by Natalie Webb
BS, RN, CPHQ, Accreditation Manager


A recent blog by Vizient’s Jodi Eisenberg shared insights about maintaining perspective on accreditation surveys in order to keep staff focused on delivering care to patients. The post included several recommendations, two of which I would like to dig into more deeply: using sources of truth and conducting mock surveys.

When it comes to a source of truth, the Centers for Medicare & Medicaid Services’ (CMS) Conditions of Participation (CoPs) are the foundational source of truth for all health care organizations, regardless of the voluntary accrediting organization that grants their accreditation. The Medicare reimbursement your organization receives is dependent upon your compliance with the CMS CoPs. It is essential that you understand and ensure that organizational policy and processes are in place to support compliance.  

Conducting regular mock surveys can help validate compliance and help to reduce staff anxiety. These mock surveys build organizational confidence and reinforce existing processes as well as identify gaps or other areas of weakness for mitigation and improvement opportunities. Basing the survey on the most current CMS CoPs will help ensure your organization is maintaining compliance with current standards as well as meeting requirements in new regulations.

Medication-specific Focus Areas 
According to CMS, some of the most common medical errors in hospitals today – which also result in accreditation issues – are related to storage, securing and handling of medications. As an experienced accreditation professional, I can confirm that numerous organizations struggle with certain medication-specific requirements and offer the following observations and suggestions. 

  • Compounding. Regardless if it is done in-house or by a contracted service, compounding must be monitored to ensure accuracy and safety. The latest CMS pharmaceutical services CoPs highlight the following measures for both in-house and contracted services to ensure compliance: 

           - Accurate labeling
           - Timeliness in providing compounded agents
           - Clarifications of unclear orders
           - Review of report of biological testing of compounding facility

  • Storage and access. Review your hospital’s policy and process for ensuring appropriate access to medications. Organizational policy should define who has access to medications. The pharmacy team should be conducting a regular review of the medication delivery and receiving process. Engage pharmacists in your mock survey by tracing the medication delivery process from pharmacy to unit to administration of medication. Additionally, review the receiving process by engaging supply chain staff. How are medications delivered from suppliers to the organization and ultimately to the pharmacy? Organizational procedures for medication storage should be in alignment with manufacturer’s guidelines for storage; for example, storage at appropriate temperature. The elements that are included in your policy and procedure can be used as a mock survey tool. Your mock survey can combine a review of the environment with observation of practice and process. Engage all staff involved in delivering medications and maintaining the environment.  
  • Preventing adverse events with medications. Ensure a process is in place with those involved in the medication management process for identifying and reporting possible adverse events related to medication administration (typically anticoagulant therapy, antibiotics and high-risk medications including IV opioids). As outlined in the CoPs, these include monitoring the effects of medication(s) to assure appropriateness of therapy and minimizing the occurrence of adverse events. While CMS does not dictate how adverse events are captured and reported, the Office of Inspector General (OIG) recommends the use of the Agency for Healthcare Research and Quality (AHRQ) Common Formats. The Common Formats define a systematic process for reporting adverse events, near misses and unsafe conditions. The use of AHRQ Common Formats is voluntary, but a hospital that uses them and is analyzing the data collected will definitely be in a better position to meet the CMS Quality Assurance and Performance Improvement (QAPI) CoPs.
  • Pharmacy staff qualifications. Within the revised interpretive guidelines there is a requirement that the pharmacy director’s qualifications must now be approved by the medical staff, similar to the requirements within the radiology and nuclear medicine CoPs relative to staff in those areas. Take your pharmacy director job description – which outlines the qualifications – to the medical executive committee and document the approval in the minutes as well as on the job description. CMS will also be updating guidance for the nursing service competency requirements concerning medication administration to clarify that hospitals must ensure staff adherence to accepted standards of practice in those limited instances when compounded sterile preparations may be prepared outside of the pharmacy.

Staying on top of the many regulatory changes that may impact accreditation status can be daunting. Regular mock surveys provide an opportunity to identify potential issues in key areas like pharmacy, allowing time for staff to move forward strategies to ensure compliance in advance of the target accreditation survey date.

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About the author. Natalie uses her more than 30 years of health care experience to provide educational, accreditation and operational improvement services to Vizient member hospitals. In addition to an extensive clinical background, she has a keen understanding of regulatory compliance, quality initiatives and patient safety.

Published: April 29, 2016