Accreditation

Make the most of CMS' surveyor IC worksheets

Briefings on Accreditation and Quality, June 1, 2017

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Editor’s note: The following is an article written by Maria Del Pilar Messner, corporate director of accreditation, regulations, and licensing at Adventist Health.

On May 18, 2012, CMS initiated the Patient Safety Initiative which included surveyor worksheets for assessing compliance with three hospital Conditions of Participation (CoP): Quality Assessment and Performance Improvement, Infection Control, and Discharge Planning.
The goal of these was to reduce hospital-acquired conditions, including healthcare infections and preventable readmissions.

What a gift this was! If CMS was sharing the surveyor worksheets, why not use them? It was a great insight to what the surveyors would be evaluating.

As an organization, we [at Adventist] decided to use the worksheets as a self-assessment tool, and developed an exercise for them. Below describes the exercise we developed for the CMS Infection Control worksheet.

The IC program

We had each of our applicable hospitals and clinics complete the worksheets, with the infection preventionist (IP) at each site as the lead. Once the worksheets were completed, the results were reviewed by the IP, the facilities director, environment services director, OR director, sterile processing director/manager, accreditation/regulatory/quality directors, and others. Plans of correction were then developed for each identified gap. Afterward, the results of the self-assessment and the plan of corrections were brought to leadership; who would then provide their recommendations.

The worksheets were entered into a software program.  This program allowed for the sites to enter the self-assessment results into the worksheets. At the corporate level, we could run reports for each individual site and of all the sites combined. From the reports, we would capture isolated gaps and systemwide gaps.

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