Before he was involved in department leadership, Shivi Sharma, MBBCh, associate director of the hospitalist service at Yale New Haven Health and assistant clinical professor of medicine at the Yale School of Medicine, both in New Haven, Conn., noticed something curious at the hospital one day.
His signs were missing.
He had posted signs about protocols around his department, meant to be convenient references for the hospital staff.
Dr. Sharma
“The signs I put up got taken down,” Dr. Sharma said. “I said, ‘Where did that sign go?’”
He was told that they hadn’t met the specifications for posting things on the walls—for fire safety and other reasons, they have to be laminated, and tape can’t be used—so they had been removed.
This was a revelation, he said. He learned about the specifications for posting signs not through any formal training, nor through a procedural handbook, and not even because someone happened to mention it to him at any point. But only because he had put up signs, and the next thing he knew, they were gone.
A “Black Box” for Frontline Clinicians
This experience, Dr. Sharma said, is a microcosm of the way in which hospitalists, along with many other members of the hospital staff, often experience accreditation surveys—typically performed by The Joint Commission, the organization that accredits and certifies most healthcare facilities in the U.S. The surveys assess everything from the handling of chemicals to infection prevention, to processes for ensuring accurate patient identification, and to, yes, signs on the walls.
The surveys, required to be performed every three years and highly anticipated at healthcare facilities as the window for the unannounced inspection looms, are a high-stakes affair, often prompting health systems to hire costly consultants to help shepherd them through the byzantine array of hospital standards, which span nearly 400 pages of a Joint Commission manual.
Even though the surveys are a vital part of running a hospital—they involve a weeklong visit by inspectors and are required for Centers for Medicare and Medicaid Services (CMS) reimbursement—hospital medicine physicians say their involvement in preparing for them is not central, and that the role that they play is on an as-needed basis, often when findings during the survey require corrective action.
Those more intimately involved with the surveys say it is always the goal of hospital administration and hospital medicine leadership to continually boost the involvement of providers, in order to make sure the hospital is as well-run as possible and that as much preparation as possible is done to get ready for the surveys.
Still, a common refrain is that the preparation for the surveys is mostly conducted at a higher level, with people such as chief medical officers acting as the point person between those doing the big-picture preparation for the surveys and those actually performing the work on the hospital floors.
Dr. Sharma, while acknowledging the importance of the surveys, said that preparing hospitalists and their practitioner colleagues for them can be difficult.
“Before I got into leadership, this was kind of like a black box” that makes engagement more difficult, he said.
Now, as associate director, he more fully understands the need for compliance—and that involves boosting awareness and buy-in from hospitalists, he said.
“Part of the onus is on middle managers to let people know what is important now,” he said. “That is a challenge—how do you direct people’s attention?”
Recently, the hospital went through its re-certification process and did well, he said.
“What really worked was the strong engagement from our senior physicians and team leaders,” Dr. Sharma said. “We even received a call-out from the evaluating team about the physician engagement. So I guess with enough guidance and time, there is hope.”
Bridging Standards and Daily Practice
Ms. Nasaysayan
Elvira Nasaysayan, chief regulatory officer in the department of regulatory affairs at Jackson Health System in Miami, said the surveys involve preparation that spans months, mostly involving communication between her department and the chief medical officer (CMO) at individual hospitals.
Hospitalists are not woven into these preparations as intimately as she might prefer, she said.
“There is a gap, I believe, when it comes to participation with preparation,” she said. “Most of the time, the CMOs are invited, but then the physicians are more on the receiving end of instructions, rather than participatory.” She said there is often some limited interaction between hospitalists and local facility leadership, but “it may not be enough for them to actually be familiar with everything as far as preparation for the survey is concerned.”
For example, when there are fire drills to prepare for the surveys, she said, she often hears that there was not much hospitalist participation.
Typically, the most involvement comes on the tail end when the hospital receives its survey results, she said.
“What they know,” Ms. Nasaysayan said, “is that when there is an audit of their documentation, they get notified by the CMO or by a medical director that, ‘Hey, you missed this or missed that.’”
She would welcome a more active role from hospital medicine physicians as facilities and health systems prepare for surveys, she said. But she said she understands that the rigor of a typical workday often precludes it.
“There’s more to you that is very important for us when we want a successful accreditation survey,” she said, referring to hospitalists. “Because the survey is not about looking good. The survey is about reviewing every process that ultimately provides quality of care and patient safety at the end of the day. That’s really the purpose of the survey.”
That said, all hospital personnel, including hospitalists and other providers, are notified with a blast email that a survey is underway, and findings are sent promptly to those who are affected, Ms. Nasaysayan said. She said that physicians always have avenues, whether at survey time or not, to recommend changes to procedures and workflow, and these suggestions are taken into consideration.
In the end, she said, not being intimately involved in survey preparation might be somewhat unavoidable, part of the nature of how a hospital functions.
“Our providers normally have very limited time, hence the challenge of really engaging them, although we long for that engagement,” she said. “I’m not saying that they’re not participating. I think that there is enough participation. But if you had to ask me, I would love for them to be in the forefront.”
