In 2004, the survey process was substantially modified to be more data-driven and patient-centered enhance thus enhancing its value, relevance and credibility. The survey process now has a greater focus on evaluating actual care processes because patients are traced through the care, treatment and/or services they receive. In addition, surveyors conduct “systems tracers” to analyze key operational systems that directly impact the quality and safety of patient care. Key components in the process include:
- Priority Focus Process: Enhances consistency and specificity by compiling and using pre-survey information to focus the on-site survey.
- Periodic Performance Review (PPR): An organization must perform a mid-cycle assessment of its standards compliance, known as a PPR. Organizations then submit Plan(s) of Action (POAs) and/or assessment of measures of success (MOS) emanating from the PPR.
- Tracer methodology: This methodology traces a number of patients, residents or clients through the organization’s care process. These tracers are used to assess both an organization’s compliance with selected standards and the organization’s systems of providing care and services.
- Physician engagement: Better engagement of physicians in the accreditation process.
- Elimination of unnecessary review: Documentation review and performance improvement “storyboard” sessions have been eliminated.
Survey agenda
- Opening conference.
- Leadership interview.
- Validation of organization’s implementation and monitoring of the Plan(s) of Action emanating from the PPR.
- Visits to care and service areas guided by the Priority Focus Process using the tracer methodology.
- Environment of care review.
- Human resources review.
- Credentials review.
- System tracers, that is, specific time slots devoted to in-depth discussion and education regarding the use of data in performance improvement (as in core measure performance and the analysis of staffing), medication management, infection control, and/or other current topics of interest to the organization.
- Closing conference.
Benefits of the survey process
- More time for the surveyors to concentrate on the issues most important to each organization surveyed.
- Survey process customized to the organization’s settings, services, patient population and demographics.
- More focus given to the delivery of care (guided by the Priority Focus Process and tracer methodology).
- Fewer formal interviews.
- Reduced paperwork and burden of preparing documentation for survey.
10/06