All Healthcare organizations receiving Medicare and Medicaid reimbursements must receive onsite surveys at least every three years from the Centers for Medicare and Medicaid Services (CMS) or a deeming agency such as Joint Commission, DNV, and others. CMS requires this practice to ensure all Conditions of Participation (CoPs) are met, which are designed to ensure safe, quality patient care is provided and to maintain eligibility to bill for Medicare and Medicaid services.
Healthcare organizations vary in their approaches to maintaining a “survey-ready” position. Unfortunately, many organizations do not formalize their approach, nor are they proactive in determining where they may be deficient before receiving their survey. A proactive approach can help identify many issues that the organization can address to mitigate risk and ensure regulatory compliance. This approach is known as the Proactive Plan of Correction (PPoC).
If you have experienced the stress associated with participating in a survey and the extensive follow-up to develop the mandated Plan of Correction, you most definitely realize the enormous investment of time and human capital expended to correct the compliance issues identified by the surveyors. In contrast, if your team identifies and proactively addresses potential problem areas through a survey readiness evaluation and a PPoC, your organization can reduce repeat citations, prevent loss of reimbursement, and save a significant amount of money. Correcting issues proactively is significantly less expensive than doing so under a corrective action mandate after a failed survey or event. Hospitals we have previously worked with have estimated the cost of reactively correcting deficiencies under regulatory duress, as $50,000–$250,000, depending on scope.
A mandated Plan of Correction (POC) involves multidisciplinary team coordination. The team typically requires clinical leadership, quality/risk managers, compliance officers, and frontline staff. The time investment may range from 40–200 staff hours, depending on the scope and number of deficiencies. Each deficiency must be analyzed for underlying issues through Root Cause Analyses and/or other methodologies depending on complexity.
Once the deficiencies are analyzed and the determination is made as to what needs to be done to correct the issues associated with the deficiency, interventions are then created and tasks assigned. Actions for improvement may include, process changes, policy/procedure developments or updates, staff education or re-education, workflow redesign, documentation change, standard work development, and ongoing monitoring and auditing.
Ensuring the sustainment of the improvements made must be an integral part of the mandatory POC. This may include monitoring specific metrics, auditing scores, reviewing compliance logs, and regularly reporting through weekly/monthly dashboards.
These changes may also be incorporated into orientation and annual competency reviews.
As described above, the mandatory POC is a very intense and time-consuming process. The most efficient and effective method for avoiding this costly investment is to undergo an internal or external survey readiness evaluation and PPoC.
Additional benefits to undergoing a readiness evaluation and PPoC are that teams tend to show improved survey performance (fewer findings, more prepared staff). The training during PPoC implementation leads to reduced survey-related downtime, improved documentation compliance, and increased provider and staff engagement, thereby leading to better patient outcomes.
PPoCs often identify and address core quality issues, such as reducing:
- Medical errors
- Infection rates
- Patient complaints and grievances
- Incidents and sentinel events
- Staff turnover
Today, more than ever, many rural hospitals are challenged to provide excellent quality care while lacking resources to commit to a post-survey mandated POC. Given the potential investment in time and cost to implement a mandated POC is extensive as noted above, organizations may save 20-50% of that cost through better planning and resource allocation by proactively implementing a readiness evaluation and a PPoC.
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