Compass Clinical Consulting was retained by an outpatient surgery center due to risk of closure by the state and the subsequent notification to the Centers for Medicare and Medicaid Services (CMS). A sentinel event had occurred when a fire caused harm to a patient and was not disclosed to the state or CMS. The state and fire marshal learned about this event months later and came to survey the organization. The organization was required to submit a Plan of Correction (POC) to fix major Condition-level and state deficiencies. If the situation was not remedied by the given deadline, the surgery center faced closure by CMS.

To exacerbate the organization’s state of distress, the surgery center’s Administrator, whose initial POC was rejected, had resigned, leaving the organization without the leadership needed to guide it through successful compliance response and recovery.

Compass was contacted to assist with response and recovery efforts, immediately deploying several compliance support services to the surgery center:

  • An accreditation and compliance expert to develop a new POC that would be submitted and accepted by the state within three days.
  • A team of clinical consultants and surveyors to review compliance with the POC, perform a CMS mock survey, and provide coaching and recommendations toward compliance with the deficiencies cited by CMS and the state.
  • An Interim Administrator to provide operational leadership and additional compliance support, including guiding the organization through correction of deficiencies; actively engaging with staff and medical teams to successfully pass the accreditation and state survey; and identifying and recommending clinical improvements of policies, procedures and
Addressing Deficiencies and Constructing a Plan of Correction

With deadlines looming, the Compass Director of Accreditation and Clinical Compliance provided support to surgery center leadership, management, and staff to develop the POC, which was submitted to CMS and the state and accepted within three days.

Then, Compass’ team of compliance and accreditation experts spent time on-site with the center for a focused assessment of the ambulatory surgery center’s implementation of the POC and assessment of compliance through observation, chart review, review of current policies, and interviews with personnel. They found deficiencies such as no labeling of medications, inaccurate time outs, inadequate sterilization records, and no temperature and humidity logs in areas other than the operating room.

Equipped with the new POC and mock survey conducted by Compass, the Interim Administrator was deployed to provide months of on-site operational leadership and support during the response and recovery process, including guiding the implementation of the POC and correcting identified deficiencies.

Additional Barriers

Following the priority tasks of implementing the POC and correcting deficiencies, the Interim focused on staff communication and the culture of the surgery center. Aware of needed changes, staff received the Interim Administrator’s entrance well, and the Interim gained the rest of their trust with upfront communication. Through an initial observation of the function and flow of the facility and meetings with the physician owners and staff, the Interim observed a lack of respect paid by the physician owners to staff members. Staff worked long hours and did not get paid overtime until after 10 hours, rather than after eight hours. There was also a lack of communication between different departments, and there were no staff meetings in place to facilitate any understanding within the organization.

To further evaluate the strengths and weaknesses of the department, the Interim created a questionnaire to assess get staff members’ perspectives on what need to be addressed. Once completed, the Interim sat down with employees to discuss these more thoroughly and to reconstruct an action plan.

The Interim Administrator was also tasked with the responsibility of reviewing and identifying opportunities for improving policies, procedures, and practices. Upon examination, the Interim found that many of the policies and procedures had not been reviewed or updated for at least three years, and finding policies was difficult due to incorrect categorization.

The Interim delegated the reviewing, revising, and updating of policies and procedures to a part-time nurse in infection control and Environment of Care. The Interim then implemented an organizational system for improved accessibility. The auditing of these tools is a process the organization plans to continue after the departure of the Interim.

Eliminating Barriers in Staff Communication

Open communication propelled open mindsets and departmental change. The Interim utilized a communication board to post accomplishments such as: fire risk assessments, counts, time outs, on-time starts, and patient satisfaction results for staff to see. She also implemented monthly staff meetings to facilitate improved communication. Staff appreciated the recognition of their efforts at the morning huddles.

The Interim implemented policies and procedures in the department such as: labeling stickers on clean decontamination objects and all objects placed on back-table, and creating unit-based competencies to have completed before next annual evaluations. Staff did not have job-specific competencies, so the Interim created competencies and these were given to staff to complete by their next evaluation. After a sudden exodus of nurses, the Interim recruited travelers for all positions, and she advertised for per diem nurses — a temporary solution the organization plans to maintain. Involving staff in these processes and explanations increased their ease and shaped their practices to continue after the departure of the interim.

The Results: Corrected Deficiencies, Shifting of Responsibilities, Improved Accountability, Sustainable Practices

The Interim and Compass team accomplished their goal of fixing deficiencies. The unannounced follow-up physical survey by the state allowed the state to observe that the POC was initiated and that deficiencies were corrected. The surveyors noticed a positive difference in the staff’s realization of the importance of the deficiencies and corrections. The state accepted all corrections and notified CMS not to close the facility.

Following this instance, the Interim received a letter from the fire marshal with the request for an additional POC in regards to the sentinel event. The Interim Administrator created this POC, which passed within the week.

The Interim’s approach went beyond simply assessing the organization and fixing identified issues; her involvement of staff led to sustainable practices in the surgery center. Staff were held accountable for their actions and practices and involved in decision making.

The Interim’s leadership style, utilizing her expertise to guide the organization and to delegate, led to standards of practice being followed and effective performance improvement in this surgery center that will continue to uphold practices to ensure safe, quality care.

Compass Clinical Consulting
(800) 241.0142 | 100 E. RiverCenter Blvd, Suite 100, Covington, KY 41011

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Compass  Clinical Consulting
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