Make the most of CMS' surveyor IC worksheets

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. 

Fixing gaps

For isolated gaps, 1:1 guidance was provided to the sites as necessary. As for systemwide gaps, we approached these as a team. We had an in-person meeting with the IPs from each site, the corporate director of infection prevention, and myself; it was an excellent meeting. The IPs are very bright and are passionate about their role and responsibilities. As we discussed each systemwide gap, we reviewed regulations (e.g., CMS, state, Joint Commission, OSHA), standards (e.g., Association of periOperative Registered Nurses, Association for the Advancement of Medical Instrumentation [AAMI]), policies and procedures, processes, and so forth. At the end, we identified what we needed to do to achieve compliance, improve patient safety, and enhance overall survey readiness.

An example would be our work on air balance/pressure (negative or positive). We found that there were a lot of gaps in this area: inconsistencies, lack of clarification and documentation, and confusion over who had monitoring responsibilities. Therefore, we decided to develop a standardized policy and procedure (P&P) on air balance/pressure in critical areas, such as the operating room, sterile processing department, and sterile storage.

 The P&P proved effective. Since implementation, air balance/pressure in critical areas are monitored at least daily by facilities and documented. And should the balance be reversed, the P&P lists guidance on who to advise and what to do.

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