Healthcare technology management (HTM) teams should prepare before surveyors like Centers for Medicare & Medicaid Services, the Joint Commission, and DNV visit their hospital. It’s a topic Rich Sable, CBET, product manager at computerized maintenance management system (CMMS) provider EQ2, LLC, recently covered in a session at AAMI 2023 alongside the Los Angeles County Department of Health Services, as well as in a whitepaper.
In this 24×7 exclusive, Sable shares tried-and-true strategies for survey preparedness and how to use CMMS technologies to manage regulations and improve survey outcomes.
24×7: To start, Which organizations typically survey a hospital?
Rich Sable: The Centers for Medicare and Medicaid Services (CMS) approved several organizations for evaluating healthcare facilities for accreditation by CMS. The State Survey Agencies perform the Medicare certification process and inspect hospitals to ensure compliance with the terms of the CoPs, or Conditions of Participation. Additionally, hospitals may elect to obtain accreditation from a private, CMS-approved accrediting organization such as The Joint Commission, DNV GL Healthcare, Healthcare Facilities Accreditation Program (HFAP), or Center for Improvement in Healthcare Quality (CIHQ), in lieu of seeking certification from the State Survey Agencies.
The CMS uses State Survey Agencies to act on behalf of CMS to perform the Medicare certification process, and the CMS uses the State Survey Agencies to perform validation inspections on some hospitals that were previously surveyed by an accrediting organization.
24×7: What benefits does a hospital receive when it maintains accreditation as the result of a survey?
Sable: The primary focus of the survey is to protect patients and staff, so one benefit is knowing that the organization provides a safe and secure environment with safe medical equipment. Other benefits include national recognition, including by insurance companies and other third parties; demonstrating your commitment to excellence in quality, accountability, and patient safety; providing a competitive advantage; improving risk management and risk reduction; providing standardization and consistency for processes across the organization; possibly reducing liability insurance costs; and assuring the organization is current with the healthcare regulations, which may improve customer satisfaction ratings. Additional benefits are that consumers may look for it when choosing hospital services, and many practitioners look for it when choosing an employer.
24×7: What are the different ways that hospital HTM teams can prepare for a future survey?
Sable: The best way to prepare for a survey is to always be prepared for a survey because it provides peace of mind, and you can’t go back in time to correct deficiencies. It’s a good idea to obtain the survey preparation guide for your surveying agency so you fully understand the necessary information being reviewed during the survey.
For some organizations, you may have a regulatory compliance officer on staff that receives regular updates from your surveying agency, and the compliance officer may hold staff meetings to review updates to each hospital team: HTM, facilities, nursing, etc. Another method is to attend survey preparation meetings at various annual conferences or local HTM meetings, especially if the presenter is from an accrediting organization.
It’s beneficial to conduct annual department policy reviews and to regularly update your medical equipment management plan. Also, ensure that your staff is familiar with the whereabouts of the department policies. This knowledge is crucial as it equips the staff to efficiently locate information that may be required when responding to questions from surveyors. Other ways are to conduct mock surveys—in-house or contracted— pop quizzes during your staff meetings, or department sweeps (scheduled checks).
24×7: How can the HTM team’s CMMS help them to prepare for a future survey?
Sable: The CMMS provides an easy way to review preventive maintenance work orders, especially if it contains dashboards that provide live data updates as work is being completed. HTM managers can review work orders to make sure they are coded properly, especially the “device-in-use” and “unable-to-locate” work orders, since CMS/JC/DNV provide compliance on these work order types if the preventive maintenance was attempted in the month due.
HTM managers can document their staff meetings as work orders in the CMMS for quick retrieval and can create scheduled work orders to review and update their policies and procedures. The CMMS enables HTM managers to monitor work-order completion through dashboards and generate regulatory compliance reports for the environment of care committee and surveyor use.
Similarly, the equipment types (device types) should be categorized as high-risk and non-high-risk based on the criteria identified in your medical equipment management plan. Also, equipment types that are going to be eligible for an alternative equipment maintenance/management) program should be identified based on your department policies.
With these assets categorized, the HTM manager can quickly provide reports on high-risk equipment or equipment that is on your AEM program or a combination of the two. In fact, EQ2’s HEMS One provides a one-click report to retrieve devices on AEM or original equipment manufacturer-recommended maintenance, and these reports can be given to surveyors on-demand or saved in your medical equipment management plan for future reference.
24×7: How important is data standardization for day-to-day survey readiness?
Sable: Standardizing data is crucial for effectively managing regulatory compliance and an AEM program within your CMMS. Specifically, the device types must be standardized to ensure that the PM procedures, risk scores, and device recalls are successfully accomplished. For example, if two similar device types are named differently in the CMMS, you may miss one group or the other during comparison for equipment replacement or when moving device types onto an AEM program.
Furthermore, your CMMS may contain specialized reports or dashboards that rely on certain data fields to stratify your equipment inventory into the correct category. In HEMS One, the system field is used to identify devices that are prohibited by CMS/JC/DNV to be placed onto your AEM program, and this is identified visually in the AEM dashboard.
Also, your PM procedures may be applied differently if the data is not standardized which can impact your regulatory compliance for these device types. Finally, the HEMS One “Best Practice” module prevents users from editing this information after being approved by the HTM Manager, which ensures that data standardization is maintained on all approved devices.