CMS Survey PreparationHospitals that are accredited by the Joint Commission (TJC) know the value of continued survey readiness. However, when it comes to preparing for a Centers for Medicare and Medicaid Services (CMS) survey, many hospitals utilize the same approach as they would for TJC survey. 

This is a mistake.

Although TJC standards are reflective of the CMS Conditions of Participation (CoPs), and TJC offers a cross-walk to match TJC standards with the CMS CoPs, they do not match word for word. In many instances, TJC cites a single standard as correlating to multiple CoPs or several TJC standards as corresponding to a single CoP. A closer examination reveals many details in the CoPs that are not evident in a TJC standard or element of performance (EP).

Hospitals assessing compliance only by reviewing TJC standards and not the CoPs can result in multiple deficiencies being cited during an on-site CMS survey.

Just as the survey processes are different, an organization’s preparation process should also reflect these differences.

TJC Survey Process

TJC surveyors are much more interactive, using hospital staff’s responses to questions to guide further queries. Documentation is examined but within the context of elements of performance (EP) validation. The response of clinical staff and physicians can keep TJC surveyors from dwelling too deeply in patient records. Policies/procedures, medical staff bylaws, and other documents are reviewed against the actual practice. Additionally, surveyors utilize tracer methodology to identify areas of noncompliance.

CMS Survey Process

CMS surveys are typically conducted by the surveyors from the state department of community health and focus much more closely on patient care documentation and the corresponding policies and procedures that drive care implementation. Surveyors are much less interactive with staff and physicians. Surveyors look at patient records for the absence of compliance with relevant CoPs and will turn to staff to ask why something was not documented or why a process deviated from stated policy. Typically, they spend less time on the patient care units than TJC surveyors do.

CMS Survey Preparation

CMS survey preparation needs to focus on the integrity and comprehensiveness of patient records. As more hospitals move toward an electronic health record format, this can be a challenge. The freestyle charting notes that are typical of paper systems are sometimes quite restricted in electronic formats, thus making evidence of CoP compliance less obvious to surveyors.

Additionally, differences in the computer documentation systems sometimes make it difficult to find information, as something may be charted in multiple places. This is when surveyors will ask staff questions using a more intensive and less gentle approach than that of TJC. Preparation must include a careful briefing of staff to the type and style of questions that may be asked. Old-fashioned chart audits for documentation weaknesses also will support better preparation. Finally, ensure that patient and hospital care policies and procedures are followed and are up-to-date with the current CoPs and any recent changes.

CMS and TJC surveys are aimed at a common purpose: assuring safe, effective care; but the assessment processes unfold quite differently and require different approaches to solid preparation.

If your organization needs help with CMS survey preparation, call our office at (800) 241.0142 or send us an email.

Image credit: Digital Vision / Thinkstock

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