Success With a Mock Survey Team

Our commitment to improve state survey results provided a bonus: It allowed for development of an interdisciplinary approach leading to an opportunity for training, learning, and advising among the staff of all four buildings. Moreover, our best practices for direct care delivery, recruitment and retention of employees, and marketing have been identified and used throughout the region.

The collaboration of the MST with our organization’s Recruitment and Retention Teams (task forces focused on employee recruitment and retention), our POWER (Positive Outcomes With Essential Relationships) Teams (focused on marketing), and our Quality and Resident Safety Committee task forces (focused on quality measures) ensured a truly interdisciplinary and interregional approach to creating a “quality comes first” environment. The interdisciplinary team members include representatives of Nursing, Social Work, Dietary, Rehabilitation, Medical Records, Plant Operations, and Marketing. All teams and task forces are appointed by the executive directors of each building.

With the increased pressure on the industry to provide quality care despite decreased funding, it is a challenge to ensure that both quality and budgetary standards are met. The proactive nature of the MST allows for the interdisciplinary/interregional team to identify potential areas for improvement in a constructive environment. This ensures that a wide variety of employees will become familiar with the process and initiatives, thereby creating a greater understanding among all disciplines of the survey process, how it impacts quality care, and how it can affect revenue, as well.

• Enhanced Set of Quality Measures, Quality Measures Resource Manual, Nursing Home Quality Initiative (NHQI ), January 2004.
• Quality for a Lifetime: 12 Steps to a Successful Quality Assurance Program, Nancy C. Day, AAHSA, 2001.
• Survey Troubleshooter: Proven Strategies for Mastering the Top 25 Nursing Home Deficiencies, Thomas Lohuis, Marblehead, Mass.: Opus Communications, 2002.

  When the MST was formulated, its goals were to:

• Create an interdisciplinary team that educates itself on the state survey process and allows for rotation of several members from each facility.
• Complete mock surveys for all four buildings within their state survey windows to review dietary delivery, healthcare delivery, plant operations, social work services, medical records, and specialized treatments.
• Conduct a thorough, unannounced survey including initial walkthrough.
• Identify best practices or problem solutions to help minimize potential survey risk.
• Collaborate with the Recruitment and Retention Teams, POWER Teams, and Quality and Resident Safety Committee to identify all areas that might affect state survey results.

At the end of each mock survey, an exit interview (simulating that of the state survey process) was to be conducted. This interview allows the MST to present results to all disciplines within the facility at once. A report of the results is also made available to the executive director, director of nursing, medical director, and president of Senior Health and Housing Services. The results are discussed and problem-solved at facility-specific meetings and, as appropriate, at the Recruitment and Retention Team, POWER Team, and Quality and Resident Safety Committee meetings.

The baseline comparison of results we started out with can be seen in the table. The 2003 state survey process resulted in no financial penalties being assessed. This in turn resulted in the organization’s increased marketability, which is reflected in our current above-average census and quality measure performance for each building.

An example of the MST in action shows how the process works. At the request of a DON, the team reviewed closely a particular resident’s chart. The resident had presented as both a fall risk and a skin risk, with many comorbidities needing complex medical management. Although the facility was moving in the right direction with its care, the chart did not accurately reveal all care plans, interventions, and communications with the physician. A DON on the MST recommended two steps: (1) an audit of the chart to identify the actual care provided, its chronology, what was missing from the documentation, and the content needed for a remedial in-servicing; and (2) the development of a quality assurance program encompassing, at a minimum, the review of 25% of all resident charts, again with a focus on missing documentation and in-service needs. The facility responded and at its later state survey received no deficiencies for care planning.

At the time of this writing, Mercy Franciscan Terrace had completed its mock survey and subsequent state survey for 2004 and achieved a deficiency-free survey.

The MST, as well as the other teams mentioned, will continue with the task set forth in 2003 and will continue to set new and more aggressive goals. The focus on finding the best opportunities to educate staff across the board continues to yield positive results and drives the purpose of this team.