection, August 24, 2009

Maintain survey readiness: A primer

Part 2

MedPAR data, an acronym for Medicare Provider Analysis and Review, is collected by CMS and includes over 800 data elements from short-stay and inpatient hospital stays. Your S3 score contains the most current three years of MedPAR data available from CMS regarding indicators for complications, mortality, and average length of stay. The report sorts the data by the colored traffic lights; by clicking on the alert, a three-year trended bar chart can be seen.

Analysis of these three reports should be initiated to determine why the red lights exist. For example, if length of stay is exceeding the goal and resulting in a red light, ask the case management department to assist in analysis.

Conduct patient tracers to evaluate compliance with the organization’s policies and procedures. These forms are supplied on the accompanying CD-ROM so you can customize them to your policy requirements. Coordinate this activity by establishing a schedule of patient care units and performing tracers at a volume that seems appropriate for your organization. These documents should be dynamic; delete items as continuous compliance is attained and add new items as standards changes occur or noncompliance is identified from another source.

Use staff from other departments to conduct tracers. Not only does this provide a new set of eyes, but it also increases the appreciation of the complexity of the patient care delivery system in patient care areas. Consider having a team of two different disciplines: a nurse (from an area other than the one being traced) and a pharmacist. Don’t forget to include your administrative staff. Nothing is more powerful than having the CEO review an H&P dictated two days after admission instead of within the required 24 hours.

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