Keeping Hospitalists Survey-Ready
Dr. Morris
Victor Morris, MD, chief medical officer at Bridgeport Hospital in Bridgeport, Conn., part of Yale New Haven Health, said that while most hospitalists are not formally involved in the survey preparation plans, they are involved regularly through consistent reminders about protocols—from where coffee mugs are allowed to prohibitions on copy-forwarding of chart notes.
“They’re key to the performance,” he said. “What we try to do is make sure all those areas of risk that they do every day, that we make sure that they do it appropriately.” Having worked as a hospitalist, he said he understands how the daily pressures of patient care can make it a challenge to dot every i and cross every t, but that participating in weekly hospitalist team meetings and visits to the floor helps ingrain safety protocols into daily habits.
“I try to let the doctors know that what is in what the Joint Commission looks at, and what the CMS conditions of participation (require), they’re really about patient safety and patient care,” he said. “If you do read them, it all makes sense.”
The goal, he said, is that “we’re always ready for the Joint Commission to walk in.” He said the latest survey at the hospital included no findings involving hospitalists, reflecting that the process works well, he said.
As a point person between the hospitalist teams and non-medical hospital administration, he relays requirements and concerns that stem from senior executive meetings, but sees himself as a buffer, needing to be sensitive to the daily demands of patient care.
“I’ll try to do it in a way that understands what they’re going through,” Dr. Morris said.
When there are findings on Joint Commission surveys or other inspections, he said, he goes to hospitalists to find out how to make corrections.
“Any time you want good solutions, you go to the frontline people, so we go to the hospitalists,” he said. “‘What are the best ways to make sure this doesn’t happen again?’ That’s where the answers are. They’re working out there every day, and they understand what the problems are.”
The surveys, in the end, play an important role in patient safety and good health outcomes, he said.
“We all want to say we do the best, we have the patient’s best interest,” he said, “but I do think these surveys play a role in making sure that we do the things that we’re supposed to do.”
The View From the Bedside
Ms. Bowden
Kasey Bowden, FNP, NP, MSN, RN, a nurse practitioner in the hospital medicine department at the University of Colorado School of Medicine in Aurora, Colo., said her role is fairly limited when it comes to preparing for Joint Commission surveys, with one or two leadership meetings ahead of time in which timing and expectations regarding the surveys are outlined.
“Typically, if there are specific areas of concern, there is more widespread messaging before an accreditation takes place,” Ms. Bowden said. “Often this is around more ‘environmental’ factors—i.e., making sure things aren’t plugged into power strips, removing food or water bottles, et cetera.”
Sometimes, reminders are given about particular clinical practices, such as hand hygiene, using two patient identifiers or consent processes, along with coaching around how to communicate in the event that a provider is asked questions about hospital or system processes, she said.
During surveys, she said nurses and nursing leadership seem more stressed. She said she feels like “there is an exhaustive level of reminders to remove water bottles from workstations,” she said, adding that she is “only partially joking.”
Many people give frequent reminders that the inspectors will be coming and give frequent intermittent coaching. Still, she said, she finds that she herself does not get particularly anxious.
“As a hospitalist advanced practice provider, I don’t feel too stressed because I feel like our clinical, communication, quality, [and] safety processes are aligned with what the accrediting bodies are evaluating,” she said.
What Surveys See—and What They Miss
The surveys can highlight environmental constraints on making the hospital safe for patients while also making it a comfortable and feasible place for providers and staff to work.
“I understand limitations on things like water bottles, purses, clutter and power strips, but once a survey is done, the day-to-day impact of all these elements really falls on the bedside providers,” Ms. Bowden said.
She said “high-level” feedback is given on things that went well during a survey, but specifics are not typically given on issues that are cited. But if something goes very poorly, changes are implemented quickly, she said.
“Accreditation processes don’t address things like hospitalist census and staffing ratios, so it hasn’t resulted in any direct changes in how we staff,” Ms. Bowden said. “Over the years, I think system-level changes have taken place around things such as how lines, tubes, [and] drains are documented, processes to escalate concerns, and there have been significant changes in our [operating room] staffing and sterile processing [and] infection control procedures.”
She said while many specifics addressed by the Joint Commission standards can seem “trivial,” they are nonetheless important.
“A lack of set expectations could allow patient care areas to become increasingly cluttered and/or unsafe,” she said. “I appreciate the insight into infection control and escalation of care measures—and the fact that these become second nature over the course of many years is a testament to the utility of these surveys.”
On the other hand, she said, surveys don’t cover all areas that affect patient quality and safety.
“I do not think surveys account for all areas that impact patient quality and safety. As such, it is possible there are big factors impacting hospitalist workforce and/or patient care, which have the potential to become minimized or go unrecognized, because they are not mandated or highlighted on an accreditation survey.”
As time goes on, surveys might end up addressing areas of concern that have been brought up previously but did not prompt changes, “only to have changes take place once mandated by a regulatory or accreditation agency,” she said.
“This does highlight the utility and benefit of these processes,” Ms. Bowden said, “but in an ideal state, healthcare systems leaders are listening to and implementing suggestions of clinical staff in real time.”
Tom Collins is a medical writer based in South Florida.